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LETTERS

Re: A prospective observational study of techniques to remove corneal foreign body in the emergency department Dear Editor, We have read the article entitled ‘A prospective observational study of techniques to remove corneal foreign body in the emergency department.’ by Quirke et al1 with interest. We congratulate the authors that they called attention to an important issue in the emergency settings. The study aimed to compare the slit-lamp-aided technique of superficial corneal foreign body (FB) removal with direct removal without the aid of a slit-lamp biomicroscopy performed by emergency physicians. In the paper, the term ‘superficial’ is undefined. Bowman’s layer is critical for corneal transparency, wound healing and epithelial reinnervation.2 For this reason, it would be better to report the depth of the FBs in the paper. The authors have assessed visual acuity just after the injury and after 12 h and 24 h. Visual acuity should be tested by means of a careful refractive error correction. Usually, it’s not possible to find necessary equipment in emergency departments to perform a thorough correction. We wonder if the visual acuity was obtained by means of refraction equipment. Furthermore, the patient may not be able to cooperate with the correction because of severe irritation and ensuing blepharospasm after such an injury. It’s not clear in the text if they used topical anaesthetic before visual acuity testing. It would also be better to document the localisation of the FBs such as central, paracentral or peripheral FB. Finally, we’d like to express our gratitude to the authors that they have emphasised the necessity of slit-lamp biomicroscope in the emergency medicine examination settings. As ophthalmologists, we want to encourage the emergency medicine practitioners to use slit-lamp biomicroscope in the extraction of corneal FBs. Abdullah Ilhan,1 Ahmet Tas,2 Salih Altun,3 Fatih C Gundogan3 1 Opthalmology Department, Erzurum Military Hospital, Erzurum, Turkey 2 Opthalmology Department, Agri Military Hospital, Agri, Turkey 3 Ophthalmology Department, Gulhane Military Medical School, Ankara, Turkey

Correspondence to Dr Ahmet TAS, Opthalmology Department, Agri Military Hospital, Agri 04000, Turkey; [email protected]

Contributors I certify that neither this manuscript nor one with substantially similar content under my authorship has been published or is being considered for publication elsewhere. I have access to any data upon which the manuscript is based and will provide such data upon request to the editors or their assignees. All authors agree to allow me to correspond with the editorial office, to review the uncorrected proof copy of the manuscript and to make decisions regarding release of information in the manuscript. All authors took part in the conception, design, intellectual content and manuscript preparation. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.

To cite Ilhan A, Tas A, Altun S, et al. Emerg Med J 2015;32:417. Accepted 8 November 2014 Published Online First 8 January 2015

▸ http://dx.doi.org/10.1136/emermed-2012-201447 ▸ http://dx.doi.org/10.1136/emermed-2014-204487

involvement. We wish to emphasise that the attempted removal of a deep CFB without the assistance of a slit lamp will almost certainly increase the risk of corneal perforation and should not be performed. In our opinion, the use of refractive equipment to assess visual acuity is not necessary in the emergency department setting. Significant alteration in visual acuity following correction with either the patient’s own spectacles or the use of a pinhole, would usually mandate ophthalmology referral. As a clarification, we did note the location of CFB (central, paracentral or peripheral) during data collection; however, our numbers were too small to perform a subanalysis on the impact of location on follow-up visual acuity. Also, in the presence of significant blepharospasm, we routinely instilled local anaesthetic to allow cooperation with visual acuity testing during the initial assessment. Michael Quirke,1 Caitriona Mullarkey,2 James Binchy1 1

Emerg Med J 2015;32:417. doi:10.1136/emermed-2014-204429

REFERENCES 1

2

Quirke M, Mullarkey C, Askoorum S, et al. A prospective observational study of techniques to remove corneal foreign body in the emergency department. Emerg Med J 2014;31:463–6. Lagali N, Germundsson J, Fagerholm P. The role of Bowman’s layer in corneal regeneration after phototherapeutic keratectomy: a prospective study using in vivo confocal microscopy. Invest Ophthalmol Vis Sci 2009;50:4192–8.

Authors’ reply We thank Drs Tas, Ilhan, Altun and Gundogan for their interest in our work1 and for their positive feedback and comments.2 In our study, superficial corneal foreign body (CFB) referred to visible foreign material present on the surface of the cornea that was easily removable with the aid of a cotton-bud or needle. We did not assess the depth of corneal involvement for a number of reasons. First, in the patient subgroup who had the CFB removed without the assistance of a slit lamp, it would be impossible to accurately assess the depth of corneal involvement. Second, we would have introduced bias by requiring pre-assessment of each patient with a slit-lamp examination. Finally, even with the use of a slit lamp, we doubt emergency physicians have sufficient training in ophthalmology to accurately record the depth of corneal Emerg Med J May 2015 Vol 32 No 5

Emergency Department, University Hospital Galway, Galway, Ireland 2 Emergency Department, University Hospital Limerick, Limerick, Ireland Correspondence to Dr Michael Quirke, c/o Mr James Binchy, Emergency Department, University Hospital Galway, Galway, Ireland; [email protected] Competing interests None. Ethics approval University Hospital Galway Research and Ethics Committee. Provenance and peer review Commissioned; internally peer reviewed.

To cite Quirke M, Mullarkey C, Binchy J. Emerg Med J 2015;32:417. Accepted 19 November 2014 Published Online First 8 January 2015

▸ http://dx.doi.org/10.1136/emermed-2012-201447 ▸ http://dx.doi.org/10.1136/emermed-2014-204429 Emerg Med J 2015;32:417. doi:10.1136/emermed-2014-204487

REFERENCES 1

2

Quirke M, Mullarkey C, Askoorum S, et al. A prospective observational study of techniques to remove corneal foreign body in the emergency department. Emerg Med J 2014;31:463–6. Tas A, Ilhan A, Yolcu U, et al. Re:A prospective observational study of techniques to remove corneal foreign body in the emergency department: Emerg Med J 2015;32:417.

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Downloaded from http://emj.bmj.com/ on August 10, 2015 - Published by group.bmj.com

Re: A prospective observational study of techniques to remove corneal foreign body in the emergency department Abdullah Ilhan, Ahmet Tas, Salih Altun and Fatih C Gundogan Emerg Med J 2015 32: 417 originally published online January 8, 2015

doi: 10.1136/emermed-2014-204429 Updated information and services can be found at: http://emj.bmj.com/content/32/5/417.1

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Re: A prospective observational study of techniques to remove corneal foreign body in the emergency department.

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