眼内异物、角膜擦伤、焊工闪光临床急救¶

透明的人类角膜是身体表面神经支配最密集的组织，每平方毫米由大约 7,000 个伤害性神经末梢通过三叉神经（颅神经 V1）的眼支提供。由于这种神经密度比人类皮肤高 300 至 600 倍，因此即使是微小的风吹沙粒、浅表指甲划痕或几秒钟无屏蔽的紫外线焊接电弧照射也会产生令人痛苦的异物疼痛、不自觉的眼睑痉挛（眼睑痉挛）和大量反射性流泪。

与此同时，高速机械活动，例如用金属撞击金属、使用旋转角磨机或操作绳式修剪器，可以将微小的金属射弹完全穿过角膜或巩膜发射到眼球内部，最初会产生看似轻微的不适。了解如何在接触眼睑之前筛查开放性眼球破裂或眼内异物，如何安全地外翻上眼睑以冲洗掉隐藏在睑板沟中的隐藏颗粒，以及为什么隐形眼镜佩戴者和家用麻醉药水会带来永久性角膜失明的严重风险，这对于保持视力至关重要。

现在就这样做¶

1. **告诉患者立即停止揉眼睛，让他们坐在光线昏暗的地方。**揉眼睛时，如果含有尖锐的玻璃、金属、铁锈或二氧化硅颗粒，碎片会像砂纸一样在脆弱的角膜上皮上更深地磨碎，按压刺破的眼球会将眼内液和虹膜从伤口中挤出。
2. 在尝试冲洗或拉动眼睑之前，在柔和的灯光下检查眼睛是否有“睁开的球体”或高速外伤危险信号。如果受伤发生在锤击金属、打磨、凿刻或接近爆炸时，或者如果您看到泪滴状或尖状瞳孔、眼睛前部积血（前房积血）、表面有突出的深色胶状珠子或物体卡在透明物体中角膜，不要冲洗眼睛，也不要触摸眼睑。
3. 如果有任何疑似穿透伤、高速金属撞击或视力丧失的情况，请拨打当地紧急电话号码或立即前往眼科急诊科。 美国和加拿大拨打 911，欧盟拨打 112，英国拨打 999，澳大利亚拨打 000，或查看电话号码簿 紧急号码。立即用刚性防护罩（例如金属 Fox 眼罩或粘在眉毛和颧骨上的纸杯底部）保护刺破或破裂的眼睛，不要对眼球施加任何纱布压力。
4. **仅当损伤是简单的低速尘埃、划痕或紫外线闪光且镜片容易滑落时，才应立即摘下隐形眼镜。**切勿将隐形眼镜留在磨损或发炎的眼睛中，因为困在镜片下方的铜绿假单胞菌细菌会在 24 小时内通过角膜融化。如果镜片被卡住，请等到用无菌盐水轻轻冲洗眼睛，使其自由漂浮。
5. 使用无菌盐水或干净的温自来水轻柔连续地冲洗眼睛中的松散灰尘、睫毛、沙子或木屑。将患者的头部倾斜到一侧，使受伤的眼睛朝向下，使水从内角（靠近鼻梁）向外流过太阳穴，防止碎片冲入未受伤的眼睛。
6. **因怀疑角膜擦伤或紫外线焊机闪光（光性角膜炎）而闭上双眼并休息，并且切勿在家中将剩余的麻木药水滴入眼睛中。**由于两只眼睛一起移动（共视），因此在暗室中轻轻闭上双眼休息可防止上眼睑刮擦原始角膜缺损。切勿在家里使用紧压眼罩，也切勿使用处方麻醉药水（丙美卡因或丁卡因）。

急性眼部异物和表面损伤的应急决策树¶

flowchart TD
    Start["Acute Eye Pain, Foreign Body Sensation, or Flash Burn"]
    StopRub["Instruct Patient: DO NOT RUB OR PRESS ON THE EYE"]
    HighVel{"High-Velocity Mechanism OR Open Globe Signs?<br/>(Hammering metal, grinding, teardrop pupil, hyphema, embedded corneal shard)"}
    ShieldGlobe["OPEN GLOBE / INTRAOCULAR FOREIGN BODY PROTOCOL<br/>1. DO NOT flush, DO NOT evert lid, DO NOT apply pressure<br/>2. Tape a rigid paper cup or Fox eye shield over bony orbit<br/>3. Keep patient seated at 30 to 45 degrees (nothing by mouth)<br/>4. Transport immediately to Emergency Ophthalmology + Orbital CT"]
    UVCheck{"History of Unshielded UV Exposure 6 to 12 Hours Ago?<br/>(Arc welding, snow/glacier reflection, tanning bed, germicidal UVC lamp)"}
    UVCare["ULTRAVIOLET PHOTOKERATITIS (WELDER'S FLASH / SNOW BLINDNESS)<br/>1. Move to dark room and remove contact lenses immediately<br/>2. Apply cool damp cloth over gently closed eyelids<br/>3. Instill preservative-free artificial tears or lubricating ointment<br/>4. Seek medical evaluation for cycloplegic drops and oral analgesia"]
    LooseFB["Low-Velocity Loose Foreign Body or Surface Scratch<br/>(Windblown dust, sand, eyelash, sawdust, fingernail, tree branch)"]
    Irrigate["Gentle Ocular Irrigation Protocol<br/>1. Tilt head so injured eye is lowest (flush inner-to-outer corner)<br/>2. Irrigate with sterile normal saline or lukewarm tap water<br/>3. Remove contact lens once lubricated"]
    CheckClear{"Did Irrigation Remove the Particle?"}
    EvertLid["Inspect & Evert Upper Eyelid (Subtarsal Sulcus)<br/>1. Ask patient to look down while gently pulling upper lashes forward/up<br/>2. Sweep visible loose speck off inner lid with wet cotton swab<br/>3. NEVER touch or scrape a speck stuck on the clear cornea"]
    PostAbrasion["Corneal Abrasion & Rust Ring Screening<br/>1. Do NOT apply a tight pressure eye patch<br/>2. Urgent clinic visit for fluorescein staining & rust ring removal<br/>3. Mandatory antipseudomonal antibiotic drops if contact lens wearer"]

    Start --> StopRub
    StopRub --> HighVel
    HighVel -->|Yes: High-Velocity or Globe Rupture| ShieldGlobe
    HighVel -->|No: Low-Velocity Surface Issue| UVCheck
    UVCheck -->|Yes: Bilateral Delayed Pain & Photophobia| UVCare
    UVCheck -->|No: Unilateral Grit or Scratch| LooseFB
    LooseFB --> Irrigate
    Irrigate --> CheckClear
    CheckClear -->|No: Still Feels Under Upper Lid| EvertLid
    CheckClear -->|Yes: Particle Flushed Out| PostAbrasion
    EvertLid --> PostAbrasion

比较眼部异物、角膜擦伤和紫外线闪光灼伤¶

由于滞留的异物、残留的角膜擦伤、早期角膜溃疡和紫外线闪光烧伤都具有**异物疼痛、流泪（溢泪）和光敏感性（畏光）**的三联征，因此通过暴露时间、偏侧性和身体外观来区分它们可以指导安全治疗。

Step 1: Screening for an Open Globe or Intraocular Foreign Body¶

Before you ever pour water into an injured eye or pull on an eyelid, you must spend 15 seconds ruling out a penetrating globe injury (open globe) or a high-velocity intraocular foreign body (IOFB). Performing eyelid eversion or pressing with a cloth on a ruptured eyeball squeezes the gelatinous vitreous humor and uveal tissue out through the laceration, causing permanent loss of the eye.

The 7 red flags of an Open Globe or Intraocular Foreign Body¶

Do NOT irrigate, do NOT remove any protruding object, and do NOT touch the eyelids if any of the following are present:

1. High-velocity mechanism: The person was hammering metal on metal, using a cold chisel, operating a high-speed grinder, wire wheel, drill, or lawn edger/weed trimmer, or was exposed to a blast or gunshot.
2. A peaked, teardrop-shaped, or irregular pupil: When the cornea or limbus (the border where the clear cornea meets the white sclera) is punctured, aqueous humor leaks out and the colored iris plugs the hole from the inside, pulling the round pupil into a pointed teardrop shape whose tip points directly toward the site of perforation.
3. A visible dark bead or blister on the cornea or sclera: Prolapsed iris or choroidal tissue looks like a tiny dark brown or black grape seed sitting on the surface of the eye. Never mistake this for a piece of dirt and never try to wipe it off.
4. Hyphema (blood pooling inside the front chamber of the eye): Visible bright red or dark reddish-black blood layering out in front of the colored iris indicates severe blunt or penetrating intraocular trauma.
5. A "bullous" 360-degree bloody conjunctiva: When the white of the eye is completely ballooned up with dark red subconjunctival hemorrhage all the way around the cornea, it frequently hides a deep scleral rupture underneath.
6. Collapse or asymmetry of the anterior chamber: Looking at the injured eye from the side and comparing it to the uninjured eye reveals that the space between the clear cornea and the colored iris is either completely flat (cornea touching iris) or abnormally deep.
7. Visible embedded shard on the clear cornea: If a piece of metal, glass, or wood is stuck directly into the clear dome of the cornea over the iris or pupil, do not try to flush or brush it off.

How to shield a suspected Open Globe in the field¶

If any of the 7 red flags above are present: * Fashion a rigid vaulted eye shield: Use a commercial perforated aluminum Fox eye shield or cut the bottom 4 centimeters (1.5 inches) off a disposable paper or foam drinking cup. * Tape the rim strictly to the surrounding facial bones: Place the rim of the shield or paper cup so it rests on the bony brow ridge (supraorbital rim) above and the cheekbone (zygomatic arch) below, arching completely over the eye without touching the eyelids or eyeball. Secure it with strips of tape running diagonally from the forehead to the cheek. * NEVER place a gauze pad underneath the shield: Stuffing folded gauze under an eye shield turns it into a pressure dressing that presses down on the ruptured eyeball. * Keep the patient seated at a 30-to-45-degree incline, calm, and NPO (nothing by mouth): Prevent vomiting, coughing, or bending over, as Valsalva straining spikes intraocular pressure. Keep the patient fasting in case emergency general anesthesia is needed for surgical globe repair.

Step 2: Safe removal of a loose surface foreign body¶

Once you have confirmed the injury was caused by a low-velocity particle (such as windblown dust, sand, sawdust, an eyelash, or an insect) and there are no signs of globe penetration, you can safely flush the ocular surface.

Technique A: Gravity-assisted ocular irrigation¶

1. Position the patient with the injured eye facing downward: Have the person sit or lie down and tilt their head to the side so the injured eye is lower than the uninjured eye. Place a folded towel against their temple or hold a kidney basin under their cheek.
2. Hold the eyelids gently apart against the bony orbital rims: Using your thumb and index finger, gently hold the upper eyelid upward against the bony brow ridge and the lower eyelid downward against the cheekbone. Never press your fingers against the soft eyeball itself.
3. Pour a slow, steady stream of sterile normal saline (0.9% sodium chloride), commercial sterile eyewash, or clean lukewarm tap water: Hold the bottle or cup 2 to 5 centimeters (1 to 2 inches) above the inner corner of the eye (medial canthus) near the bridge of the nose, letting the water flow smoothly across the surface of the eye and drain off the outer corner (lateral canthus).
4. Have the patient roll their eye in all directions during flushing: Ask the person to look up, down, left, and right while the water flows so the fluid reaches deep into the upper and lower conjunctival sacs (fornices).

Technique B: Inspecting the lower lid and everting the upper eyelid¶

If flushing does not wash the particle out and the person still feels a sharp scratch under the upper lid every time they blink, the particle is almost certainly lodged in the subtarsal sulcus, a shallow horizontal groove located 2 millimeters (0.08 inches) inside the inner surface of the upper tarsal plate.

1. Check the lower eyelid sac (inferior fornix) first: Ask the patient to look up toward the ceiling while you gently pull the lower eyelid skin downward against the cheekbone. If you see a speck resting on the pink inner lining (palpebral conjunctiva), gently touch it with the tip of a clean cotton swab moistened with sterile saline so it sticks to the wet cotton and lifts away.
2. Evert (flip) the upper eyelid using the cotton-swab fulcrum method:
3. Step 1: Stand in front of the seated patient and instruct them to look continuously down at their feet while keeping their head level. Looking down relaxes the levator palpebrae superioris muscle, which is required to flip the rigid tarsal plate.
4. Step 2: Grasp the upper eyelashes gently between the thumb and index finger of one hand and pull the upper lid slightly forward (away from the eyeball) and downward.
5. Step 3: With your other hand, place the wooden or plastic shaft of a cotton-tipped applicator horizontally across the outer skin of the upper eyelid at the upper crease (roughly 1 centimeter / 0.4 inches above the lash line, at the top edge of the firm tarsal plate).
6. Step 4: Press very lightly downward on the applicator shaft as a hinge while pulling the eyelashes upward and backward over the shaft. The rigid tarsal plate will fold neatly inside-out, exposing the pink subtarsal sulcus.
7. Step 5: Hold the lashes gently against the brow with your thumb while the patient continues looking down. If you see a speck of grit, dust, or an eyelash sitting on the flipped inner eyelid, gently dab it off using a saline-moistened cotton swab.
8. Step 6: To return the eyelid to its normal position, simply release the eyelashes and ask the patient to look up toward the ceiling and blink once. The lid will snap smoothly back into place.

Corneal abrasions, rust rings, and the contact lens danger¶

Even after a loose foreign body is successfully flushed out, or after a direct scratch from a baby's fingernail, tree twig, paper edge, or cosmetic brush, the patient frequently continues to feel as though something is still stuck in the eye. This phantom foreign-body sensation occurs because the upper eyelid brushes across the raw, denuded nerve endings of a corneal abrasion with every blink.

How corneal abrasions heal and why rust rings need a doctor¶

The superficial layer of the cornea (the stratified squamous corneal epithelium) regenerates remarkably fast: healthy basal epithelial cells surrounding a scratch flatten out, slide across the bare basement membrane like an amoeba, and undergo mitosis to resurface most small abrasions within 24 to 48 hours without leaving a scar, provided Bowman's layer and the underlying corneal stroma were not penetrated.

However, two specific foreign-body scenarios prevent normal healing and require same-day professional ophthalmologic care:

1. Corneal metallic foreign bodies and Ferrous Rust Rings: When a hot microscopic fleck of iron or steel from an overhead car repair, brake rotor, or grinding wheel embeds in the cornea, tear film electrolytes begin oxidizing the iron within 2 to 6 hours, creating a circular orange-brown ferrous rust ring that chemically infiltrates the surrounding corneal epithelium and anterior stroma. Even if the central metal speck falls out, the toxic rust ring acts like a persistent foreign body that prevents epithelial closure, triggers sterile white blood cell infiltration (iridocyclitis), and leaves a permanent opaque visual scar over the pupil unless a clinician numbs the eye under a slit-lamp microscope and gently burrs away the oxidized tissue using a low-speed ophthalmic Alger brush.
2. Organic and vegetative trauma (Fungal Keratitis risk): Scratches caused by tree branches, pine needles, rose thorns, landscaping mulch, or agricultural stalks inoculate filamentous fungi (Fusarium and Aspergillus) or Acanthamoeba into the corneal defect. Vegetative corneal abrasions must never receive steroid drops and require close ophthalmologic monitoring.

Why we no longer apply tight pressure eye patches to corneal abrasions¶

For decades, first aid courses and emergency departments routinely taped a tight folded gauze pad (pressure patch) over an abraded eye to keep the eyelid from moving. Modern randomized controlled ophthalmology trials (including Cochrane systematic reviews) have established that routine pressure patching of corneal abrasions is no longer recommended and can be harmful:

• Patching does not speed up epithelial healing rates or reduce pain in small-to-moderate abrasions (< 10 millimeters squared).
• A warm, dark, closed patch raises the temperature of the ocular surface and cuts off oxygen tear exchange, creating an incubator that promotes rapid bacterial proliferation.
• Patching a contact lens wearer or an organic vegetative scratch is strictly contraindicated, as it dramatically increases the risk of a devastating Pseudomonas or fungal corneal ulcer.
• Putting on an eye patch immediately eliminates binocular depth perception (stereopsis), increasing the risk of tripping, falling, or motor vehicle collisions.

Instead of a tight patch, have the patient rest comfortably in a dimly lit room with both eyes gently closed, wear dark wrap-around sunglasses when walking, and use prescribed ophthalmic antibiotic ointment (such as erythromycin ointment for non-contact-lens wearers) which acts as a thick liquid cushion between the eyelid and the abraded cornea.

The contact lens emergency: Pseudomonas aeruginosa¶

If a person who wears soft or rigid contact lenses develops a corneal abrasion, foreign-body scratch, or red painful eye:

• Remove the contact lens immediately and place it in its storage case (bring the lens and case to the eye doctor in case microbiological cultures are needed).
• Mandatory antipseudomonal antibiotic drops: Contact lens wear alters the tear film and traps Pseudomonas aeruginosa, an aggressive Gram-negative bacterium that secretes elastase and alkaline protease enzymes capable of liquefying and perforating the human cornea within 24 to 48 hours. Standard erythromycin eye ointment does not cover Pseudomonas; contact lens wearers with a corneal abrasion must be prescribed topical antipseudomonal fluoroquinolone eye drops (such as moxifloxacin, ciprofloxacin, or ofloxacin) or tobramycin by a clinician, must never have their eye patched, and must be re-examined within 24 hours.
• Do not resume wearing contact lenses until a clinician confirms the corneal epithelium has completely healed and the patient has been symptom-free off drops for several days.

Welder's flash and snow blindness (Ultraviolet Photokeratitis)¶

Ultraviolet photokeratitis (commonly called welder's flash, arc eye, or snow blindness) is an acute radiation burn of the superficial corneal epithelium and conjunctiva caused by unprotected exposure to short-wavelength ultraviolet rays, primarily UVB (280 to 315 nanometers) and UVC (100 to 280 nanometers).

Common sources of UV photokeratitis¶

• Industrial arc welding (MIG, TIG, stick, and plasma cutting): Looking at an unshielded welding arc from 2 to 5 meters (6 to 16 feet) away for a cumulative total of 5 to 30 seconds without an auto-darkening or shade 10-to-14 welding helmet delivers enough UVC/UVB radiation to burn the cornea. Bystanders working nearby without UV-blocking polycarbonate safety glasses are frequently burned by reflected side-flash.
• Snow blindness (High-altitude and polar environments): Fresh snow reflects up to 80 to 85 percent of ambient UV radiation upward from the ground, while every 1,000 meters (3,280 feet) of altitude gain increases UV intensity by roughly 10 to 12 percent.
• Indoor tanning beds, shattered high-intensity discharge (HID) mercury-vapor or metal-halide lamps, and germicidal UVC sanitization bulbs: Unshielded UVC disinfection lamps cause severe bilateral photokeratitis within minutes.

Why welder's flash wakes the victim up in the middle of the night¶

Ultraviolet radiation acts photo-chemically rather than thermally. As UVB and UVC photons are absorbed by the outer squamous cells of the corneal epithelium, they induce DNA thymine dimers and cellular apoptosis. During the welding job or ski trip, the person feels completely normal. Over a 6-to-12-hour latent period, the damaged superficial epithelial cells die and slough off in thousands of pinpoint dots across the cornea (superficial punctate keratitis), exposing raw subepithelial nerve endings. Consequently, the patient typically wakes up between Midnight and 4:00 AM in severe, bilateral burning pain, feeling as though both eyes are packed with hot sand, unable to open their swollen eyelids in the light (photophobia and blepharospasm), with profuse watery tearing.

Step-by-step first aid and medical management for welder's flash¶

1. Move the person into a dark room immediately and keep both eyes gently closed: Dimming all lights and resting with both eyes shut stops pupillary constriction spasms and prevents the eyelids from rubbing over the raw punctate corneal defects.
2. Remove contact lenses immediately: Flush with sterile saline or artificial tears so lenses slide out easily without tearing more epithelium.
3. Apply a cool, damp compress over the closed eyelids: Lay a clean washcloth soaked in cool water over both closed eyes for 15 to 20 minutes at a time. Never place ice directly on the eyelids.
4. Instill preservative-free artificial tears or lubricating ophthalmic ointment frequently: Single-use preservative-free artificial tear drops or sterile lubricating night ointment applied every 1 to 2 hours coats exposed nerve endings. Do not use vasoconstrictor drops or non-sterile home remedies (such as raw potato slices, breast milk, or tea bags).
5. Seek medical care for oral analgesia, antibiotic ointment, and cycloplegic relief: A clinician will stain the corneas with fluorescein dye to rule out embedded metal sparks, and typically prescribes oral NSAIDs or acetaminophen/paracetamol, lubricating antibiotic ointment, and occasionally a single short-acting cycloplegic drop. Symptoms almost always resolve completely within 24 to 72 hours without permanent vision loss.

First aid steps protect your sight after an eye injury, but they do not replace professional medical evaluation or hands-on training. Consider taking a certified first aid course through your national Red Cross or Red Crescent society, St John Ambulance, or an occupational safety provider, and always wear ANSI Z87.1 / EN 166 wrap-around polycarbonate safety glasses when working with tools or UV light.

常见问题¶

来源已检查¶

• American Academy of Ophthalmology (AAO, United States): Preferred Practice Pattern and Clinical Guidance on Corneal Abrasion, Ocular Foreign Bodies, Open Globe Injuries, and Bacterial Keratitis.
• The College of Optometrists (United Kingdom): Clinical Management Guidelines: Corneal Abrasion, Foreign Body, Microbial Keratitis, and Photokeratitis (Arc Eye).
• National Health Service (NHS, United Kingdom) & Moorfields Eye Hospital NHS Foundation Trust: Eye Injuries, Foreign Bodies, and Welder's Flash Emergency Patient Guidance.
• Cochrane Database of Systematic Reviews (International): Patching for Corneal Abrasion (Turner & Rabiu) and Interventions for Corneal Rust Rings.
• National Institute for Occupational Safety and Health (NIOSH / CDC, United States): Eye Safety for Emergency Response and Industrial Ultraviolet Radiation (Welding Arc) Protection.
• World Health Organization (WHO, International): Primary Eye Care Manual: Assessment and Emergency Management of Ocular Trauma.

相关指南¶

• Eye injuries and chemical eye burns
• 严重烧伤和化学冲洗
• Chili pepper and capsaicin burns in the eyes
• Head injuries and concussion signs
• 穿刺和嵌入异物稳定
• 紧急号码和国际调度