Street Smarts

The Alger Brush Off

By Dan Beck, OD
Leland, N.C.

IN PAST COLUMNS, I‘ve often addressed topics or areas of interest in the average practice. With this writing, I will address a specific, clincal situation: Corneal rust.

If you‘ve not yet removed a metallic foreign body from an agonizing patient's cornea, you're in for a unique eyecare experience. Unlike organic foreign bodies, metal that enters the eye (with the exceptions of galvanized metal or stainless steel), will rapidly oxidize and form rust. Removing the metal is the easy part. Usually, a quick flick with a spud tool will do the job. The deep rust underneath, however, is the real challange.

The main method of rust removal used by most ODs is the Alger Brush. Its spinning burr quickly removes even deeply embedded rust. The burr also rips up and eviscerates a good deal of healthy corneal tissue.

Most manufacterors of Alger Brushes claim their burrs stop if pressed too hard against the cornea and rarely penetrate into the stroma. That is a flat-out lie. The distinct, round scars they leave behind should be all the proof you need.

Over the years, I've personally left many circular corneal tattoos on patients.

Several years ago, I ditched my Alger Brush for a vastly different approach to rust removal. After removing the metal, I prescibe a steroid-antibiotic combination—1 drop every 4 hours for 2 days. The steroid will help the rust move toward the surface and solidify. The antibiotic will help keep the area sterile. When the patient returns, the rust should be one piece that almost always comes out with just a spud. The epithelial break underneath the rust is also much smaller than an Alger brush would leave behind. Many times, little if any scarring results.

While this technique is by no means new or unique, I've discovered that it isn't widely used among optometrists.

The goal of any procedure is to improve or correct the patient's condition while causing as little trauma as possible. The technique described here should help you accomplish that goal. nOD