What is the emergency room protocol for a patient who believes they have a foreign body, such as sand, in their eye and has already attempted to flush it out?

Emergency Room Protocol for Suspected Foreign Body in the Eye

For a patient who believes they have sand in their eye and has already attempted flushing, the emergency room protocol should include a thorough eye examination with slit-lamp biomicroscopy to identify and remove any remaining foreign material, followed by assessment for corneal damage and appropriate treatment.

Initial Assessment

• Visual acuity testing: Measure baseline visual function with and without correction
• Pupillary examination: Check for normal pupillary responses
• External examination: Look for signs of:
  • Redness
  • Tearing
  • Eyelid swelling
  • Conjunctival injection

Foreign Body Evaluation and Removal

Examination Technique

1. Fluorescein staining: Apply to visualize corneal abrasions or embedded foreign bodies

   • Foreign bodies and abrasions will appear yellow under normal light and green under cobalt blue light 1

2. Slit-lamp biomicroscopy: Gold standard for examination 2

   • Thoroughly examine all layers of the cornea using various techniques (sclerotic scatter, specular reflection) 1
   • Evert the upper eyelid to check for hidden foreign bodies
   • Assess for:
     • Location and depth of foreign body
     • Associated corneal abrasions
     • Signs of infection

Removal Procedure

1. Apply topical anesthetic (e.g., proparacaine or tetracaine)
2. Remove visible foreign body using:
   • Moistened sterile cotton-tipped applicator
   • Irrigation with sterile saline
   • Fine-gauge needle (for embedded particles) under slit-lamp guidance
   • Spud or small gauge needle for stubborn particles

Post-Removal Assessment and Treatment

1. Re-examine with fluorescein to confirm complete removal and assess for residual abrasion

2. Document corneal status including:

   • Size and location of any abrasion
   • Depth of injury
   • Presence of inflammation

3. Treatment plan:

   • Pain management: Consider topical NSAIDs or oral analgesics 3
   • Infection prevention: Consider topical antibiotics for corneal abrasions
   • Do NOT patch the eye - patching does not improve pain and may delay healing 3

Follow-up Recommendations

• Small uncomplicated abrasions (≤4mm): May not require follow-up if symptoms are resolving and vision is normal 3
• Larger abrasions or complicated cases: Re-evaluation within 24 hours
• Warning signs requiring immediate return:
  • Worsening pain
  • Decreased vision
  • Increased redness
  • Purulent discharge

Special Considerations

• High-velocity injuries (grinding, machinery) require immediate medical attention due to risk of penetrating injury 1
• Persistent foreign body sensation after removal may indicate:
  • Incomplete removal
  • Corneal abrasion
  • Inflammatory reaction

Common Pitfalls to Avoid

1. Failing to evert the eyelids to check for hidden foreign bodies
2. Incomplete removal of foreign material
3. Missing signs of infection or deeper injury
4. Inappropriate patching which can delay healing
5. Inadequate follow-up instructions for worsening symptoms

Remember that thorough documentation of the examination, removal procedure, and post-removal status is essential for proper follow-up care and medical records.