What is the most appropriate next step for a middle-aged man with severe eye pain after a metal foreign body became lodged in his cornea (corneal foreign body)?

Management of Corneal Metallic Foreign Body

The most appropriate next step is to refer to ophthalmology (Option A), particularly for a metal foreign body that is lodged/embedded in the cornea, as this requires specialized removal techniques and carries risk of rust ring formation and potential complications including corneal perforation. 1

Immediate Assessment and Triage

For any corneal foreign body with severe pain, the priority is determining whether this is an embedded foreign body versus a superficial one that can be safely removed in primary care:

• High-velocity metallic foreign bodies (from grinding, nailing, or metal work) require immediate ophthalmology referral due to risk of penetrating injury or intraocular foreign body 2, 1
• Metal foreign bodies specifically pose additional risk because they create rust rings that require specialized removal and can lead to corneal melting if not properly managed 3, 4
• The term "lodged" in this clinical scenario suggests an embedded foreign body rather than a superficial one that can be easily irrigated out 1

Why Ophthalmology Referral is Preferred

For embedded metallic corneal foreign bodies, ophthalmology referral is the safest approach because:

• Metal foreign bodies frequently leave rust rings that require specialized instrumentation (burr drill) for complete removal 3, 5
• Incomplete removal of rust material can lead to persistent inflammation and corneal scarring 4
• Metallic foreign bodies from occupational injuries (metal cutting, grinding) are often high-velocity and may have penetrated deeper than clinically apparent 4
• Attempted removal by non-specialists risks further corneal damage, particularly if the foreign body is embedded 1

If Primary Care Removal is Attempted (Lower Risk Scenarios Only)

If the foreign body appears truly superficial and easily removable, the following approach applies:

• Remove the foreign body atraumatically and irrigate with sterile saline 1, 3
• Apply broad-spectrum topical antibiotic prophylaxis (e.g., moxifloxacin four times daily) 1
• Never use topical steroids, as they promote ulceration and corneal melting, particularly with fungal contaminants or in the setting of corneal injury 3, 6
• Eliminate any rust ring completely - incomplete removal leads to ongoing inflammation 3
• Provide pain management with topical NSAIDs (ketorolac) and/or oral analgesics, plus cycloplegics for ciliary spasm 1

Critical Pitfalls to Avoid

• Never prescribe topical anesthetics for home use - they mask pain from retained foreign bodies or developing corneal ulcers 3
• Never use topical corticosteroids - they dramatically increase risk of corneal perforation, especially with metallic foreign bodies 6
• Do not patch the eye routinely - modern evidence from the American Academy of Ophthalmology recommends against patching for corneal abrasions 1
• Do not allow patients to self-treat or delay removal - delayed extraction increases complications including rust ring formation and corneal melting 6

Answer to Multiple Choice Question

The correct answer is A: Refer to ophthalmology. 1 While option B (remove and irrigate) might be appropriate for superficial, easily removable foreign bodies, a metal foreign body that is "lodged" in the cornea requires specialized removal to ensure complete elimination of the foreign body and any rust ring, preventing serious complications including corneal perforation 3, 6.