What is the treatment for a foreign body (splinter) in the eyeball?

Treatment for Ocular Foreign Body (Splinter in Eyeball)

Immediately assess for penetrating injury and remove superficial foreign bodies with irrigation, then apply topical antibiotics (moxifloxacin four times daily) and topical NSAIDs for pain, with mandatory ophthalmology follow-up within 24-48 hours. 1

Immediate Assessment for Red Flags

Before attempting any treatment, you must identify whether this is a true penetrating injury requiring emergency ophthalmology referral:

• Check visual acuity immediately to establish baseline function and identify acute vision loss 1
• Examine the pupil carefully - an irregular pupil after trauma indicates globe penetration and requires immediate ophthalmology referral 1, 2
• Ask about mechanism - high-velocity injuries (grinding, hammering metal, nailing) carry high risk of intraocular foreign body and require immediate specialist evaluation 1, 2, 3
• Look for eye bleeding or vision loss - these are absolute indications for emergency ophthalmology referral 1, 2
• Assess pain severity - moderate-to-severe pain with photophobia suggests significant injury 1
• Use fluorescein staining to identify corneal defects, visible corneal damage, haze, opacity, or purulent discharge 1

Initial Management for Superficial Foreign Bodies

If red flags are absent and the foreign body appears superficial:

• Do NOT rub the eye - this embeds the foreign body deeper and worsens corneal abrasion 2
• Irrigate with sterile saline first to flush loose material 1, 3
• Allow natural tears to work or use tap water/commercial eye wash if sterile saline unavailable 1, 2
• Shield the eye with a hard plastic eye shield, paper cup, or plastic cup to prevent unintentional touching 1, 2

Foreign Body Removal

• Evert the eyelid to inspect the tarsal conjunctiva for retained foreign bodies that may be hidden 1
• Use slit-lamp biomicroscopy to evaluate depth, location, and presence of rust ring (for metallic foreign bodies) 1
• Remove superficial foreign bodies with appropriate technique; if embedded or difficult to remove, refer immediately to ophthalmology 3
• A foreign-body spud under topical anesthesia facilitates corneal foreign body removal 4

Post-Removal Treatment Protocol

After successful foreign body removal, the following regimen is essential:

• Broad-spectrum topical antibiotic prophylaxis - moxifloxacin four times daily or gatifloxacin to prevent infection 1, 3
• Topical NSAID - ketorolac for pain, photophobia, and foreign body sensation 1, 3
• Cycloplegic agent - cyclopentolate to reduce ciliary spasm pain and anterior segment inflammation 1, 3, 4
• Oral analgesics - acetaminophen or NSAIDs for additional pain relief 1, 2, 3
• Do NOT patch the eye unless specifically indicated, as modern evidence does not support routine patching 3

Mandatory Follow-Up and Warning Signs

• All patients require ophthalmology follow-up within 24-48 hours after foreign body removal to monitor for infection development 1, 3
• For metallic foreign bodies, assessment for rust ring formation and ensuring complete removal is crucial at follow-up 1
• Obtain cultures if there are associated infiltrates, ≥1+ cells in anterior chamber, multiple corneal infiltrates, or atypical features 1

Patient Instructions for Immediate Return

Instruct patients to return immediately if they develop:

• Worsening pain or vision 1
• Increasing redness 1
• Discharge or purulent material 1
• Persistent foreign body sensation despite treatment 1, 2

Special Considerations

• Contact lens-related injuries require immediate lens removal and discontinuation of contact lens use 1, 2
• Chemical injuries require irrigation until pH normalizes, then treat as corneal abrasion 4
• Suspected intraocular foreign body requires immediate ophthalmology referral and protective shielding without any manipulation 3