What is the appropriate management for a foreign body in the eye?

Management of Ocular Foreign Body

For a foreign body in the eye, immediately assess visual acuity and mechanism of injury to determine if this is a low-energy superficial foreign body that can be managed with irrigation and removal, or a high-velocity injury requiring urgent ophthalmology referral for possible globe penetration. 1

Immediate Red Flag Assessment

Before attempting any intervention, identify features requiring emergency ophthalmology consultation:

• High-velocity mechanisms (grinding, metal work, hammering) carry significant risk of globe penetration and mandate immediate specialist evaluation 1
• Irregular pupil after trauma indicates penetrating injury requiring emergency referral 1
• Eye bleeding or vision loss requires emergency ophthalmology consultation 1
• Sharp or metal objects causing injury suggest possible intraocular foreign body 2
• Test and document visual acuity immediately to establish baseline function 1

Initial Management for Low-Energy Superficial Foreign Bodies

If no red flags are present and mechanism suggests superficial injury:

• Do not allow the patient to rub the eye, as this embeds the foreign body deeper and causes corneal abrasion 2
• Irrigate with sterile saline to flush loose material first, or allow natural tears to wash out the object 1
• Tap water or commercial eye wash solutions are acceptable alternatives for irrigation 1, 2
• Shield the eye with a hard plastic eye shield, paper cup, or plastic cup taped over the eye to prevent unintentional touching 1, 2

Foreign Body Removal Technique

For embedded superficial foreign bodies requiring removal:

• Apply topical anesthetic (proparacaine) prior to examination and removal 3
• Perform slit-lamp biomicroscopy to evaluate corneal epithelium for defects, foreign body location, depth, and presence of rust ring 1
• Use fluorescein staining to identify epithelial defects 1
• Evert the eyelid to inspect tarsal conjunctiva for retained foreign bodies 1
• Remove foreign body under magnification; deeply embedded objects may require a surgical opening 4
• Metallic foreign bodies require assessment for rust ring formation, which must be completely removed 1, 4

Post-Removal Treatment Protocol

After successful foreign body removal:

• Broad-spectrum topical antibiotic prophylaxis: moxifloxacin or gatifloxacin four times daily 1
• Topical NSAID (ketorolac) for pain, photophobia, and foreign body sensation 1
• Cycloplegic agent (cyclopentolate) to reduce ciliary spasm pain 1
• Oral acetaminophen or NSAIDs for additional pain relief 1, 2
• Test corneal sensitivity in all patients, as corneal anesthesia enhances risk of corneal melting and perforation 5

Critical Follow-Up Requirements

• All patients require ophthalmology follow-up within 24-48 hours after foreign body removal to monitor for infection development 1
• Cultures are indicated for corneal foreign bodies with associated infiltrates, ≥1+ anterior chamber cells, multiple infiltrates, or atypical features 1

Patient Warning Signs for Immediate Return

Instruct patients to return immediately for:

• 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
• Delayed presentation and organic foreign bodies are associated with higher endophthalmitis risk 6
• Avoid topical corticosteroids in corneal foreign body cases, as they can lead to corneal melting and perforation, particularly when combined with corneal anesthesia 5
• For intraocular foreign bodies, prompt globe closure with aggressive antibiotic prophylaxis is critical even if definitive foreign body removal must be delayed 6