What is the management for severe eye swelling secondary to a foreign body?

Management of Severe Eye Swelling Secondary to Foreign Body

Immediately shield the eye with a hard plastic eye shield or cup to prevent further trauma, irrigate with sterile saline if the foreign body is superficial, and obtain urgent ophthalmology consultation for same-day evaluation—do not attempt removal yourself if there is severe swelling, high-velocity mechanism, or any red flag features. 1

Immediate Red Flag Assessment

Before any intervention, rapidly assess for features requiring emergency ophthalmology referral:

• Test visual acuity immediately to establish baseline function and identify acute vision loss 1
• Examine the pupil shape—an irregular pupil indicates globe penetration and requires immediate ophthalmology referral 1
• Check for eye bleeding or vision loss, both of which mandate emergency ophthalmology consultation 1
• Assess the mechanism of injury—high-velocity mechanisms (grinding, metal work, nailing) carry higher risk of penetrating injury and require immediate specialist evaluation 1, 2
• Look for visible corneal damage including fluorescein uptake, ulceration, haze, opacity, or purulent discharge—these are critical red flags 1
• Evaluate pain severity—moderate-to-severe pain and photophobia suggest significant ocular injury 1

Initial Stabilization and Protection

For patients without immediate red flags but with severe swelling:

• Shield the eye immediately with a hard plastic eye shield, paper cup, or plastic cup to prevent unintentional touching or pressure 1, 2
• Do NOT rub the eye or allow the patient to touch it, as this can embed the foreign body deeper or cause corneal abrasion 2
• For superficial, low-energy foreign bodies only, irrigate with sterile saline, tap water, or commercial eye wash to flush loose material 1, 2
• If contact lens-related, remove the contact lens immediately and discontinue use 1, 2

Foreign Body Removal (Ophthalmologist-Performed)

Foreign body removal in the setting of severe swelling should be performed by an ophthalmologist, not in primary care:

• Topical anesthesia with proparacaine or tetracaine is necessary prior to examination and removal 3, 4
• Slit-lamp biomicroscopy is required to evaluate corneal epithelial defects, foreign body location, depth, and presence of rust ring 1
• Fluorescein staining identifies epithelial defects and helps differentiate true defects from pooling 1
• Evert the eyelid to inspect the tarsal conjunctiva for retained foreign bodies, as organic material can remain asymptomatic for months and cause delayed inflammation 1, 5
• In uncooperative patients or children, examination under general anesthesia may be necessary to identify retained foreign bodies 5

Post-Removal or Post-Assessment Treatment

Once the foreign body is removed or if removal is deferred pending specialist evaluation:

• Broad-spectrum topical antibiotic prophylaxis is mandatory—moxifloxacin or levofloxacin four times daily is recommended in the UK, or gatifloxacin as an alternative 3, 1
• Topical NSAID (ketorolac) for pain, photophobia, and foreign body sensation 1
• Cycloplegic agent (cyclopentolate) to reduce ciliary spasm pain 1, 6
• Oral acetaminophen or NSAIDs for additional pain relief 1, 2
• Two-hourly lubricant application (nonpreserved hyaluronate or carmellose drops) if there is significant corneal epithelial damage 3

Special Considerations for Severe Swelling with Epithelial Defects

• Topical corticosteroid drops (nonpreserved dexamethasone 0.1%) may reduce ocular surface damage when supervised by an ophthalmologist, but should be used with caution in the presence of corneal epithelial defects as they can mask signs of infection 3
• Daily ophthalmological review is necessary during the acute phase if there is significant epithelial damage 3
• Ocular hygiene to remove inflammatory debris must be performed by an ophthalmologist or ophthalmically trained nurse using saline irrigation, squint hook, and forceps—blind sweeping with cotton buds is not recommended 3

Culture Indications

Obtain cultures in the following scenarios:

• Corneal foreign bodies with associated infiltrates, particularly central or large infiltrates with significant stromal involvement or melting 1
• ≥1+ cells in the anterior chamber 1
• Multiple corneal infiltrates or atypical features 1
• Suspected corneal infection manifesting as stromal loss—culture for both bacteria and fungus (Candida keratitis is relatively common in surface disease) 3

Mandatory Follow-Up

• All patients require ophthalmology follow-up within 24-48 hours after foreign body removal to monitor for infection development 1
• For metallic foreign bodies, assess for rust ring formation and ensure complete removal 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

Critical Pitfalls to Avoid

• Never attempt removal in primary care if there is severe swelling, high-velocity mechanism, irregular pupil, or any penetrating injury concern—these require immediate ophthalmology referral 1, 2
• Do not use topical corticosteroids without ophthalmology supervision, as they mask infection signs 3
• Always obtain imaging (CT or x-ray) for high-velocity metal injuries to rule out intraocular foreign bodies 6, 7
• Do not miss retained organic foreign bodies (wood)—they can remain asymptomatic for months before causing severe inflammation or corneal ulceration 5, 8
• Avoid cycloplegics/mydriatics in patients at risk for angle-closure glaucoma 6