What is the appropriate treatment for a patient with a foreign body in their eye?

Management of Ocular Foreign Body

For a patient with a foreign body in the eye, immediately assess visual acuity and mechanism of injury, irrigate superficial foreign bodies with sterile saline, shield the eye to prevent further trauma, and arrange urgent ophthalmology evaluation within 24-48 hours—or immediately if high-velocity mechanism, irregular pupil, vision loss, or eye bleeding is present. 1

Immediate Assessment and Red Flag Identification

Before attempting any intervention, establish baseline visual acuity to identify acute vision loss requiring emergency referral 1. Critical red flags that mandate immediate ophthalmology consultation include:

• High-velocity mechanisms (grinding, metal work, hammering) which carry significantly higher risk of globe penetration 1, 2
• Irregular pupil shape after trauma, indicating penetrating injury 1, 2
• Eye bleeding or vision loss 1, 2
• Moderate-to-severe pain with photophobia 1
• Visible corneal damage including fluorescein uptake, ulceration, haze, opacity, or purulent discharge 1
• Contact lens-related injuries requiring immediate lens removal and discontinuation 1, 3

Initial Management for Low-Energy Foreign Bodies

For superficial foreign bodies without red flag features:

• Do not rub the eye, as this embeds the foreign body deeper and causes corneal abrasion 3
• Irrigate with sterile saline to flush loose material, or allow natural tears to wash out the object 1, 3
• Shield the eye with a hard plastic eye shield, paper cup, or plastic cup to prevent unintentional touching 1, 3, 2
• Provide oral analgesia with acetaminophen or NSAIDs for discomfort 1, 3

Foreign Body Removal Technique

If removal is attempted in the clinical setting:

• Apply topical anesthesia with proparacaine or tetracaine—instill 1-2 drops prior to removal 2, 4
• Use slit-lamp biomicroscopy to evaluate corneal epithelial defects, foreign body location, depth, and presence of rust ring 1, 2
• Apply fluorescein staining to identify epithelial defects 1
• Evert the eyelid to inspect tarsal conjunctiva for retained foreign bodies 1

Critical caveat: Do not attempt removal yourself if severe swelling, high-velocity mechanism, or red flag features are present—these require immediate ophthalmology referral 2.

Post-Removal Treatment Protocol

After successful foreign body removal, initiate the following regimen:

• Broad-spectrum topical antibiotic prophylaxis: Moxifloxacin or levofloxacin four times daily (gatifloxacin is an alternative) 1, 2
• Topical NSAID: Ketorolac for pain, photophobia, and foreign body sensation 1, 2
• Cycloplegic agent: Cyclopentolate to reduce ciliary spasm pain 1
• Oral analgesics: Acetaminophen or NSAIDs for additional pain relief 1

Special Considerations for Metallic Foreign Bodies

Metallic foreign bodies require heightened vigilance:

• Assess for rust ring formation at follow-up, as incomplete removal can lead to complications 1
• Obtain cultures if associated infiltrates are present, particularly for central lesions with significant stromal involvement, ≥1+ anterior chamber cells, or multiple infiltrates 1

Mandatory Follow-Up Requirements

All patients require ophthalmology follow-up within 24-48 hours after foreign body removal to monitor for infection development 1, 2. For severe epithelial damage, daily ophthalmological review during the acute phase is recommended 2.

Return Precautions

Instruct patients to return immediately for:

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

Information to Report to Ophthalmology

When consulting or referring, communicate:

• Visual acuity and mechanism of injury 1
• Presence of fluorescein uptake and rust ring 1
• Any red flag features identified 1
• Corneal sensitivity status 1