What is the recommended work‑up and initial management for a patient with a suspected foreign body in the eye?

Foreign Body in Eye: Workup and Initial Management

The workup for a suspected ocular foreign body must immediately prioritize identifying vision-threatening injuries through visual acuity testing, mechanism assessment, and systematic examination—with urgent ophthalmology referral for any high-velocity mechanism, penetrating injury signs, or persistent symptoms. 1, 2

Immediate Red Flag Assessment

The first critical step is determining whether this requires emergency ophthalmology consultation based on mechanism and examination findings:

High-Risk Mechanisms Requiring Immediate Specialist Evaluation

• High-velocity injuries from grinding, nailing, machinery, or metal work carry significantly elevated risk of globe penetration and mandate immediate ophthalmology referral 1, 2, 3
• Sharp or metallic object penetration requires emergency consultation 1

Vision-Threatening Examination Findings

• Irregular pupil shape after trauma indicates penetrating injury—this is an emergency 1, 2, 3
• Eye bleeding (hyphema) after trauma requires immediate referral 1, 2, 3
• Acute vision loss mandates emergency ophthalmology consultation 1, 2, 3
• Visible corneal ulceration, haze, opacity, or purulent discharge are critical red flags 2, 3

Initial Workup Protocol

Step 1: Visual Acuity Testing

Test visual acuity immediately to establish baseline function and identify acute vision loss requiring urgent referral 2, 3. This is the first objective measurement and guides all subsequent decisions.

Step 2: Mechanism and History Documentation

Document the following critical details 3:

• Timing of trauma and exact mechanism of injury
• Nature of foreign body material (organic vs. metallic vs. other)
• Velocity of impact (low-energy like dust/eyelash vs. high-velocity)
• Contact lens use at time of injury (requires immediate removal and discontinuation) 1, 2
• Symptoms: diplopia, vision loss, pain severity, photophobia 3

Step 3: Systematic Eye Examination

Perform the following examination components 3:

• Pupillary examination for shape irregularity and reactivity
• Confrontational visual field testing
• External inspection for obvious penetration, bleeding, or deformity
• Eyelid eversion to inspect tarsal conjunctiva for retained foreign bodies 2

Step 4: Slit-Lamp Biomicroscopy (If Available)

Under slit-lamp, evaluate 2, 3:

• Corneal epithelium for defects, foreign body location, and depth
• Presence of rust ring (indicates metallic foreign body)
• Anterior chamber cells (≥1+ cells requires cultures) 2, 3
• Fluorescein staining to identify epithelial defects 2, 4

Step 5: Imaging When Indicated

• CT scan is required if there is any concern for ferrous-metallic foreign body or suspected intraorbital/intraocular foreign body 3, 5, 6
• CT provides sufficient information about orbital fractures and entrapment 3

Initial Management Based on Risk Stratification

Low-Energy Mechanism (Dust, Dirt, Eyelash)

For superficial foreign bodies without red flags 1:

• Irrigate with sterile saline, tap water, or commercial eye wash to flush loose material 1, 2
• Allow natural tears to wash out the object 1
• Shield the eye with hard plastic eye shield, paper cup, or plastic cup to prevent unintentional touching 1, 7
• Never rub the eye 1

Contact Lens-Related Foreign Body Sensation

• Remove contact lens immediately and discontinue use 1, 2
• Seek medical attention even if symptoms improve 1

Embedded or Persistent Foreign Body

Do not attempt removal yourself if 7:

• Severe swelling present
• High-velocity mechanism
• Any red flag features present
• Foreign body appears embedded on cornea

These require professional removal under topical anesthesia with slit-lamp visualization 2, 7.

Post-Removal Treatment Protocol

After successful foreign body removal by a healthcare professional 2, 3, 7:

Antibiotic Prophylaxis

• Broad-spectrum topical antibiotic: moxifloxacin or levofloxacin four times daily, or gatifloxacin as alternative 2, 3, 7
• Note: While commonly prescribed, the utility of routine antibiotic prophylaxis for simple corneal abrasions remains unclear 1

Pain Management

• Topical NSAID (ketorolac) for pain, photophobia, and foreign body sensation 2, 3, 7
• Cycloplegic agent (cyclopentolate) to reduce ciliary spasm pain 2, 3
• Oral acetaminophen or NSAIDs for additional pain relief 1, 2, 3

Culture Indications

Obtain cultures if 2:

• Corneal infiltrates present, particularly if central, large, or with stromal involvement
• ≥1+ cells in anterior chamber
• Multiple corneal infiltrates or atypical features

Mandatory Follow-Up Requirements

All patients require ophthalmology follow-up within 24-48 hours after foreign body removal to monitor for infection development 2, 3, 7. This is non-negotiable.

Return Precautions—Instruct Patient to Return Immediately For:

• Worsening pain or vision 2, 3, 7
• Increasing redness 2, 3, 7
• Discharge or purulent material 2, 3, 7
• Persistent foreign body sensation despite treatment 2, 3, 7

Common Pitfalls to Avoid

• Missing intraocular foreign body in high-velocity injuries—always obtain CT imaging if metallic foreign body suspected 3, 5, 6
• Failing to evert eyelids—retained foreign bodies on tarsal conjunctiva are commonly missed 2
• Inadequate follow-up—corneal abrasions and foreign body removals can develop infectious keratitis within 24-48 hours 2, 7
• Attempting removal of embedded foreign bodies without proper equipment—this requires slit-lamp and topical anesthesia 7
• Not documenting visual acuity—this is medicolegally essential and guides management 2, 3