What is the proper method to remove a foreign body from the eye?

Removal of Ocular Foreign Bodies

For superficial foreign bodies, begin with irrigation using sterile saline or tap water to flush loose material, then proceed to manual removal under topical anesthesia if the object remains embedded; however, any high-velocity injury, irregular pupil, vision loss, or suspected globe penetration requires immediate ophthalmology referral before attempting removal. 1, 2

Initial Assessment and Red Flag Identification

Before attempting any removal, you must identify vision-threatening injuries that mandate immediate specialist referral:

• High-velocity mechanisms (grinding, metal work, hammering) carry significantly elevated risk of globe penetration and require urgent ophthalmology consultation before any manipulation 1, 2
• Irregular pupil shape after trauma indicates penetrating injury—do not attempt removal 1, 2
• Eye bleeding (hyphema) or acute vision loss requires emergency referral 1, 2
• Visible corneal ulceration, haze, opacity, or purulent discharge are red flags necessitating specialist evaluation 1, 2
• Test and document visual acuity immediately to establish baseline function 1, 2

Stepwise Removal Protocol for Low-Risk Foreign Bodies

Step 1: Initial Conservative Measures

• Irrigate copiously with sterile saline (or tap water/commercial eye wash if sterile saline unavailable) to flush loose material first 1, 2
• Allow natural tears to assist in washing out the object 1
• Shield the eye with a hard plastic eye shield, paper cup, or similar barrier to prevent inadvertent touching 1, 2
• Instruct the patient never to rub the affected eye 2

Step 2: Topical Anesthesia for Embedded Objects

• Instill 1-2 drops of proparacaine hydrochloride 2-3 minutes prior to removal 3
• This provides adequate topical anesthesia for foreign body removal without requiring injection 3

Step 3: Examination Under Slit-Lamp

• Evaluate the corneal epithelium for defects, foreign body location, depth, and presence of rust ring under slit-lamp biomicroscopy 1, 2
• Apply fluorescein staining to identify epithelial defects and assess the extent of injury 1
• Evert the eyelid to inspect the tarsal conjunctiva for retained foreign bodies that may be causing persistent symptoms 1

Step 4: Manual Removal Technique

• For conjunctival foreign bodies: Remove with a moistened cotton-tipped applicator or gentle irrigation without anesthesia in most cases 4
• For superficial corneal foreign bodies: Use a sterile cotton-tipped applicator or fine forceps under slit-lamp visualization after topical anesthesia 1, 4
• For embedded corneal foreign bodies: A 25-gauge or 27-gauge needle can be used to gently lift the foreign body from the corneal surface under slit-lamp magnification 4
• If the foreign body is deeply embedded or you lack experience with removal, refer to ophthalmology rather than risk corneal perforation 1, 5

Step 5: Rust Ring Management

• Metallic foreign bodies often leave rust rings that require removal to prevent ongoing inflammation 1, 4
• Rust rings should be assessed and removed by ophthalmology within 24-48 hours if not completely removed during initial foreign body extraction 1

Post-Removal Treatment Protocol

Antibiotic Prophylaxis

• Apply broad-spectrum topical antibiotic such as moxifloxacin 0.5% four times daily or gatifloxacin after foreign body removal 1, 5
• This prevents secondary infection of the corneal epithelial defect 1, 5

Pain Management

• Topical NSAID (ketorolac tromethamine) for pain, photophobia, and foreign body sensation 1, 5
• Cycloplegic agent (cyclopentolate) to reduce ciliary spasm pain and anterior segment inflammation 1, 5
• Oral acetaminophen or NSAIDs for additional systemic pain relief 1, 5

What NOT to Do

• Do not patch the eye—patching is not recommended for corneal abrasions and may increase infection risk 5
• Avoid topical anesthetics for home use—these delay healing and can cause severe corneal toxicity 4

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, 2
• Instruct patients to return immediately for: worsening pain or vision, increasing redness, discharge or purulent material, or persistent foreign body sensation despite treatment 1, 2

Special Considerations

Contact Lens-Related Injuries

• Immediately remove the contact lens and discontinue use 1, 2
• These patients require prompt medical assessment regardless of symptom resolution 2

Metallic Foreign Bodies

• Obtain cultures if there are associated infiltrates, ≥1+ anterior chamber cells, multiple corneal infiltrates, or atypical features 1
• CT scan is required if there is any concern for intraocular metallic foreign body 2

When to Refer Before Attempting Removal

• Suspected intraocular foreign body 5
• Foreign body projecting into the anterior chamber 6
• Central corneal location with significant stromal involvement 1
• Lack of adequate equipment (slit lamp) or experience 1