A point of care reference for the clinician seeing the patient first, in the same four steps as Where Do I Start.
The first five minutes
Check vision, pressure, and pupils. Significant visual decline points to a more significant pathology.
Anesthetize, then evert and sweep the lid. Additional foreign bodies are often found this way.
View the cornea at the slit lamp. You are determining the depth of involvement.
Do not attempt removal if untrained, or if it sits near the visual axis. Scarring there costs vision.
Fluoroquinolone drops, ophthalmology in one to two days. Even if you got it out.
1
Pertinent questions when taking the history
What was the mechanism of injury?
What was the timing, meaning when did the injury happen?
Has the patient been treating with anything at home, over the counter, or from another facility?
Can you rule out an orbital or intraocular foreign body?
Is additional imaging necessary? It is not usually needed for small pieces of metal from grinding accidents. Imaging is more commonly needed when the foreign body comes from a higher force hammer, power tool, or pressure instrument.
Could there be a chemical component to the injury?
2
Visual vital signs
Vision, pressure, and pupils, recorded and handed off like any other vital sign. In a corneal foreign body they are also how you decide whether this is what it looks like.
Visual acuity
Check vision with the patient's usual glasses. Vision will usually be slightly decreased from a foreign body. Significant visual decline suggests a more significant pathology.
Usually unaffected by a corneal foreign body. Checking with a tonopen is appropriate once open globe has been excluded. Very high or very low pressure points to an alternate pathology.Do not check if open globe is suspected.
The pupil may be slightly constricted as a compensatory response to inflammation from the injury, but an afferent pupillary defect should not be present. An APD suggests alternate or additional pathology.
3
Describe the focused anatomy
Size and location of the foreign body, and the suspected composition of the material.
Concurrent corneal abrasions or conjunctival injuries should be described and observed.
Confirm the anterior chamber is formed and there is no irregularity of the pupil.
Evert the eyelid to check for additional foreign bodies.
After placing proparacaine or tetracaine, consider sweeping the lower and upper lid fornices if additional foreign bodies or debris are suspected.
4
Supporting imaging, if needed
ImageIn a high force injury that might lead to intraocular, intraorbital, or periorbital penetration and injury.
Usually no imaging neededForeign bodies from grinding, yardwork, and wind often do not require additional imaging.
5
Treatment
Removal at the bedsideRemove the foreign body if you are able to do so at the bedside and it is not embedded within the cornea. View the cornea with a bedside slit lamp to determine the depth of involvement.
InstrumentsA clinician trained in the procedure may remove it at the bedside slit lamp using a 30G needle, corneal spud, sterile Q-tip, corneal burr, or other appropriate tool.
If you cannot determine the depthPrevent infection with a topical ophthalmic fluoroquinolone such as ciprofloxacin 0.3% or ofloxacin 0.3%, one drop four to six times daily into the affected eye, and arrange ophthalmology follow up in one to two days for complete foreign body removal.
If foreign body sensation persistsAdditional foreign bodies are often found on lid eversion with a Q-tip at the bedside. Anesthetize the ocular surface with proparacaine, then evert and sweep the palpebral conjunctiva.
Do not attempt removal if
the examining clinician is unfamiliar or untrained in the procedure, the foreign body sits close to the visual axis, or additional scarring or corneal damage is likely to result from the manipulation.
6
Follow up
AntibioticTreat with a topical fluoroquinolone ophthalmic antibiotic such as ofloxacin, ciprofloxacin, or moxifloxacin.
IntervalArrange ophthalmology follow up in one to two days for complete excision, additional recommendations, and ongoing follow up.
Red flags
Irregular pupil.
Very elevated or very low intraocular pressure.
Extensive subconjunctival hemorrhage.
Excessive pain that does not relieve with proparacaine or tetracaine.
Foreign body sensation that persists despite removal of the object, which may mean another object is lodged in the fornices.
High pressure or high impact injuries.
Vision that seems much worse than the injury and clinical findings would suggest.
When a red flag is not explained by the examining clinician, consider additional consultation with ophthalmology for point of care triage guidance.
Additional resources
Where an ASOT resource covers this diagnosis in greater depth, it will be linked here.
Manual of Ophthalmic Emergencies and Trauma reference to be added on publication. In development