American Society of Ophthalmic Trauma Pilot · In development

Management by diagnosis  /  Corneal foreign body

EmergencyQuick reference

Corneal foreign body

A point of care reference for the clinician seeing the patient first. It follows the same four steps as Where Do I Start, so the assessment you do here is the assessment the ophthalmologist will ask for.

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.

Intraocular pressure

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.

Pupillary exam

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

Imaging is recommended in a high force injury that might lead to intraocular, intraorbital, or periorbital penetration and injury.

Foreign bodies from grinding, yardwork, and wind often do not require additional imaging.

5

Treatment

Remove 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.

If the depth cannot be determined with the instrumentation available, prevent 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.

Additional foreign bodies are often found on lid eversion with a Q-tip at the bedside. If the patient still reports a foreign body sensation despite what appeared to be a complete removal, anesthetize the ocular surface with proparacaine, then evert and sweep the palpebral conjunctiva.

A clinician trained in the procedure may remove the foreign body at the bedside slit lamp using a 30G needle, corneal spud, sterile Q-tip, corneal burr, or other appropriate tool.

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

Treat with a topical fluoroquinolone ophthalmic antibiotic such as ofloxacin, ciprofloxacin, or moxifloxacin.

Arrange ophthalmology follow up in one to two days for complete excision, additional recommendations, and ongoing follow up.

Red flags

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

Clinical content by Kristen Hawthorne, MD. Draft for committee review.