Removal of foreign body from eye

Foreign body in eye is a very common presentation seen in the emergency department. Patients often complain of a foreign body sensation in the eye and pain on eye movement or on blinking. There may be a history of trauma or using tools, but it can also be caused by things such as eyelashes in the eye causing this foreign body sensation. Metal can often be very adherent and difficult to remove from the cornea and we will look at steps to remove foreign body in more detail below.

History

  • Mechanism of injury.
  • The use of any eye protection when the incident happened.
  • Any change in vision.
  • Symptoms such as photophobia, pain and discharge.

It is important to take a careful history of the mechanism of injury to preclude any possibility of orbital or intraocular involvement as this will affect the immediate management plan. A history of high-velocity injury such as explosion or striking of metal upon metal should raise a high index of suspicion for orbital or intraocular foreign bodies. In these instances, patients will require an urgent referral to the ophthalmologist for further imaging tests to minimise the risk of missing a retained orbital or intraocular foreign body which is associated with serious complications that can lead to irreversible blindness.

Examination steps
  • look to see if any visible foreign body can be seen.
    • It can be obvious in many patients but sometimes it requires a slit lamp to do so.
  • Check the visual acuity, visual field, ocular movement, and pupillary reflexes.
  • Look at the eye under the slit lamp with white light
    • Observe the conjunctiva and the cornea.
    • Make sure to also look under the upper and lower eyelids (see image 1) as that is where foreign body such as eyelashes can sit, giving the foreign body sensation.
  • Next, instil one drop of local anaesthetics eyedrop (e.g., proxymetacaine 0.5% or tetracaine 0.5%) and one drop of 0.25% fluorescein eyedrop to the affected eye.
    • Now observe for corneal staining with blue light under the slit lamp.
If a foreign body has been confirmed

If the presence of a foreign body is confirmed, use a cotton bud which has been moistened in 0.9% sodium chloride solution to gently remove the foreign body away from the corneal surface. It takes practice and much patience to do this as it involves good hand-eye coordination using the slit lamp whilst removing the foreign body. If it is not successful, a needle may be used to remove the foreign body under appropriate magnification and if you are trained and feel confident in doing it (see image 2).

Follow up

  • Once foreign body is removed, patient is sent home with a seven-day course of chloramphenicol eye ointment, to be used four times a day and a follow up appointment with an Ophthalmologist in the next few days to assess for any leftover foreign body, any signs of inflammation or infection.
  • If there is a significant rust ring from a metallic foreign body the patient may need onward ophthalmology review to consider debridement and removal.
  • It is always good practice to hand out patient information leaflet on foreign body in eye to patient.
  • Remember to always safety net patient to seek immediate medical attention if sight suddenly deteriorates and offer advice to wear eye protection to prevent another injury in the future.
  • It is also useful to ask patient to get over-the-counter lubricative eyedrops and oral analgesia if needed to ease the discomfort of the eye due to corneal abrasion.
image 3
Image 1: Method for upper eyelid eversion (source)
image 4
 
Image 2: Removing corneal foreign body with a needle (source)

References

  1. Moorfields – Corneal Foreign Body
  2. MSD Manuals – Eye Injuries – Hyphema
  3. Moorfields – Ocular Foreign Body
  4. Eyewiki – Orbital Foreign Body

Written by Dr Marjorie Su Yin Teo (GPST1) & reviewed by Mr Ernest Lim (ST4 Ophthalmology)

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