Preparation

• Gloves
• Fluorescein stain
• Ophthalmic anesthetic drops (e.g., tetracaine)
• Ophthalmoscope
• Slit lamp or loupes
• Cotton-tipped applicator
• Sterile saline with plastic syringe
• Sterile 25-27 gauge needle placed onto a 3mL syringe (or insulin needle/syringe)

Procedure Steps

Step 1: Health history and physical assessment

Assess timing of the complaint, mechanism of injury, eye surgeries, prescription drop use, corrective glasses/contact lens use. Anesthetize as needed to facilitate a thorough eye examination.

Physical assessment:

• visual acuity (Snellen eye chart, near vision)
• visual fields (confrontation test)
• extraocular muscle function (corneal light reflex, cover test, cardinal positions of gaze)
• external eye structures
• anterior eyeball structures (cornea and lens, iris and pupil)
• ocular fundus (elicit red light reflex at minimum)

Step 2: Instill ophthalmic anesthetic drops

Anesthetic can make assessment of the pupils and fundus difficult due to pupillary constriction.

Pull down on the lower eye lid to create a well. Tilt the patient’s head back and instill 1-2 drops. Have the patient blink to distribute the drops. Instill just prior to evaluation.Tetracaine: onset of action 30 seconds; duration of action 10-20 minutes.

Step 3: Instill fluorescein stain

The fluorescein stain examination should only be completed after the assessment of visual acuity, penlight examination of the pupils, and the fundus.

Pull down the lower lid and allow a drop of the fluorescein stain to run off into the eye. Have the patient to blink to distribute the dye over the ocular surface.

Step 4: Inspect the cornea

Stained abrasion appears yellow with the naked eye; visualization is enhanced with the use of a cobalt blue filter on an ophthalmoscope. There is increased uptake of the dye by the abrasion or ulcer. Abrasions appear linear and ulcers appear rounded and crater-like.

Step 5: Assess for retained foreign body under the upper lid

• Ask patient to keep both eyes open and look down to keep the eyelid relaxed.
• Slide upper lid along the bony orbit to life up the eyelashes.
• Grasp the eyelashes between your thumb and forefinger and pull down and outward.
• Use the other hand to place the cotton-tipped applicator on the upper eye lid.
• Push down with the stick as the lashes are lifted up to flip the upper eyelid inside out. Do not push on the eyeball with the stick.
• Maintain the everted position by holding the lashes against the bony orbit rim.
• Inspect for foreign bodies, color changes, swelling, or lesions.

Step 6: Remove superficial foreign body from cornea or conjunctiva

• Do not apply pressure as this may further embed the foreign body or scrape the cornea.
• Ensure eye is adequately anesthetized to facilitate comfort and cooperation.
• Position patient supine and have them fix their gaze.
• Irrigate eye with sterile saline to moisten cornea.
• Use a wetted cotton-tipped applicator and gently rolling motion to remove the foreign body.

Step 7: Remove embedded foreign body

• If you do not have access to adequate resources (e.g., slit lamp or loupes) and cannot see the foreign body clearly with magnification, refer to ophthalmologist to prevent globe penetration or further damage to the cornea. Do not approach the globe with a sharp instrument if you are uncomfortable or untrained in this procedure. Ensure eye is adequately anesthetized to facilitate comfort and cooperation.
• Position patient supine and have them fix their gaze.
• Hold the syringe and needle with your thumb and index finger of your dominant hand.
• Steady your hand by resting the ulnar side of your hand and fifth finger on the patient’s head near the inferior orbital rim.
• Face the bevel toward you and approach the eye using a tangential approach.
• Gently attempt to flick the foreign body out of the cornea. Do not dig deeply into the cornea.
• If the foreign body sticks superficially, remove with wetted cotton-tipped applicator.

Step 8: Prescribe topical antibiotic therapy to prevent superinfection and lubricate the eye

Avoid use of antibiotic preparations that contain corticosteroids as this can delay healing.

Non contact lens wearers: Erythromycin ointment QID x 3-5 days
Contact lens wearers: Choose antibiotic with pseudomonas coverage such as a fluoroquinolone

Step 9: Assess tetanus status

For any patient with any injury that penetrates the cornea or sclera.

A tetanus booster dose is required if the patient has not had a tetanus booster in the last ten years. The combined preparation of tetanus and diphtheria toxoid formulated for adults (Td) is preferred. If the patient has not received pertussis since childhood then tetanus, diphtheria, pertussis (TdP) should be given. If the wound is excessively dirty, tetanus immune globulin should also be given. See Tetanus immune globulin in the Canadian Immunization Guide (recent edition) for further information.

Aftercare

• Oral NSAIDs for pain relief.
• Avoid rubbing the eye to prevent further damage.
• Avoid use of contact lenses until symptoms have resolved.
• Small corneal abrasions are self-limited and typically heal within 24-48 hours.
• Avoid use of eye patches as they slow healing and cause blurred vision; evidence shows lack of proven benefit.

Patient Education

Follow-up

• Consider daily follow-up for large corneal ulcers due to increased risk of secondary bacterial infection.
• Return if symptoms persist beyond 48 hours.
• Return if symptoms continue to worsen in the initial 24-48 hours.
• Pediatric patients who are unwilling to open their eye after 24 hours should be referred to ophthalmology.

Key Takeaways

• If you do not have access to adequate resources (e.g., slit lamp or loupes) and cannot see the foreign body clearly with magnification, refer to ophthalmologist to prevent globe penetration or further damage to the cornea.
• Do not approach the globe with a sharp instrument if you are uncomfortable or untrained in this procedure.
• Patient presentation of corneal abrasions is similar to that of foreign bodies.
• Assess tetanus status following any injury that penetrates the cornea or sclera.
• Optic antibiotics are required to prevent superinfection following foreign body removal from the eye.