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Referral and warning signs
When to refer
Refer URGENTLY to Eye Specialist (Ophthalmologist) / HC4 with eye care capacity if: Unable to remove the foreign body. Suspected penetrating intraocular or intraorbital foreign body (history of high velocity injury, abnormal pupil, low vision, blood in anterior chamber). Significant corneal abrasion or ulcer. Presence of a rust ring. Chemical burn (after initial copious irrigation). Persistent pain or blurred vision after removal. Significant reduction in visual acuity.
Red flags
- Suspected penetrating injury (mechanism, wound, irregular pupil, hyphema)
- Inability to remove FB
- Significant decrease in visual acuity
- Large or central corneal abrasion/defect
- Signs of infection (purulent discharge, corneal infiltrate)
- Severe chemical exposure (especially alkali burns)
- Persistent symptoms despite removal
Signs and symptoms
- Foreign body sensation ('something in the eye')
- Pain (often sharp, worse with blinking)
- Tearing (epiphora)
- Redness (conjunctival injection)
- Photophobia (light sensitivity)
- Blurred vision (if cornea involved or excessive tearing)
- Visible foreign body (may be on cornea, conjunctiva, or under eyelid)
Risk factors
- Windy conditions (dust, debris).
- Occupational exposure (grinding metal, cutting wood, construction) without eye protection.
- Outdoor activities (insects, plant matter).
- Contact lens use.
- Chemical splashes.
Diagnosis
Clinical assessment
Based on history of exposure and symptoms. Careful examination is key: - Visual Acuity check (before manipulation/irrigation). - Inspection of cornea and conjunctiva (use good lighting, magnification if possible). Look for FB, abrasions, rust ring (metal FB). - Evert upper eyelid to check for FB hidden underneath (double eversion sometimes needed). - Fluorescein staining (with cobalt blue light) highlights corneal abrasions or tracks.
Investigations
- Visual acuity testing.
- Slit lamp examination (Ophthalmologist/Specialist level) provides detailed view.
- Consider orbital X-ray or CT if suspected intraocular or intraorbital penetrating foreign body (high velocity injury).
Diagnostic criteria
Clinical finding of a foreign body on the ocular surface or under the eyelid, or symptoms highly suggestive even if FB not visualized (may have caused abrasion).
Management
Non-pharmacological management
- Superficial Foreign Body Removal: Attempt gentle irrigation with sterile saline or clean water first.
- If irrigation fails, use a moistened cotton-tipped applicator (thin 'finger' of cotton wool per UCG) to gently lift/sweep the FB off the conjunctiva or cornea (use topical anesthetic drop like Tetracaine first if available).
- Foreign body spud or fine needle (by trained personnel, ideally with magnification/slit lamp) may be needed for embedded corneal FBs.
- Evert eyelid to remove FBs trapped underneath.
- Chemical Splash: Immediate and copious irrigation with sterile saline, Ringer's Lactate, or clean water for at least 15-30 minutes. Use eyelid retractors if needed. Check pH (aim 7.0-7.4) and continue irrigation until neutral.
Pharmacological treatment
- Topical Anesthetic: (e.g., Tetracaine, Proparacaine) 1-2 drops to facilitate examination and removal. Do NOT dispense to patient.
- Antibiotic Ointment/Drops: After FB removal, especially if corneal abrasion present. Apply Chloramphenicol or Tetracycline eye ointment 1% (UCG rec) or Erythromycin ointment, or drops (e.g., Ofloxacin, Ciprofloxacin) QID for 3-5 days.
- Cycloplegic Drops: (e.g., Cyclopentolate 1%) may be used for photophobia/pain associated with larger corneal abrasions (relaxes ciliary muscle).
- Analgesia: Oral analgesics (Paracetamol, NSAIDs) if significant discomfort.
- Tetanus Prophylaxis: Consider if injury from contaminated object.
Monitoring
Follow-up needed if significant corneal abrasion, persistent symptoms, or risk of infection. Typically review in 24-48 hours to ensure healing and rule out infection/retained FB.
Complications
- Corneal abrasion
- Corneal ulcer / Infectious keratitis
- Corneal scarring / Opacity
- Uveitis / Iritis
- Retained foreign body (subtarsal, corneal)
- Rust ring (from metallic FB)
- Penetrating eye injury (if high velocity)
- Chemical keratitis/conjunctivitis (from splashes)
Prevention
- Wear appropriate safety glasses or goggles during high-risk activities (grinding, welding, cutting, construction, gardening, chemistry work).
- Use face shields.
- Wear sunglasses outdoors in windy conditions.
Patient education
- Explain how the FB was removed.
- Instruct on use of antibiotic ointment/drops.
- Advise on symptoms warranting return (increasing pain, decreased vision, discharge).
- Reinforce importance of eye protection for prevention.
Uganda-specific notes
Access to magnification (slit lamp) and specialized removal tools may be limited. Thorough irrigation and gentle removal with cotton bud are key first steps. Tetracycline eye ointment is recommended by UCG. Early referral for embedded corneal FBs, rust rings, or suspected penetration is crucial to preserve vision.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 20, Section 20.3.1