Foreign Bodies

Patients regularly present in practice complaining of foreign body sensation in their eyes and it is vitally important that detailed questioning takes place to ascertain the events leading up to the problem- this will help with a tentative diagnosis of the concern.

Many foreign body sensations can be linked to dry eye (see dry eye section of this A-Z for diagnosis and treatment options) but it is important that underlying diagnosis of dry eye does not rule out the possibility of a foreign body. Many other conditions such as corneal ulcers, epithelial erosions etc will give rise to foreign body sensation and this is where questioning of the patient will help. Consider the following questions:

• What activity were you doing when this happened?
• Were you wearing eye protection?
• What material were you handling?
• Has this happened before/is this a regular occurrence?
• Where were you when you first noticed this?

Many minor eye conditions/CUES pathways have triage forms which can help in the management of patients presenting with foreign body sensation.

Signs/Symptoms:

• Discomfort/pain
• Epiphora
• Reduced VAs
• Red/pink eye
• Discharge/sticky eye/lid crusting
• Photophobia
• Usually monocular
• Bullous subconjunctival haemorrhage
• Positive Seidel Test (Seidels test is performed using fluorescein to ascertain if the foreign body has caused perforation of the globe/cornea)
• Signs of “rust ring”- these are usually apparent under slit lamp exam sometimes after the original foreign body has been removed.
• Corneal stromal oedema
• Sectorial hyperaemia (may help point to the area where the foreign body is positioned)

Differential Diagnosis:

• Corneal ulcer
• Concretion
• Dry eye

Causes:

• Any object that is not naturally part of the eye’s structure would be considered to be a foreign body
• Can range from high speed debris entering the eye (from metal grinding for example) to debris from mascara, wind born dust, damaged contact lenses etc.
• It is vital that detailed questioning of the patient takes place to understand and isolate the cause of the foreign body- this will lead to a tentative plan of action to be taken and flag up when emergency referral needs to take place.

Treatment:

• Is dependent on outcome of detailed patient questioning
• Will vary dependant on both the type of suspect foreign body- metal, non-ferrous, plastic or organic and the speed- windborne or high speed grinding/drilling etc
• Always record VAs before any intervention!
• If a penetrating injury is suspected- emergency referral is always the most appropriate action.
• For non- metallic, low speed foreign bodies a suitably accredited eye care practitioner (ECP) may attempt examination and removal using a range of anaesthetics and suitable equipment for removal. This may include but not be limited to saline rinses, cotton buds, PVA spears, and needles. The ECP must hold accreditation and indemnity insurance specific to the procedures they wish to undertake and must always work within their capabilities.
• Any foreign body that is central on the cornea i.e. within the visual axis area should be referred if it cannot be dislodged with a saline rinse. Removal of foreign bodies in the central corneal area may lead to scarring and permanent loss of vision and therefore should not be attempted- referral following local criteria should take place.
• Organic foreign bodies such as wood, garden debris, plant material eye should be treated with caution due to the risks associated with fungal infections of the globe.
• Anterior chamber should always be checked for secondary infections/cells/flare.

Central corneal foreign body- due to position this would be referred to HES.

Demonstration of needle to removed foreign body

Additional information:

Extended Services accredited CLOs can carry out foreign body removal if they feel it is within their capabilities. Instillation of any anaesthesia must be carried out with an optometrist on the premises. This is not for the purposes of supervision but to comply with present MHRA regulations.
Referral for prophylactic antibiotics should be considered where appropriate.

Red Flags:

• Organic foreign bodies.
• Centrally positioned.
• Penetrating.
• Rust rings- removal of rust rings is normally considered a secondary care decision.
• Anterior chamber reaction.
• Drop in VA

Red Flags: When one or more of these red flags is raised, a conversation with another registrant in practice should take place following which appropriate referral or management should be actioned and noted. If there are no other registrants in practice then contact should be made with colleagues elsewhere or contact should be made for advice to the local Hospital Eye Service.