Foreign Body in the Eye: Emergency Assessment, Safe Removal and Trauma Care

A foreign-body sensation may come from loose dust under an eyelid, a particle embedded in the cornea, or a high-speed fragment that has entered the globe. The emergency clinician must first decide whether the eyewall is intact. That decision determines whether it is safe to irrigate, evert the lid, instil examination drops or remove anything. This guide covers the complete supplied 20-slide presentation and adds a practical emergency approach to blunt, penetrating, chemical, thermal, ultraviolet and foreign-body injuries.

Learning objectives

• Define an ocular foreign body and classify eye trauma using open-globe versus closed-globe terminology.
• Recognize the mechanisms that produce corneal, conjunctival, orbital and intraocular foreign bodies.
• Identify symptoms and signs that suggest perforation, retained intraocular foreign body, orbital compartment syndrome, chemical injury, infection or retinal damage.
• Carry out a structured, safe assessment, including mechanism-focused history, visual acuity, pupil function, motility and slit-lamp examination when appropriate.
• Distinguish a superficial foreign body that a trained clinician may remove from a deep, central or penetrating object needing ophthalmology.
• Describe immediate first aid for chemical and thermal burns and safe protection of suspected open globe.
• Plan nursing assessment, symptom support, patient education and follow-up while avoiding pressure, unsafe patching or delayed referral.

1. What counts as an ocular foreign body?

A foreign body (FB) is material from outside the body that enters or adheres to the ocular surface or tissues. It may lie on the conjunctiva, hide in a lid fornix, embed in the corneal epithelium or stroma, penetrate the eyewall into the anterior or posterior segment, or pass into the orbit without entering the globe. Common materials include dust, sand, grit, metal, glass, wood, plant matter, plastic, cement and fragments of tools or projectiles. The location and mechanism are at least as important as the object’s size: a tiny metallic particle travelling at high speed can perforate the globe, while a larger loose eyelash may cause irritation only.

Symptoms depend on location and depth. A surface particle may cause foreign-body sensation, tearing, blinking, pain and photophobia. A deeper corneal FB may cause focal pain, reduced vision or a visible rust ring. A penetrating object can produce little pain initially despite serious damage. Orbital FBs may present with a wound, bruising, restricted movement, proptosis, infection or delayed inflammation. Absence of pain, a small entry mark or a nearly normal external appearance does not rule out an intraocular FB.

2. Classify trauma before touching the eye

The Birmingham Eye Trauma Terminology System separates injuries by whether the eyewall is full-thickness disrupted. The eyewall consists of cornea and sclera.

Use “open globe” as a clinical emergency category, not as a label to prove at the bedside by pressing or manipulating the eye. A peaked pupil pointing toward a wound, uveal prolapse, visible full-thickness defect, abnormal anterior-chamber depth, irregular/deformed globe, dense 360-degree subconjunctival haemorrhage or high-velocity mechanism should increase suspicion. A negative Seidel test does not exclude a self-sealed or posterior wound. If uncertain, protect the eye and discuss urgently with ophthalmology.

3. Mechanisms and pathophysiology

Ocular trauma can follow road traffic collisions, assault, falls, sports, farm or construction work, household cleaning, animal injury, explosions, firearms, welding and recreational activities. Blunt objects include fists, balls, sticks and falling objects. Sharp lacerations can be caused by glass, metal, a knife, scissors, nails, pencils, cosmetic tools, fingernails or animal claws. High-speed fragments commonly result from hammering or grinding metal-on-metal, drilling, mowing, explosions and industrial machinery. Foreign bodies may also be blown by wind, sand, soil, plants or construction debris.

Blunt impact briefly compresses the globe from front to back and expands it sideways. This can damage the orbit and any ocular layer, causing bruising, hyphema, iris tears, lens subluxation, angle recession, vitreous haemorrhage, retinal dialysis or detachment, optic-nerve injury and occasionally inside-out globe rupture. A blow to the bony orbit may cause a floor or medial-wall fracture, muscle entrapment, orbital emphysema or retrobulbar bleeding. If pressure rises within a confined orbit, perfusion to the optic nerve and retina falls; orbital compartment syndrome can cause rapid permanent visual loss.

Acids generally cause coagulative damage at the ocular surface, while alkalis can saponify cell membranes and penetrate more deeply. The distinction does not make acid burns safe: either can destroy the cornea, limbus and conjunctiva. The time until effective irrigation is a key determinant of injury. Heat may burn lids, conjunctiva or cornea; ultraviolet radiation can cause delayed epithelial injury, and lasers or ionizing radiation can injure deeper tissue. Repeated rubbing of a surface FB may enlarge an epithelial defect, and iron can begin depositing a rust ring within hours.

4. Emergency priorities: life first, then sight

Use the trauma primary survey for a patient with major injury: airway, breathing, circulation, cervical spine and neurologic status come before a long eye examination. Look for head injury, facial fractures, haemorrhage, inhalation burns and associated limb or chest injuries. Document the time, location and mechanism, especially the speed and direction of a projectile, the activity being performed, eye protection, suspected chemical and first aid already given. Ask about pain, photophobia, tearing, blur, diplopia, flashes, floaters, a field curtain, nausea, headache and loss of consciousness. Record previous ocular surgery, contact-lens use, baseline vision, medicines such as anticoagulants, allergies and tetanus status.

1. Stabilize and protect: manage systemic threats and prevent further contamination. If open globe is possible, use a rigid shield without pressure and avoid manipulation.
2. Record visual acuity in each eye as early as feasible: use habitual correction and a chart; if unavailable, document counting fingers, hand movement, light perception or no light perception. Do not delay chemical irrigation to measure vision.
3. Compare pupils and function: note pupil shape/reactivity, relative afferent pupillary defect, eye movements, diplopia and visual fields when safe. Do not force the lids apart if there is a suspected wound or protruding object.
4. Inspect the face and orbit: look for bruising, wounds, proptosis, enophthalmos, emphysema, lid margin injury, embedded material and signs of orbital fracture.
5. Exclude possible open globe before drops, pressure or contact procedures: when suspected, do not perform tonometry, gonioscopy, forceful lid eversion, pressure patching, ocular ultrasound or routine fluorescein manipulation.
6. Examine the surface only when safe: slit lamp, fluorescein, lid eversion and fornix inspection help identify a superficial FB and corneal abrasion. Check anterior chamber, lens and fundus when injury permits.
7. Image and refer: obtain CT when fracture, IOFB, orbital injury or open globe is suspected and it will affect care. Do not let imaging delay urgent specialist contact or transfer.

5. Red flags and disposition

6. Superficial conjunctival and corneal foreign bodies

Examination when the globe is intact

Ask what the object was, when and how it entered, the activity and speed, whether eye protection was worn, and whether any material remains. Soil or plant material raises concern for bacterial or fungal infection; metal may rust; glass and fiberglass may be difficult to see. Check visual acuity first when feasible. Under good light or slit lamp, inspect the cornea and conjunctiva, measure the defect, note depth and location, and use fluorescein to identify epithelial loss. Evert the upper lid when safe and trained: a small particle hidden under the lid can scratch the cornea with every blink and create vertical linear staining. Inspect the fornices for fragments, taking care not to press on a possibly ruptured globe.

What can be removed, and by whom?

A loose particle can often be rinsed away with sterile saline or clean water once open globe has been excluded. A very superficial, freely mobile particle may be lifted with a moistened sterile applicator by a trained clinician. A superficial corneal FB is usually assessed and removed under magnification at a slit lamp by a clinician trained in the procedure. A topical anaesthetic may be instilled in the clinic/ED to permit examination or clinician-performed removal; do not send the patient home with repeated-use anaesthetic drops. A magnetic spud is a controlled ophthalmic instrument, not a reason to bring a handheld magnet near an injured eye.

Do not attempt removal when the object is embedded deeply, central over the visual axis, large, multiple, poorly visualized, associated with a rust ring near the visual axis, near the limbus, suspected to penetrate, or when the patient cannot cooperate safely. Never probe a wound or remove a protruding object. A deep FB may need removal under an operating microscope to reduce perforation risk. Some inert glass or fiberglass fragments may be observed by an ophthalmologist if attempting removal would cause greater damage; this is a specialist decision.

After a clinician removes a surface FB, re-examine the cornea for residual fragments, measure the epithelial defect and assess its depth. Fluorescein can help reveal abrasion; Seidel testing is appropriate only if safe and a deep residual defect raises concern. Check the anterior chamber, pupil and vision again. If a metallic FB leaves a rust ring, its removal must be balanced against corneal damage; avoid aggressive digging. Set a clear follow-up plan, generally within days and sooner for central, deep, infected or high-risk injuries. Return immediately for worse pain, blur, photophobia, redness, discharge or failure to improve.

Complications of a corneal FB

Complications include epithelial abrasion, recurrent erosion, corneal infection, ulceration, stromal infiltrate, rust ring, scarring, irregular astigmatism, corneal melt, perforation and, rarely, endophthalmitis if the globe was penetrated. Iron may leave a rust deposit after several hours; an organic fragment can carry microbes and promote aggressive infection. Contact lenses increase concern for bacterial keratitis. A central scar may permanently reduce vision. Pain out of proportion, reduced vision, a white corneal infiltrate, hypopyon or worsening symptoms needs urgent reassessment rather than repeated surface removal.

7. Intraocular and orbital foreign bodies

An IOFB may enter through the cornea or sclera after metal-on-metal work, a projectile, explosion or penetrating object. A tiny, self-sealed entry wound is possible. Inspect for focal corneal oedema, an irregular pupil, iris transillumination defect, hyphema, lens opacity or instability, vitreous haemorrhage and retinal damage when safe. A negative Seidel test does not rule out a sealed entry. A foreign body can injure tissue mechanically, carry organisms, trigger endophthalmitis or cause metal toxicity. Retained iron may cause siderosis bulbi; copper may cause chalcosis. Organic material can be heavily contaminated and may carry bacterial or fungal infection risk.

For suspected IOFB, place a rigid shield without pressure and get urgent ophthalmology involvement. Thin-slice noncontrast CT of the orbits is generally the first-line imaging study for metallic or glass fragments and orbital fractures. Small, low-density wood or plastic may be difficult to detect; a negative CT does not prove that no FB is present. Plain X-rays detect only some radiopaque material. MRI must not be used until ferromagnetic metal has been definitively excluded because magnetic force can move a fragment and cause further injury. Do not use B-scan ultrasound over a suspected open globe; after the globe has been repaired or ophthalmology has determined contact imaging is safe, ultrasound may help assess posterior injury.

IOFB removal, globe closure, intravitreal antimicrobial treatment, vitrectomy and retinal repair are specialist surgical procedures. The priority is to protect and close the globe and address infection risk, not to extract an object at the bedside. An orbital FB may remain outside the globe, but can still damage the optic nerve, muscles, vessels or sinuses. Organic orbital material and contaminated wounds need urgent imaging and specialist assessment; do not blindly explore a deep tract.

8. Penetrating injury and suspected open globe

Open-globe injury can follow a sharp object, a high-speed fragment or blunt force that ruptures the eyewall. Findings can include a full-thickness corneal or scleral wound, uveal or vitreous prolapse, peaked pupil, abnormal chamber depth, irregular contour, extensive subconjunctival haemorrhage, hyphema, lens disruption, intraocular air or a visible entry object. Posterior scleral wounds may be concealed. Associated injuries can include lid/canalicular laceration, orbital fracture, traumatic brain injury, IOFB, retinal tear and endophthalmitis.

Do not apply a pressure dressing or tight eye pad. A loose non-pressure cover may be used only if a rigid shield is not immediately available and the object is not protruding, but a protective cup is preferred. Stabilize a protruding object in place and pad around it without pushing. Vomiting, coughing, squeezing and straining may increase pressure; control nausea and avoid unnecessary manipulation. Primary repair is generally urgent, commonly within 24 hours under current open-globe guidance. Whether an eye can be repaired or must be removed is a surgical decision; routine ED enucleation to prevent sympathetic ophthalmia is not appropriate.

9. Chemical injuries

Cleaning agents, bleach, drain cleaners, cement, lime, ammonia, industrial acids and alkalis can burn the ocular surface. Alkali often penetrates deeply, while acid may coagulate surface proteins; both can cause severe injury. Check the environment for hazards and protect rescuers. Remove contaminated clothing and brush dry cement/lime from skin or periocular area before it is washed into the eye. If chemical eye exposure is present and open globe is not suspected, irrigate immediately with clean tap water if saline or a balanced solution is not immediately available. Do not wait for visual acuity, pH paper, a slit lamp, transport or the product label. Do not neutralize acid with alkali or alkali with acid, and do not use milk, sugar, boric acid or another home antidote.

1. Begin continuous irrigation at once; saline, lactated Ringer’s or clean running water is appropriate for initial flushing.
2. Remove contact lenses as soon as possible. Direct fluid away from the unaffected eye, and have the patient blink and look in different directions.
3. After initial irrigation, a trained clinician should evert the lids and remove retained particles from the fornices, especially lime or cement. Persistent particles can keep changing pH.
4. Measure pH in the lower fornix of each eye after flushing, continue irrigation until near-physiologic pH, pause briefly and recheck for rebound. Irrigate again if pH drifts or debris remains.
5. Once pH is stable and globe integrity has been considered, assess acuity, pupils, cornea, conjunctival loss, limbal ischemia and anterior chamber; arrange urgent ophthalmology review for significant burns.

A topical anaesthetic can be used by a clinician to relieve blepharospasm and enable irrigation, but must not be prescribed for repeated use at home. A continuous irrigation lens may help in a suitable patient after open globe is considered. Chemical burns can lead to epithelial loss, limbal stem-cell failure, corneal melt, infection, scarring, symblepharon, dry eye, glaucoma, cataract and visual loss. Eye drops, fornix sweeping, anti-inflammatory therapy and ocular-surface reconstruction are determined by ophthalmology after irrigation has begun.

10. Thermal and ultraviolet burns

Heat from flame, boiling water, hot oil, steam, molten metal or an explosion may injure the eyelids, conjunctiva and cornea. Start with the trauma survey and assess associated facial burns, airway injury, inhalation exposure, blast trauma and open globe. Cool burnt skin according to burn-care protocols; do not put ice directly on the eye. Do not apply a pressure dressing. Reduced vision, corneal haze, epithelial injury, limbal damage, inability to close the eye or a mixed blast mechanism needs urgent ophthalmology and burn/trauma support. Antibiotic drops, analgesia, lid treatment or skin grafting depend on the injury and are not automatic for every heat exposure.

Ultraviolet photokeratitis can follow welding without a shield, a germicidal lamp, intense sun or reflected UV from snow/water. Symptoms are often delayed by several hours and may affect both eyes: severe pain, tearing, photophobia, blepharospasm and a gritty sensation. A trained clinician can confirm diffuse punctate epithelial staining after excluding retained FB, chemical exposure and open globe. Supportive lubrication and oral analgesia are commonly used; uncomplicated cases often improve as the epithelium heals over 24–72 hours. Reduced vision, unilateral symptoms, a contact lens, retained metallic FB, corneal opacity, worsening pain or failure to improve warrants urgent review. Do not send topical anaesthetic home or apply tight pressure patches. Prevent recurrence with properly rated welding eye protection or UV-blocking eyewear suited to the exposure.

11. Blunt trauma, orbital fracture and associated injuries

A blunt injury can produce eyelid bruising, conjunctival haemorrhage, corneal abrasion, hyphema, iris sphincter tears, lens displacement, vitreous haemorrhage, commotio retinae, choroidal rupture, retinal dialysis, optic neuropathy or globe rupture. New floaters, flashes, a curtain or field defect require urgent retinal assessment. Painful diplopia, restricted movements, cheek numbness, enophthalmos, subcutaneous emphysema or a facial fracture suggest orbital injury. Children can have an occult “white-eyed” trapdoor fracture with muscle entrapment, nausea, vomiting, bradycardia or pain on movement despite little bruising. Avoid nose blowing or forceful Valsalva when orbital fracture or emphysema is suspected.

Rapid proptosis, tense eyelids/orbit, reduced acuity or colour vision, RAPD and restricted movements after trauma suggest orbital compartment syndrome. It is a clinical emergency. A trained clinician may need immediate lateral canthotomy with inferior cantholysis once globe rupture has been considered; do not wait for a CT scan when the diagnosis is clinically evident. If a ruptured globe may coexist, obtain immediate ophthalmology and trauma assistance to determine the safest approach. A routine cold compress cannot treat orbital compartment syndrome.

12. Nursing assessment, diagnoses and care plan

Assessment

• Record mechanism, time, location, object/chemical, velocity, eye protection, first aid, contact-lens use, baseline vision, past eye surgery, allergies, medicines and tetanus status.
• Ask about pain, photophobia, tearing, blur, diplopia, flashes, floaters, field loss, headache, nausea/vomiting, discharge and foreign-body sensation.
• Measure vital signs and assess airway, breathing, circulation, neurologic status and associated facial/head injury.
• Document visual acuity in each eye when safe, pupil responses, RAPD, ocular movement and visible wounds or foreign bodies without pressing or forcing the eyelids.
• For chemical exposure, record the product if known, start time of irrigation, fluid used, pH and whether it remained stable after a pause.
• Report urgent changes immediately: falling vision, abnormal pupil, hyphema, proptosis, protruding object, severe pain, infection signs or inability to move the eye.

Priority nursing problems and responses

13. Safe management by presentation

Systemic antibiotics, topical antibiotics, cycloplegics, steroids, pressure-lowering medicine, surgery and admission depend on the injury, infection risk, local formulary and ophthalmology plan. Do not infer a drug regimen from the source slide list. In an open globe, antibiotics and repair are urgent but should follow the local eye-trauma protocol; topical drops should not be instilled unless the ophthalmologist directs them. Tetanus prophylaxis is considered for penetrating or contaminated wounds according to immunization history and national guidance.

14. Patient education and injury prevention

Explain the diagnosis being considered, what has and has not been ruled out, why some examination or removal steps must wait, and exactly where the patient will be reviewed. Give written instructions when possible. The patient should avoid rubbing or pressing the injured eye, keep the shield in place as directed, use only prescribed medicines and avoid contact lenses until cleared. Do not reuse another person’s drops. Explain return precautions: decreasing vision, worsening pain, photophobia, increasing redness, discharge, new flashes/floaters, a dark curtain, vomiting, proptosis, fever or failure to improve needs urgent reassessment.

Prevention is practical: use correctly rated safety glasses/face shields during grinding, hammering, drilling, mowing, metalwork and chemical handling; fit guards on tools; follow chemical label and workplace procedures; wear UV-rated welding filters; supervise children around projectiles and sharp objects; and use sports eye protection appropriate to the sport. Keep household cleaners and caustic products stored safely. After any serious injury, teach follow-up importance because infection, corneal scarring, cataract, angle-recession glaucoma, retinal detachment or sympathetic ophthalmia can appear later.

15. Case-based emergency application

Case 1: dust after sanding wood

A patient has tearing and a gritty feeling after sanding a plank. Vision is normal, pupils are round and there is no high-velocity tool injury or visible wound.

Approach: Check acuity in both eyes, inspect the surface and evert the upper lid when safe. Irrigate a loose particle. If fluorescein shows only a small uncomplicated abrasion and no FB remains, provide care according to local guidance and clear follow-up/return precautions. Wood and soil exposure raise infection risk if a penetrating fragment is possible; worsening pain, reduced vision or infiltrate needs urgent review.

Case 2: metal-on-metal grinding

A grinder develops a small red eye and mild blur after a metal chip struck him. There is a pinpoint corneal mark and an irregular pupil.

Approach: Assume possible open globe/IOFB despite the small mark. Do not use a needle, handheld magnet, pressure, tonometry or ocular ultrasound. Apply a rigid shield, keep nil by mouth, control pain/nausea, contact ophthalmology urgently and obtain thin-slice noncontrast orbital CT if it will assist management. Avoid MRI until metal is excluded.

Case 3: cement splash

A mason has dry cement dust on his face and reports burning in one eye. He is holding the eye closed while a colleague searches for the product label.

Approach: Protect staff, brush dry powder from surrounding skin, then begin immediate copious irrigation if open globe is not suspected. Remove contact lenses, evert lids and clear retained particles after initial flushing, check pH and recheck for rebound. Do not delay to identify the brand, do not neutralize and arrange urgent eye review.

Case 4: object projecting from the eye

A patient arrives after a fall onto a sharp tool, with the handle still projecting near the eye. The eyelids are swollen and the patient is vomiting from pain.

Approach: Do not remove, move or push the object. Stabilize it with padding around it and a rigid shield that does not touch the globe; avoid forced lid opening. Give systemic analgesia/antiemetic, keep nil by mouth, check associated head injury and tetanus, and arrange immediate ophthalmology/trauma transfer.

Case 5: welder’s flash

A welder who did not use eye protection develops bilateral severe photophobia and tearing several hours after an arc flash. Vision is almost normal and there is diffuse punctate fluorescein staining.

Approach: Photokeratitis is likely after checking for retained FB, unilateral injury, chemical exposure and open globe. Give supportive care and oral analgesia according to local guidance, avoid home topical anesthetic, reinforce UV protection and arrange review for reduced vision, worsening pain or delayed recovery.

16. Knowledge check

1. What defines an open-globe injury?
2. Why is a tiny entry mark after metal-on-metal work still concerning?
3. Which imaging test is usually preferred for suspected metallic IOFB, and what must be excluded before MRI?
4. What are three steps that should be avoided when open globe is possible?
5. What is the first aid priority for a chemical splash when rupture is not suspected?
6. Why does lid eversion matter in a patient with vertical corneal scratches?
7. Who should remove a deep or central corneal foreign body?
8. Which symptoms after blunt trauma suggest retinal tear or detachment?
9. What should a clinician do with an object protruding from the globe?
10. Name two prevention measures for workplace eye injury.

Answers

1. A full-thickness wound through cornea and/or sclera communicating with the inside of the globe.
2. A high-speed particle may enter through a self-sealing wound and cause an intraocular foreign body or posterior damage.
3. Thin-slice noncontrast orbital CT is usually first line; ferromagnetic metal must be definitively excluded before MRI.
4. Do not press or patch tightly, measure IOP, instil drops, manipulate the wound, remove an embedded object or perform ocular ultrasound.
5. Immediate continuous irrigation with clean water or saline; do not wait for a full examination or product identification.
6. A particle trapped under the lid can repeatedly abrade the cornea and cause vertical linear staining.
7. An experienced ophthalmologist or clinician trained in slit-lamp FB removal, with urgent referral for central, deep or uncertain cases.
8. New flashes, floaters, a curtain/field defect or sudden loss of vision.
9. Leave it in place, stabilize without pushing, protect with a rigid shield and transfer urgently.
10. Wear correctly rated safety glasses/face shield and use guards/procedures during grinding, hammering, drilling or chemical handling.

Key takeaways

• Mechanism, location and depth determine risk; a small superficial symptom can conceal an open globe or IOFB.
• Establish that the eyewall is intact before applying pressure, using drops, everting lids, measuring IOP or removing a foreign body.
• For suspected open globe: rigid shield without pressure, no manipulation, NPO, pain/nausea control and urgent ophthalmology.
• For chemical exposure without suspected rupture: irrigate immediately and copiously; remove retained particles and recheck pH.
• Only loose or superficial accessible material should be removed by a trained clinician; deep/central/penetrating material needs eye-service care.
• CT is generally preferred for suspected metallic IOFB; MRI is unsafe until ferromagnetic material has been excluded.
• Teach prevention and clear return precautions, and make follow-up specific because infection, scarring, cataract, glaucoma and retinal injury may be delayed.

References and further reading

1. Bijukumar Vasupillai. Foreign body & trauma to the eye. Supplied 20-slide presentation, SlideShare.
2. American Academy of Ophthalmology EyeWiki. Pre-Ophthalmologist Management of Eye Trauma.
3. American Academy of Ophthalmology EyeWiki. Removal of Corneal Foreign Bodies.
4. American Academy of Ophthalmology EyeWiki. Intraocular Foreign Bodies.
5. American Academy of Ophthalmology EyeWiki. Anterior Segment Trauma: Evaluation, Considerations and Initial Management.
6. American Academy of Ophthalmology EyeWiki. Ocular Trauma: Acute Evaluation, Cataract and Glaucoma.
7. Agency for Clinical Innovation, New South Wales. Eye Emergency Manual, 3rd edition, 2023.
8. Royal Children’s Hospital Melbourne. Clinical Practice Guideline: Penetrating Eye Injury.
9. American Academy of Ophthalmology EyeWiki. Chemical Injury of the Conjunctiva and Cornea.
10. Royal College of Ophthalmologists. Open Globe Injury Guidelines, August 2026.