This patient has a fleck of metal embedded in his cornea from grinding. First, treat pain by placing an anesthetic drop in the eye. Retract the inferior lid and place the drop in the inferior fornix. As the patient blinks the anesthetic is distributed.
Use a cotton-tipped applicator to evert the upper eyelid to check for a retained foreign body. The upper lid will invert around the tarsal plate when you apply pressure to the superior aspect while gently pulling the lid upwards.
Use a fluorescein stain with cobalt blue light to look for corneal injury, especially signs of globe rupture, such as Seidel sign.
Before removing the foreign body, place an eyelid retractor if you have one. Compress it closed, gently slide under the eyelids, and slowly open.
For a first attempt at removing the foreign body, try using a cotton-tipped applicator to see if a gentle sweep dislodges it. This typically works well if the foreign body is embedded in the palpebral conjunctiva (inside of the eyelid). In this case, the first attempt failed, and the next attempt will be with a needle.
Some sources recommend a small gauge needle, such as an insulin needle with a syringe (typically about 30 gauge), and others prefer a larger 18-gauge needle that is more rigid. A 30-gauge needle may be too flexible or small in some cases, and the choice is based on clinician preference.
With the bevel of the needle facing outward toward the operator, use very gentle and small sweeps to remove the foreign body. Brace your hand on the patient’s face for stability in case the patient moves. With a few small sweeps, most of the metal is dislodged and then removed with a cotton-tipped applicator.
The remaining metal is removed using an 18-gauge needle, but a rust ring remains and, of course, a corneal abrasion. The rust can either be removed with a corneal burr, or the patient can follow up in an ophthalmology clinic for rust ring removal.
Remember to repeat the fluorescein stain afterward to confirm there was no globe rupture during the procedure. The patient should be discharged with ophthalmic antibiotic ointment and close follow-up to make sure the corneal abrasion heals.