Foreign Body Removal Procedure Note (Corneal/Conjunctival)

Date/Time: [Date and time of procedure]

Clinician: [Clinician name and credentials]

Location: [ED / urgent care / clinic / slit lamp room / bedside]

Eye: [OD / OS / OU] (Laterality is mandatory—never leave blank. If unclear from dictation, insert placeholder requiring specification.)

Indication

[Indication and working diagnosis including mechanism, timing, and suspected material such as metal, wood, glass, or sand] (Explicitly flag high-risk mechanisms: high-speed metal-on-metal, hammering, explosion. Note contact lens use if relevant.)

Pre-Procedure Assessment

Visual acuity (pre-procedure): [Measurement and method: uncorrected / corrected / pinhole] (If not obtained, state reason.)

Pupils: [Shape and reactivity]

Extraocular movements: [Grossly intact / Abnormality noted]

Anterior segment exam: [Brief description]

Magnification used: [Slit lamp / loupes / none]

Fluorescein staining: [Findings]

Seidel test (pre-procedure): [Positive / Negative / Not performed] (Document only when clinically indicated by deep defect or suspicious mechanism. Do not document as negative unless actually assessed; if not performed, state reason.)

Decision: [No signs of open globe or perforation; removal attempted / Concern for open globe or intraocular foreign body—procedure aborted, eye shield placed, emergent ophthalmology consultation and imaging arranged]

Consent

[Verbal / Written] consent obtained; patient had capacity. Discussed: nature of procedure, expected benefits, material risks (pain, bleeding, infection, corneal abrasion, scarring, retained foreign body, need for ophthalmology follow-up, iatrogenic perforation if needle or burr used), and alternatives (irrigation only, ophthalmology removal, observation with return precautions). Questions answered; patient agreed. (If consent was constrained by urgency, language barrier, or capacity issues, document constraints and how addressed.)

Time-Out

[Time-out performed confirming correct patient, procedure, and eye laterality / Not performed—reason]

Preparation and Anesthesia

Positioning: [Slit lamp seated / Supine bedside]; patient instructed to fixate.

Ocular preparation: [Irrigation with sterile saline / Debris cleared / Antiseptic used]

Anesthesia: [Topical anesthetic name, concentration, number of drops]; [Patient tolerance]

Procedure

Target site: [Conjunctiva / Cornea]; [Location by clock hour]; [Central / Paracentral / Peripheral]

Foreign body characteristics: [Superficial adherent / Embedded]; [Material description]; [Approximate size]

Instruments used: [Irrigation / Moist cotton-tipped applicator / Eye spud / Needle with gauge and tangential approach / Jeweler's forceps / Alger burr] (List in order of escalation; include only instruments actually used.)

Lid eversion and fornix sweep: [Performed with findings / Not performed]

Material removed: [Number of fragments]; [Removed intact / Fragmented]

Rust ring: [Not applicable / Present—removed via method / Present—deferred with reason and plan / Absent] (Document for metallic foreign bodies.)

Irrigation after removal: [Yes / No]

Completion status: [Complete removal / Partial removal / Aborted] (If incomplete or aborted, document what remains, why stopped, and escalation plan.)

Post-Procedure Findings

• Visual acuity (post-procedure): [Measurement and method] (If not obtained, state reason.)
• Fluorescein staining: [Uptake pattern, epithelial defect size and location]
• Seidel test (post-procedure): [Positive / Negative / Not performed] (Required after deep defect work or sharp/burr instrumentation; do not document as negative unless actually assessed.)
• Anterior chamber: [Deep and quiet / Cells, flare, or hyphema noted]
• Residual foreign body: [None seen / Suspected]
• Complications: [None apparent / Complication described]
• Patient tolerance: [Tolerated well / Tolerance concerns] (Note fixation quality and any adverse reaction.)

Medications

Given in clinic/ED: [Medications administered with doses]

Discharge prescriptions:

• Topical antibiotic: [Name, formulation, frequency, duration] (Use antipseudomonal coverage if contact lens wearer.)
• Cycloplegic: [Name and dosing if prescribed; counseling provided] (Include only if used.)
• Oral analgesics: [Regimen if recommended]
• Topical anesthetic: [Not prescribed for home use / Provided under protocol with eligibility criteria, duration limit, and instructions]

Disposition and Follow-Up

Disposition: [Discharged / Observation / Same-day ophthalmology evaluation]; [Condition at disposition]

Eye protection: [Patch avoided / Patch applied / Shield placed]

Follow-up: [Specific ophthalmology follow-up timeframe] (Expedite for: central defect, contact lens wearer, organic material, incomplete removal, rust ring, deep defect, infection concern.)

Return precautions:

• Worsening or severe pain
• Decreased or blurry vision
• Increasing redness, discharge, or swelling
• Persistent foreign body sensation after 24 hours
• Worsening photophobia
• Fever or systemic symptoms

Activity counseling: No contact lens wear until healed and cleared; avoid rubbing eye; protective eyewear for work or high-risk activities.

(Documentation rules: Laterality must never be omitted. Pre- and post-procedure visual acuity should be documented; if not obtained, state reason. Seidel test results should only appear when actually performed. Consent must not be left blank. For other elements not assessed, omit rather than insert placeholder text.)

Clinician Signature: [Electronic signature or name, credentials, date/time]