What is the emergency room management for a patient with a metal foreign body in the eye?

Emergency Room Management of Metal Foreign Body in the Eye

A patient with a metal foreign body in the eye requires immediate ophthalmologic consultation and should NOT undergo MRI imaging under any circumstances due to risk of further injury from movement of the metal object. 1, 2

Initial Assessment and Management

1. Immediate Evaluation:

   • Assess for signs of penetrating eye injury: irregular pupil, eye bleeding, vision loss 1
   • Determine mechanism of injury (high-velocity vs. low-velocity) 1
   • Check visual acuity in both eyes (if possible)
   • Perform external examination without applying pressure to the globe

2. Critical Actions:

   • DO NOT attempt to remove embedded metal foreign bodies in the ER 1
   • DO NOT allow the patient to rub the eye
   • DO NOT order MRI - metallic objects can move during MRI causing catastrophic damage 1, 2
   • Apply eye shield (not pressure patch) to protect the eye from further injury

3. Imaging:

   • Order non-contrast thin-section orbital CT with multiplanar reconstructions 1
   • Plain radiographs are insufficient and have been largely replaced by CT 1
   • CT is superior for identifying:
     • Location of metallic foreign body
     • Integrity of orbital bones
     • Fractures or displaced bone fragments
     • Narrowing of optic canal 1

Management Algorithm

For Superficial Foreign Bodies (visible on surface):

• If the object appears to be loose on the surface (not embedded):
  • Irrigation with commercial eyewash or sterile saline may be attempted 1
  • If irrigation fails, urgent ophthalmology consultation is required

For Embedded/Intraocular Foreign Bodies:

• MANDATORY ophthalmology consultation
• Place protective eye shield without applying pressure
• Keep patient NPO in preparation for possible surgical intervention
• Administer tetanus prophylaxis if indicated
• Consider broad-spectrum antibiotics after consultation with ophthalmology

Complications to Monitor

• Penetration of the globe
• Intraocular hemorrhage
• Traumatic cataract
• Retinal damage
• Infection
• Vision loss
• Sympathetic ophthalmia (inflammation in the uninjured eye)

Common Pitfalls to Avoid

1. Never attempt removal of embedded metal foreign bodies in the emergency department - this requires specialized equipment and expertise 1

2. Never order MRI for patients with suspected metal in the eye - movement of the metal can cause catastrophic damage including hyphema and further tissue injury 1, 2

3. Don't delay ophthalmology consultation - time is critical for preserving vision

4. Don't miss signs of globe penetration - irregular pupil, hyphema, or hypotony can indicate open globe injury requiring immediate surgical intervention

5. Don't forget to document visual acuity - this is the vital sign of the eye and provides important baseline information

Metal foreign bodies in the eye represent true ophthalmologic emergencies that require prompt recognition, appropriate imaging with CT (never MRI), and urgent ophthalmology consultation to preserve vision and prevent further injury.