What is the next step in managing a patient with a metal object lodged in their eye?

Management of Metal Foreign Body Lodged in the Eye

Immediate referral to ophthalmology is mandatory for a metal object lodged in the eye—do not attempt removal yourself. This is a sight-threatening emergency requiring specialized evaluation and surgical intervention by an ophthalmologist 1, 2.

Why Immediate Ophthalmology Referral is Critical

Metal foreign bodies embedded in the eye represent high-velocity penetrating injuries that require urgent specialist management. 1, 2

• High-velocity eye injuries (such as from grinding or nailing metal objects) demand immediate medical attention and are beyond the scope of primary care removal 1, 2
• Penetrating eye injuries from sharp or metal objects require immediate ophthalmology evaluation 1, 2
• These injuries carry significant risk of vision loss, with studies showing 8% of metallic intraocular foreign bodies ultimately requiring enucleation or evisceration 3

Initial Stabilization Before Transfer

While arranging urgent ophthalmology consultation, take these protective measures:

• Shield the eye immediately with a hard plastic eye shield, paper cup, or plastic cup taped over the eye to prevent unintentional touching or rubbing 1
• Do not rub or manipulate the eye, as this can embed the foreign body deeper or cause additional corneal damage 1
• Do not attempt irrigation or removal of embedded foreign bodies—this differs from superficial foreign bodies 1, 2
• Provide oral analgesics (acetaminophen or NSAIDs) for pain control while awaiting specialist evaluation 1

Why Primary Care Removal is Contraindicated

The evidence clearly distinguishes between superficial and embedded foreign bodies:

• Low-energy foreign bodies (dust, eyelashes) can be managed with irrigation and natural tearing 1
• Embedded or high-velocity metal foreign bodies require specialized surgical techniques, often including pars plana vitrectomy, electromagnets, or microscalpel extraction 4, 5
• Metallic intraocular foreign bodies frequently cause complications including vitreous hemorrhage, traumatic cataract, retinal detachment, and require multiple surgical interventions in 40% of cases 5, 3

Diagnostic Imaging Considerations

CT scan is the imaging modality of choice for suspected metallic foreign bodies—MRI is absolutely contraindicated. 6

• Noncontrast thin-section orbital CT with multiplanar reconstructions is superior for identifying metallic foreign bodies and assessing globe integrity 6
• MRI is contraindicated when metallic foreign body is suspected, as it can cause movement of ferrous metal and catastrophic eye damage 6, 7
• Plain X-rays have poor sensitivity and specificity for detecting metallic foreign bodies and should not be relied upon 7

Common Pitfalls to Avoid

• Never attempt removal of embedded foreign bodies in primary care—this requires ophthalmologic surgical expertise 2
• Never order MRI without first ruling out metallic foreign body with CT imaging 6, 7
• Do not delay referral for imaging—arrange simultaneous ophthalmology consultation and CT if needed 6, 2
• Do not patch the eye—use a protective shield instead to avoid pressure on a potentially perforated globe 1

Prognostic Factors

Understanding these helps communicate urgency to the patient:

• Only 31% of metallic intraocular foreign body injuries achieve final visual acuity of 20/50 or better 3
• Posterior segment location, uveal prolapse, and presenting vision of light perception or worse are associated with poor outcomes 3
• Younger age and presence of afferent pupillary defect increase risk of globe loss 3