Management of Metal Intraocular Foreign Body
Immediate referral to ophthalmology is mandatory for a middle-aged man with a metal object lodged in his eye—do not attempt removal in a non-specialist setting as this requires specialized equipment, expertise, and carries significant risk of vision-threatening complications including endophthalmitis, retinal detachment, and ocular siderosis. 1, 2
Immediate Actions in Primary Care/Emergency Setting
- Do NOT attempt removal of the foreign body yourself—this requires ophthalmologic expertise and specialized equipment 1
- Obtain urgent ophthalmology consultation immediately, ideally within hours 1
- Shield the eye (rigid eye shield, NOT pressure patch) to prevent further trauma 1
- Keep patient NPO (nothing by mouth) in case urgent surgical intervention is needed 1
- Obtain plain X-rays or CT scan of the orbit to confirm presence and location of metallic foreign body before any magnetic resonance imaging 2, 3
Why Ophthalmology Referral is Essential
Metal intraocular foreign bodies require specialized management because:
- Diagnostic complexity: Slit-lamp biomicroscopy, gonioscopy, indirect ophthalmoscopy with scleral depression, B-scan ultrasonography, and potentially optical coherence tomography are needed to fully assess the injury 1, 2
- Surgical expertise required: Removal requires specialized instruments (Barkan lens, intraocular forceps), three-port pars plana vitrectomy capabilities, and management of potential complications 2, 4
- Risk of severe complications: Metallic foreign bodies can cause ocular siderosis (iron) or chalcosis (copper), endophthalmitis, retinal detachment, chronic uveitis, corneal endothelial damage, and progressive vision loss even when initially asymptomatic 2, 3, 4
- Time-sensitive: Even asymptomatic metallic foreign bodies cause progressive ocular damage and require prompt removal 3, 4
Common Pitfalls to Avoid
- Never perform MRI before excluding metallic foreign body—this can cause catastrophic eye injury from foreign body movement 3
- Do not dismiss based on lack of trauma history: Patients with occupational risk (construction workers, metalworkers) may have penetrating injuries without recalling specific trauma 2
- Do not delay referral even if patient is asymptomatic—metallic foreign bodies cause progressive damage including siderosis and endothelial cell loss over time 3
- Avoid pressure patching—use rigid shield only to prevent inadvertent pressure on the globe 1
What the Ophthalmologist Will Do
The ophthalmologist will perform comprehensive evaluation including measurement of visual acuity, slit-lamp examination for entry wound and anterior chamber assessment, gonioscopy to visualize angle structures, dilated fundus examination with scleral depression, and imaging (B-scan ultrasound, CT) 1, 2. Surgical removal will be performed urgently, typically within 24-48 hours, using appropriate technique based on foreign body location (anterior chamber removal with corneal incision and forceps, or pars plana vitrectomy for posterior segment foreign bodies) 2, 4. Post-operative management includes topical antibiotics, corticosteroids, and close monitoring for complications including endophthalmitis, retinal detachment, and development of siderosis 1, 4.
Out-patient follow-up alone is completely inappropriate—this is a sight-threatening emergency requiring immediate specialist intervention 1, 2.