Management of Metallic Intraocular Foreign Body
A. Referral to ophthalmology is the most appropriate initial step for a middle-aged man with a metal shard lodged in his eye.
Immediate Management Priority
Do not attempt removal of the foreign body or apply a patch—immediate ophthalmology consultation is essential. 1 Attempting to remove an intraocular foreign body (IOFB) without proper expertise and equipment can cause catastrophic complications including further globe injury, vitreous loss, and permanent vision loss. 2
- Patients with high-velocity eye injuries (such as metal shards from hammering, grinding, or construction work) require immediate medical attention to prevent further damage 1
- The American College of Cardiology specifically recommends against rubbing or manipulating the eye after trauma 1
- A hard plastic eye shield should be taped over the eye to prevent unintentional touching or pressure on the globe 1
Why Other Options Are Incorrect
Applying a patch (Option B) is contraindicated because it may apply pressure to the globe, potentially worsening the injury by pushing the foreign body deeper or causing additional intraocular damage. 1
Removal and irrigation (Option C) is dangerous when performed by non-ophthalmologists, as metallic IOFBs require:
- Specialized surgical techniques with appropriate incisions and forceps 3
- Gonioscopic examination to localize the foreign body precisely 4, 5
- Operating room facilities with proper instrumentation 3
- Expertise to manage potential complications including lens injury, retinal damage, and hemorrhage 2
Outpatient follow-up (Option D) is inappropriate as metallic IOFBs constitute an ophthalmologic emergency requiring urgent surgical intervention. 4, 2
Critical Clinical Considerations
Maintain high clinical suspicion even without trauma history. Occupational risk factors (construction workers, metalworkers, mechanics) mandate consideration of IOFB even when patients deny trauma. 4, 5 In one case series, 40% of metallic IOFB patients required additional interventions beyond initial foreign body removal. 2
Imaging is essential before any intervention. Orbital computed tomography must be performed to confirm the presence and location of metallic foreign bodies before attempting removal. 4 MRI is absolutely contraindicated if metallic IOFB is suspected, as it can cause catastrophic movement of ferromagnetic material. 6
Prognostic Factors
Poor visual outcomes (final acuity <20/200) are associated with:
- Uveal prolapse at presentation 2
- Posterior segment IOFB location 2
- Presenting vision of light perception or worse 2
Globe loss requiring enucleation/evisceration occurs in 8% of cases and is associated with younger age, BB/pellet injuries, and afferent pupillary defects. 2