What is the diagnosis and management for a patient with a metallic object penetrating their eye, presenting with a teardrop pupil and cloudy anterior chamber, suggestive of an open globe injury?

Open Globe Injury

This patient has an open globe injury (Option A), and requires immediate ophthalmology consultation for urgent surgical exploration and primary closure. 1

Diagnostic Features

The clinical presentation is pathognomonic for open globe injury:

• Teardrop pupil indicates full-thickness disruption of the eyewall with iris prolapse through the defect, representing a hard sign of penetrating ocular injury 1
• Cloudy anterior chamber suggests disruption of normal ocular anatomy with possible aqueous humor leakage, hyphema, or lens material in the anterior chamber 2
• Metallic foreign body mechanism creates high-velocity projectile injury with high risk for intraocular foreign body (IOFB) and penetrating trauma 2, 3

Immediate Management Algorithm

Step 1: Protect the Eye

• Apply a rigid eye shield without applying any pressure to prevent extrusion of intraocular contents 1
• Avoid any manipulation of the eye, including lid eversion or pressure application 2
• Prevent Valsalva maneuvers that could extrude ocular contents 3

Step 2: Systemic Antibiotics

• Administer immediate empiric broad-spectrum systemic antibiotics to reduce endophthalmitis risk, which affects up to 16.5% of open globe injuries 4, 5

Step 3: Imaging

• Order non-contrast thin-section orbital CT with multiplanar reconstructions (94.9% sensitivity for metallic intraorbital foreign bodies) 2, 1
• MRI is absolutely contraindicated when metallic foreign body is suspected due to potential movement of the object from the magnetic field 2, 6
• Do not delay surgical consultation for imaging if the diagnosis is clinically obvious 1

Step 4: Urgent Ophthalmology Consultation

• Request immediate ophthalmology consultation for emergent surgical exploration and primary closure 1, 4
• Prompt primary repair (ideally within 24 hours) reduces endophthalmitis rates and supports visual acuity recovery 5, 7

Step 5: Tetanus Prophylaxis

• Update tetanus vaccination status 3

Why Not the Other Options

• Corneal abrasion (Option B) does not present with teardrop pupil or cloudy anterior chamber; these findings indicate full-thickness eyewall disruption, not superficial epithelial injury 4
• Iritis (Option C) presents with ciliary flush, photophobia, and miosis, not teardrop pupil with iris prolapse through a defect 2

Critical Pitfalls to Avoid

• Never apply pressure to the eye or attempt detailed examination that could extrude intraocular contents 1
• Do not perform point-of-care ultrasound on suspected open globe due to risk of globe content extrusion 3
• Do not delay surgical repair beyond 24 hours, as this increases endophthalmitis risk and worsens visual outcomes 7
• Do not order MRI when metallic foreign body is suspected 2, 6

Prognostic Considerations

Poor visual prognosis factors include: intraocular foreign bodies, vitreous hemorrhage, lacerations ≥5mm, ciliary body detachment, and endophthalmitis 1. However, even eyes with no light perception may regain some visual function with appropriate management 5.