Management of Metal Shard Lodged in Eye
The correct answer is A: Immediate referral to ophthalmology. A metal intraocular foreign body requires urgent ophthalmologic consultation, ideally within hours, and should never be removed by non-ophthalmologists in the emergency or primary care setting. 1
Immediate Actions Required
Do not attempt removal of the foreign body. The American Academy of Ophthalmology explicitly recommends against removal attempts by non-specialists, as this can cause catastrophic additional trauma to intraocular structures. 1
Critical First Steps:
- Shield the eye immediately with a rigid eye shield (not a pressure patch or eye patch) to prevent further mechanical trauma from eye movement or external pressure 1
- Keep the patient NPO in anticipation of urgent surgical intervention that will likely be needed within 24-48 hours 1
- Arrange urgent ophthalmology consultation within hours, as metal foreign bodies require specialized diagnostic equipment and surgical expertise 1, 2
Why Other Options Are Incorrect
Option B (Removal and irrigation) is dangerous and contraindicated. Attempting removal of an embedded intraocular foreign body without specialized equipment, surgical expertise, and proper visualization can result in:
- Additional laceration of ocular structures 3
- Expulsion of intraocular contents 4
- Conversion of a potentially salvageable eye to one requiring enucleation 3
- Worsening of any underlying open globe injury 5
Option C (Outpatient follow-up) represents a critical delay. Metal intraocular foreign bodies require surgical removal within 24-48 hours to prevent complications including endophthalmitis, retinal detachment, and siderosis (iron toxicity to the retina). 1
Option D (Eye patch) is inadequate and potentially harmful. A soft eye patch provides no protection and may apply pressure to the globe, potentially extruding intraocular contents if an open globe injury exists. Only a rigid shield is appropriate. 1
Diagnostic Complexity Requiring Specialist Care
Metal intraocular foreign bodies demand specialized diagnostic evaluation that cannot be performed in primary care or standard emergency settings, including:
- Slit-lamp biomicroscopy for detailed anterior segment examination 1
- Gonioscopy to assess angle structures 1
- Indirect ophthalmoscopy with scleral depression for posterior segment evaluation 1
- B-scan ultrasonography to localize the foreign body 1
- Optical coherence tomography for retinal assessment 1
Surgical Management Rationale
Surgical removal must be performed urgently by an ophthalmologist using technique-specific approaches based on foreign body location (anterior chamber, vitreous cavity, or retina). 1 Post-operative management requires topical antibiotics, corticosteroids, and intensive monitoring for sight-threatening complications. 1
The case report of a 28-year-old man with a similar hammering injury resulting in double-penetrating trauma demonstrates the complexity: despite emergency scleral repair, foreign body removal, and subsequent vitrectomy, vision was reduced to hand motion perception due to the severity of initial trauma. 4 This underscores why immediate specialist referral—not delayed or attempted primary care management—is essential for any chance of visual preservation.