What is the next step in managing a middle-aged man with a metal shard lodged in his eye?

Management of Metal Shard Lodged in the Eye

Apply an eye shield immediately and refer urgently to ophthalmology—do not attempt removal or irrigation of an embedded foreign body. 1, 2

Immediate First Aid Management

The correct answer is D: Apply eye shield. A metal shard lodged in the eye represents a penetrating ocular injury that is a sight-threatening emergency requiring specialized surgical intervention by an ophthalmologist. 1, 2

Critical Initial Steps

• 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, 2
• Do not attempt removal of the embedded foreign body—this requires ophthalmologic surgical expertise and attempting removal in primary care can cause catastrophic damage. 1, 2
• Do not irrigate the eye—irrigation is only appropriate for chemical exposures or superficial foreign bodies, not for embedded metallic objects. 3, 1
• Do not patch the eye—use only a protective shield to avoid applying pressure on a potentially perforated globe. 1
• Do not allow the patient to rub or manipulate the eye, as this can embed the foreign body deeper or cause additional corneal damage. 1, 2

Urgent Referral Protocol

• Immediate ophthalmology consultation is mandatory—metal foreign bodies represent high-velocity penetrating injuries that are beyond the scope of primary care management. 1, 2
• Provide oral analgesics for pain control while awaiting specialist evaluation. 1
• Arrange for simultaneous ophthalmology consultation and imaging if needed—do not delay referral. 1

Diagnostic Imaging Considerations

• CT scan is the imaging modality of choice for suspected metallic foreign bodies—noncontrast thin-section orbital CT with multiplanar reconstructions is superior for identifying metallic objects and assessing globe integrity. 1, 2
• MRI is absolutely contraindicated when a metallic foreign body is suspected, as ferrous metal can move during imaging and cause catastrophic ocular damage. 1, 2, 4
• Never order MRI without first ruling out metallic foreign body with CT imaging. 1, 2

Red Flags Requiring Emergent Action

• Irregular pupil shape, vision loss, or significant visual impairment require emergent ophthalmology intervention. 2
• Penetrating injury with visible entry wound is a critical finding necessitating immediate action. 2
• Subconjunctival hemorrhage, vitreous hemorrhage, or any evidence of globe perforation demands urgent specialist care. 5

Common Pitfalls to Avoid

• Never attempt removal in primary care—embedded foreign bodies require specialized surgical techniques and equipment available only to ophthalmologists. 1
• Do not confuse this with superficial corneal foreign bodies—superficial foreign bodies can be removed in primary care, but embedded objects cannot. 1, 6
• Do not delay for imaging—shield the eye and refer immediately; imaging can be arranged by the ophthalmologist. 1
• Attempting irrigation or removal of embedded foreign bodies differs fundamentally from management of chemical exposures or superficial debris. 3, 1