Management of Sharp Metallic Object Lodged in the Eye
The immediate next step is to apply a rigid eye shield (hard plastic shield, paper cup, or plastic cup) to the affected eye to prevent further trauma, followed by urgent ophthalmology referral—do not attempt removal of the object. 1
Critical First Actions
Shield application is the priority intervention because any pressure on a penetrated globe can expulse intraocular contents and significantly worsen the injury. 1, 2 The shield must vault over the eye without touching it—patching and placing gauze between the shield and eye are both contraindicated. 2
Why Each Answer Option is Right or Wrong:
Option B (Apply a shield) is correct as the immediate next step because it prevents iatrogenic worsening during transport and evaluation. 1, 2
Option C (Removal and irrigation) is dangerous and contraindicated for penetrating injuries from sharp metal objects, as this can cause expulsion of intraocular contents and permanent vision loss. 2, 3 Irrigation is only reasonable for low-energy mechanisms like dust or dirt blown into the eye. 1
Option A (Referral to ophthalmology) is necessary but not the immediate next step—the eye must be protected with a shield first, then immediate referral follows. 1
Option D (Outpatient follow-up) is completely inappropriate for penetrating injuries from sharp metal objects, which require immediate medical attention. 1
Algorithmic Approach After Shield Placement
Immediate Assessment (While Arranging Urgent Referral):
Test visual acuity immediately to establish baseline function and identify acute vision loss. 4, 5, 6
Examine pupil shape—an irregular pupil indicates globe penetration and confirms the need for emergency intervention. 1, 4, 6
Check for eye bleeding or vision loss, both of which mandate emergency ophthalmology consultation. 1, 4
Document mechanism of injury—high-velocity mechanisms (grinding, nailing, metal work) carry significantly higher risk of globe penetration. 1, 5, 6
Additional Immediate Measures:
Administer prophylactic systemic antibiotics to prevent endophthalmitis after suspected penetrating injury. 7, 3
Keep the patient NPO (nothing by mouth) in anticipation of urgent surgical repair. 3
Obtain CT imaging if there is concern for intraocular foreign body—CT is required rather than MRI for any possible ferrous-metallic foreign body. 1, 6
Common Pitfalls to Avoid
Never attempt to remove a penetrating object or irrigate the eye—this is the most critical error that can lead to permanent blindness. 2, 3 Studies document that 95.8% of ocular trauma cases at the point of injury fail to receive proper initial management, often due to inappropriate manipulation. 2
Do not apply any pressure to the eye—unlike hemorrhagic injuries where direct pressure is indicated, any pressure on a penetrated globe expulses intraocular contents. 2
Do not delay referral based on initial visual acuity—poor initial visual acuity is not a guarantee of poor final outcome, and timely primary repair of ruptured globes is essential for sight preservation. 7
Definitive Management Timing
Primary surgical repair should be performed in a timely fashion once the patient reaches ophthalmology. 7 The final visual outcome can typically be predicted after approximately 3-4 weeks, and secondary procedures are often required later for optimal sight preservation. 7