Limbal Wound After Hammering Metal
A 32-year-old metal worker presents 1 hour after a piece of metal struck his right eye while he was hammering without safety glasses. He has severe pain, tearing, and blurred vision. Visual acuity is hand motions OD and 20/20 OS. There is a 2-mm limbal wound, a shallow anterior chamber, and a positive Seidel test. The pupil is irregular. Intraocular pressure is 6 mmHg. He has no relative afferent pupillary defect. The fundus cannot be seen clearly. He took no food for 6 hours. He has no known allergies. He is asking to go home because the pain is improving. There is no proptosis and no orbital emphysema. He has no history of eye surgery. He is otherwise healthy and takes no medications. He has no history of amblyopia.
1. What immediate steps would you take in the emergency department?
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This is a suspected open globe with an intraocular foreign body. I would not remove anything, not apply pressure, and not instil ointment. Place a rigid shield, keep the patient NPO, start broad-spectrum IV antibiotics (for example cefazolin plus gentamicin, or vancomycin plus ceftazidime per local policy), update tetanus, give antiemetics and analgesia, and arrange urgent CT of the orbits without contrast. I would avoid MRI because the foreign body may be metallic. I would involve ophthalmology immediately for primary repair and not send the patient home despite improving pain. Check for other injuries and document visual acuity, pupil, and Seidel test.
2. What are the priorities at surgery?
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The priorities are to restore globe integrity, remove the intraocular foreign body, and prevent infection. Primary repair should be done urgently, usually within 24 hours. I would explore the wound, reposition uvea, and close the cornea/sclera with fine sutures under magnification. If the foreign body is in the posterior segment, a vitreoretinal surgeon should plan removal, often with vitrectomy, and repair retinal damage. I would obtain cultures and use intraoperative antibiotics according to local protocol. I would avoid unnecessary manipulation and ensure the eye is not hypotonous. Postoperative plan includes topical and systemic antibiotics, cycloplegia, and close monitoring.
3. What complications would you counsel about?
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Counsel about endophthalmitis, retinal detachment, traumatic cataract, glaucoma, and persistent visual loss. There is also a small risk of sympathetic ophthalmia in the fellow eye after penetrating trauma, so warn about new visual symptoms in the good eye. The patient needs follow-up within days and long term, with instructions to return urgently for pain, redness, or vision loss. I would discuss eye protection at work and report the injury. The final visual outcome depends on the posterior segment and infection control.