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The most important consideration with any eye injury is the possibility of a penetrating globe injury with residual intraocular foreign body (IO FB). Patients may report FB sensation, but subtle presentations occur. Obtain a meticulous history about mechanism of injury (grinding or metal on metal).
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Management and Disposition
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For suspected subtle injury, a careful examination is required. Bedside ultrasound can be a useful adjunct and allows rapid identification of an IO FB. Care must be taken to avoid any pressure on the globe. A slit-lamp examination with Seidel test (copious amounts of fluorescein instilled and observed for streaming away from the site of perforation) may reveal a microperforation.
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Maintain a high index of suspicion for penetrating globe injury, especially in mechanisms involving use of “metal on metal” such as grinding or hammering. A positive Seidel test demonstrates corneal microperforation.
If ocular penetration is suspected, a diligent search for a retained FB is indicated. Careful bedside ultrasound using a high-frequency transducer with copious gel (to avoid any pressure on the globe) can be used initially, but computed tomography (CT) is the diagnostic study of choice. Avoid magnetic resonance imaging (MRI), which should be saved for indeterminate results or when confirmation is required.
If using x-ray, obtain in both up and down gaze to assist localization of the metallic FB.
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