Intraocular Foreign Body, Traumatic Optic Neuropathy and Lid Lacerations
Last updated: November 2026
Three trauma problems are easy to get wrong in a busy casualty: a small, missed intraocular foreign body, the temptation to give high-dose steroids for traumatic optic neuropathy, and a lid laceration that involves the canaliculus.
Intraocular foreign body (IOFB)
- Suspect it with hammering, chiselling, grinding or any high-velocity injury, even if the entry wound is tiny.
- Look for: a small corneal or scleral wound, a hole in the iris, a localised lens opacity, vitreous haemorrhage.
- CT orbit (thin slices) is the investigation of choice; never MRI if a metal foreign body is possible. B-scan if CT is unavailable, gently.
- Iron causes siderosis (brown iris, heterochromia, pupil dilated and poorly reactive, ERG changes); copper causes chalcosis (sunflower cataract, Kayser-Fleischer ring) or acute suppurative inflammation.
- Management: primary wound repair, systemic and intravitreal antibiotics as indicated (high endophthalmitis risk), and early vitrectomy to remove the IOFB.
Traumatic optic neuropathy
- Reduced vision and an RAPD after head or face trauma with an initially normal disc (pallor appears after 3–6 weeks).
- Imaging to look for a bony fragment or haematoma compressing the nerve.
- Evidence: the CRASH trial showed high-dose steroids increased mortality after head injury, and IONTS showed no benefit of steroids or decompression over observation. Many units now observe, with steroids only after individual discussion.
- Orbital compartment syndrome is different: tense orbit and rising IOP need immediate lateral canthotomy and cantholysis.
Eyelid lacerations
| Injury | Repair |
|---|---|
| Skin-only laceration | Clean and close with fine sutures (6-0 or 7-0) |
| Lid margin laceration | Align the grey line and lash line precisely with vertical mattress sutures; repair the tarsus with absorbable sutures to avoid notching |
| Canalicular laceration (medial to the punctum) | Repair ideally within 48 hours with a silicone stent (mono- or bicanalicular) under the microscope |
| Levator or orbital fat prolapse | Suggests deep injury: explore and repair the levator; check for an open globe and orbital foreign body |
| Dog bites | Thorough irrigation, tetanus and rabies prophylaxis, antibiotics |
Always exclude an open globe before working on the lids.
Where residents slip
- Ordering an MRI for a suspected metallic IOFB.
- Missing a small entry wound after hammering.
- Repairing a lid laceration without checking the canaliculus.
- Giving high-dose steroids routinely for traumatic optic neuropathy.
Test yourself: flip cards
Related: Open Globe Injury: The BETT Classification, Ocular Trauma, Eye Injury & Emergency Treatment Ahmedabad.
Key sources
- CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10,008 adults with clinically significant head injury. Lancet. 2004;364:1321-1328
- Levin LA, et al. The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study. Ophthalmology. 1999;106:1268-1277
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