A worker is struck by a metal fragment at a grinding wheel. He presents with a dark uveal prolapse, shallowed anterior chamber, and hypotony (IOP 4 mmHg). What is the FIRST step in emergency management of this open globe injury?

• A Instil topical antibiotics and patch the eye with a pressure bandage
• B Place a rigid protective shield over the eye without applying pressure; arrange urgent surgical repair ✓
• C Attempt to reposition the prolapsed uvea with forceps
• D Perform B-scan ultrasound to assess vitreous haemorrhage

Explanation

In an open globe injury, the critical first step is to protect the eye from further damage by placing a rigid (Fox) shield over the orbit — never applying pressure (pressure dressings or eyelid squeezing can extrude intraocular contents). Topical drops are contraindicated as they may introduce infection through the wound. IV antibiotics (moxifloxacin or cefazolin + gentamicin) are given systemically. Surgical primary repair should be performed within 24 hours. B-scan ultrasound may be performed gently if needed but should not delay protective shielding.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.