Rosen & Barkin's 5-Minute Emergency Medicine Consult (177 page)

• 415.0 Acute cor pulmonale
  
• 416.9 Chronic pulmonary heart disease, unspecified
  

BASICS

• Any tear or defect in the corneal epithelium
  
• May be traumatic, spontaneous, due to foreign body, or contact lens related
  

• Traumatic:
  
  • Human fingernail
    
  • Branches
    
  • Hairbrushes/combs
    
  • Sand/stones
    
  • Snow
    
  • Pens/pencils
    
  • Toys
    
  • Chemical burn
    
  • Airbag deployment
    
  • Pepper spray
    
  • Paper/cardboard
    
  • Make-up applicator
    
  • Animal paws
    
• Foreign body related:
  
  • Wood
    
  • Glass
    
  • Metal
    
  • Rust
    
  • Plastic
    
  • Fiberglass
    
  • Vegetable matter
    
  • Eyelid foreign body
    
• Contact lens related:
  
  • Over-worn
    
  • Improperly fitting or cleaned
    
• Spontaneous:
  
  • Usually previous traumatic corneal abrasion or an underlying defect in the corneal epithelium
    

DIAGNOSIS

• Severe ocular pain
  
• Gritty (scratchy) discomfort
  
• Tearing
  
• Blepharospasm
  
• Foreign body sensation
  
• Photophobia (particularly if secondary traumatic iritis present)
  
• Conjunctival injection
  
• Diminished or blurred vision
  
• Headache
  

• Any direct trauma to the globe
  
• Any known or potential foreign body
  
• Contact lens use
  
• Any history of previous corneal abrasion
  
• Ocular/periocular surgery
  
• Pre-existing visual impairment
  
• Time of onset
  
• Associated symptoms or concomitant injury
  
• Treatment before visit
  
• Use of safety glasses (pounding, drilling, grinding metal) or eyeglasses
  
• Systemic disease (diabetes, autoimmune disorders)
  
• Tetanus status
  

• Signs and symptoms may differ:
  
  • Excessive crying
    
• Younger than 12 mo:
  
  • Frequently no history of eye trauma
    
  • Might present as the crying inconsolable infant
    
  • In 1–12 wk old may be an incidental finding and not the cause of their irritability or crying
    
• Older than 12 mo:
  
  • More often will have history of minor eye trauma
    
  • Positive eye signs
    

• If indicated, evaluate for other life-threatening injuries with attention to the primary survey.
  
• Complete eye exam:
  
  • Focus is to evaluate for evidence of penetrating injury and/or infection
    
  • Gross visual inspection
    
  • Visual acuity
    
  • Penlight exam to evaluate for conjunctival injection, the pupil shape/reactivity, and for any evidence of corneal infiltrate or opacity
    
  • Evert upper lids to check for retained foreign body
    
  • Slit-lamp exam to evaluate for anterior chamber reaction, infiltrate, corneal laceration, and penetrating trauma
    
  • Fluorescein dye to identify size and location of corneal epithelium defect
    

Handheld slit-lamp and Wood lamp: Helpful in exam of pediatric eye

• Conjunctivitis, viral, or bacterial
  
• Corneal ulcer
  
• Glaucoma
  
• Herpes zoster
  
• Keratitis, viral or bacterial, or ultraviolet induced
  
• Recurrent corneal erosion syndrome
  
• Uveitis
  
• More extensive pathology than corneal abrasion:
  
  • Laceration of cornea
    
  • Perforation of cornea
    
  • Hyphema
    
  • Iris prolapse
    
  • Lens disruption
    

TREATMENT

Instill topical anesthetic (proparacaine/tetracaine).

• Removal of superficial foreign body:
  
  • A residual rust ring does not need emergent removal. It can be removed at 24–48 hr
    
• Oral pain control:
  
  • Oral narcotics or NSAID or acetaminophen
    
• Topical pain control:
  
  • Studies have demonstrated efficacy; however, there are scattered reports of adverse effects
    
  • Avoid in patients with other ocular surface disease and in postoperative patient
    
  • Topical diclofenac or ketorolac
    
• Cycloplegic (optional):
  
  • Cyclopentolate (mydriasis 1–2 days)
    
  • Tropicamide (mydriasis 6 hr)
    
  • Homatropine 5%
    
• Topical antibiotic:
  
  • This practice has not been rigorously studied.
    
  • Concern is for superinfection
    
  • Ointment better than drops because also a lubricant
    
  • Discontinue antibiotics once symptom free for 24 hr
    
  • Contact lens wearers must have anti-Pseudomonal coverage:
    
    • Ciprofloxacin
      
    • Erythromycin
      
    • Gentamicin
      
    • Sulfacetamide
      
    • Tobramycin/Tobradex
      
    • Polytrim
      
• Eye patch:
  
  • Does not appear to improve healing or reduce pain particularly in the 1st 24 hr
    
  • Not recommended for small abrasions
    
  • Never patch the patient who wears contact lens
    
  • Never patch infection-prone injury (organic matter is at high risk)
    
  • More research needed to evaluate efficacy of patching in abrasions >10 mm
    
• Contact lens
  
  • No contact lens wear till abrasion healed and eye feels normal for a wk without medication
    
  • Might consider bandage contact lens in severe pain. Be certain no infection and will need daily follow-up
    
• Tetanus prophylaxis:
  
  • Routine tetanus not necessary
    
  • Update tetanus if abrasion caused by or contaminated with organic matter or dirt
    
• Emergent ophthalmologic consultation required for retained intraocular foreign body, penetrating injury to globe (or other more serious injury) and any patient with a corneal infiltrate, white spot, or opacity
  

• Ciprofloxacin: 0.35% 1 drop QID
  
• Cyclopentolate: 0.5%, 1%, or 2% drops (mydriasis 1 or 2 drops TID)
  
• Diclofenac: 0.1% drops 1 drop QID
  
• Erythromycin: 0.5% ointment QID
  
• Gentamicin: 0.3% ointment QID
  
• Gentamicin: 0.3% 2 drops q6h
  
• Homatropine: 5% solution 2 drops BID
  
• Ketorolac: 0.5% drops 1 drop QID
  
• Proparacaine: 0.5% 1 drop once
  
• Sulfacetamide: 10% drops 2 drops QID
  
• Sulfacetamide: 10% ointment QID
  
• Tobradex: Suspension 0.1%/0.3% 2 drops q4–6h
  
• Tobramycin: 0.3% drops 2 drops q6h
  
• Tobramycin: 0.3% ointment q6h
  
• Tropicamide: 0.5%, 1% drops (mydriasis 6 hr) 1 drop q4h
  

FOLLOW-UP

Associated injuries requiring admission

All simple corneal abrasions

No studies on optimal follow-up. Practice recommendations however dictate all corneal abrasions require follow-up to ensure healing without infection or scarring.

• Follow-up with ophthalmologist for re-exam and ongoing care in 24 hr if in contact lens wearer, the eye has been patched or bandage contact lens applied
  
• Follow-up with ophthalmologist if central or large abrasion in 24 hr; otherwise follow-up can be in 48–72 hr
  

• Always diligently evaluate for penetrating trauma to the globe.
  
• Always diligently evaluate for evidence of infection.
  
• Do not discharge the patient with any topical anesthetic. It is felt to be toxic to the epithelium and retards healing, although a recent small study indicated it might be safe to discharge with dilute proparacaine.
  
• Do not use a mydriatic agent on a patient with a history of glaucoma.
  
• Do not recommend return to contact use until followed up and cleared by ophthalmology.