Rosen & Barkin's 5-Minute Emergency Medicine Consult (179 page)

• Chemical exposure: Alkalis/acids/mace:
  
  • Continuous irrigation to achieve pH 7.3–7.5 (1–2 L via a Morgan lens >30–60 min):
    
    • Measure pH every 30 min
      
    • Dip pH paper in inferior conjunctival fornix
      
  • Topical anesthetic (proparacaine) may be necessary during irrigation
    
  • pH should be evaluated at 5 and 30 min after irrigation to ensure normalization of pH
    
  • Evaluate fornices in detail and eye in full range of motion to ensure removal of all particulate chemical substance
    
  • Antibiotic prophylaxis for Staphylococcus/Pseudomonas until epithelialization is complete:
    
    • Gentamicin ointment + erythromycin
      or
      
    • Bacitracin
      
  • Cycloplegics to minimize posterior synechiae formation:
    
    • Cyclopentolate 1%
      
    • Atropine 1%
      
  • Oral analgesics
    
  • If increased intraocular pressure:
    
    • Immediate ophthalmologic consultation
      
    • Administer acetazolamide 125 mg PO QID and timolol 0.5% drops BID
      
• Topical steroids to control anterior uveitis (consult ophthalmology)
  
• Eye patch (consult ophthalmology)
  
• May require surgical intervention if frank corneal penetration
  
• Ophthalmologic consultation by phone in mild injuries
  
• Immediate ophthalmologic consultation in all moderate to severe injuries; if unavailable at your hospital, arrange transfer to closest eye center
  
• HF acid:
  
  • Treat as above, + 1% calcium gluconate eyedrops
    
  • Systemic analgesia for 24 hr
    
• Thermal exposure:
  
  • Frequent moist dressing changes
    
  • Antibiotics drop QID
    
  • Generous lubricant application
    
  • Moisture chamber when extensive injury to eyelid
    
  • Steroids (consult ophthalmologist; do not use for >1 wk)
    
  • Ophthalmology consultation for any 2nd- or 3rd-degree burn to eyelids
    
  • Cigarette ash and hot liquid splashes usually result in corneal epithelial injury:
    
    • Treat as corneal abrasion
      
• Electrical injury:
  
  • Irrigation
    
  • Wound care
    
  • Antibiotic ointment
    
  • Cycloplegic (if anterior uveitis)
    
  • Analgesia
    
• Radiation injury:
  
  • Topical anesthetic
    
  • Short-acting cycloplegic
    
  • Antibiotic ointment
    
  • Consider oral opioids for pan control
    

• Patching poorly tolerated
  
• May require systemic analgesia for complete exam
  

• Artificial tears
  
• Atropine: 0.5%, 1%, 2% drops (cycloplegia 5–10 days, mydriasis 7–14 days) 1 drop TID
  
• Bacitracin ointment: QID
  
• Ciprofloxacin: 0.35% 1 drop QID
  
• Cyclopentolate: 0.5%, 1%, 2% drops (cycloplegia 1–2 days, mydriasis 1–2 days) 1 drop TID
  
• Erythromycin: 0.5% ointment QID
  
• Gentamicin: 0.3% ointment QID
  
• Gentamicin: 0.3% drops 1 drop q6h
  
• Homatropine: 5% drops 1–2 drop BID–TID
  
• Proparacaine: 0.5% drops 1 drop
  
• Sulfacetamide: 10% ointment QID
  
• Sulfacetamide: 10% drops QID
  
• Tetracaine: 0.5% drops 1–2 drops
  
• Tobramycin: 0.3% ointment q6h
  
• Tobramycin: 0.3% drops q6h
  
• Tropicamide: 0.5%, 1% drops (cycloplegia none; mydriasis 6 hr) 1 drop
  

FOLLOW-UP

• Intractable pain
  
• Increased intraocular pressure
  
• Corneal penetration requiring immediate surgical intervention
  
• HF acid burn; admit for 24 hr of systemic analgesia
  
• Suspected child abuse
  

All mild corneal burns

Mandatory follow-up with ophthalmologist in 12–24 hr; arrange before patient discharge

• In chemical exposures, delay exam until eye has been irrigated
  
• All patients with epithelial defects need 12–24 hr ophthalmology follow-up
  
• Do not prescribe topical anesthetics for discharged patients
  

• Dargin JM, Lowenstein RA. The painful eye.
  Emerg Med Clin North Am.
  2008;26(1):199–216.
  
• Khaw PT, Shah P, Elkington AR. Injury to the eye.
  Br Med J
  . 2004;328:36–38.
  
• Marx J, Hockberger R, Walls R, eds.
  Rosen’s Emergency Medicine.
  7th ed. Elsevier, 2009.
  
• Naradzay J, Barish RA. Approach to ophthalmologic emergencies.
  Med Clin N America
  . 2006;90:305–328.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Corneal Abrasion
  
• Red Eye
  

CODES

• 940.2 Alkaline chemical burn of cornea and conjunctival sac
  
• 940.3 Acid chemical burn of cornea and conjunctival sac
  
• 940.4 Other burn of cornea and conjunctival sac
  

BASICS

• Foreign material on or in the corneal epithelium
  
• Corneal epithelium disrupted:
  
  • Abrasion if only epithelium disrupted
    
  • Scar if deeper layers of cornea involved
    

• Foreign material causes inflammatory reaction:
  
  • May develop conjunctivitis, corneal edema, iritis, necrosis
    
• Poorly tolerated:
  
  • Organic material (plant material, insect parts)
    
  • Inorganic material that oxidizes (iron, copper)
    
• Well tolerated:
  
  • Inert objects (paint, glass, plastic, fiberglass, nonoxidizing metals)
    

DIAGNOSIS

• Foreign body (FB) sensation
  
• Eye pain
  
• Conjunctiva and sclera injection
  
• Tearing
  
• Blurred or decreased vision
  
• Photophobia
  
• Visible FB or rust ring
  
• Iritis
  

Common complaint: Something fell, flew, or otherwise landed in my eye:

• Hot, high-speed projectiles may not produce pain initially.
  

• Complete eye exam:
  
  • Visual acuity
    
  • Visual fields
    
  • Extraocular movements
    
  • Lids and lashes
    
  • Pupils
    
  • Sclera
    
  • Conjunctiva
    
  • Anterior chamber
    
  • Fundi:
    
    • Slit-lamp
      
    • Fluorescein exam
      
    • Perform Seidel test (visualization of flow of aqueous through corneal perforation during fluorescein slit-lamp exam)
      
    • Intraocular pressure if no evidence of perforation
      

• Injury history to determine type of FB and likelihood of perforation
  
• Exclude intraocular FB:
  
  • Suspect intraocular FB with high-speed mechanisms, such as machine operated or hammering metal on metal, or positive Seidel test.
    

• Orbital CT scan or B-mode US when suspect intraocular FB
  
• Orbital plain radiograph to screen for intraocular metallic FB
  

• Conjunctival FB
  
• Corneal abrasion
  
• Corneal perforation with or without intraocular FB
  
• Corneal ulcer
  
• Keratitis