Corneal Abrasion

[periopdoc]

How do you evaluate them? How do you treat them? What is the evidence?

- pod

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[PMPMD]

How do you evaluate them? How do you treat them? What is the evidence?

- pod

We would typically use bacitracin. Our protocol suggested using fluorescein for Dx but I've never used it.

 

[Trisomy13]

See the pt, evaluate for any gross abnormalities, known eye disease or obvious foreign body, and if the symptoms are c/w abrasion then Tobramycin drops q6 x 24 hrs then consult ophthalmology if it persists. That routine has served me well.

 

[thegasman]

If symptoms are consistent then I give tetracaine eye drop x1 for relief and if sx persist then consult ophtho. I never really dealt with these in training, but this is what my partners do and it seems to work well. Some of the guys also put a patch on the affected eye but I usually don't worry about it. I get the rn to flush the eye with saline first just in case there might be something in there. Honestly I have never used the florescein (sp?) woods lamp thing so i would not know where to start.

 

[imfrankie]

Tetracaine please (my ophtho buddies say a few drops of Lido is fine also). These things hurt like the dickens (from a former hard contact lense wearer). Nothing like the relief of a bit of local until it heals.

 

[jwk]

If symptoms are consistent then I give tetracaine eye drop x1 for relief and if sx persist then consult ophtho. I never really dealt with these in training, but this is what my partners do and it seems to work well. Some of the guys also put a patch on the affected eye but I usually don't worry about it. I get the rn to flush the eye with saline first just in case there might be something in there. Honestly I have never used the florescein (sp?) woods lamp thing so i would not know where to start.

Nothing to it - give a drop of tetracaine ophthalmic, then either touch the fluorescein strip to the sclera or drip a drop or two of saline on the strip and allow that to drop onto the eye. Wait a minute or two (long enough for the Woods lamp to warm up), turn the lights out in the room, and hold the lamp a foot or so away from the eye. The corneal abrasions we see are usually pretty obvious.

See this article for a good discussion of treatment. http://emedicine.medscape.com/article/799316-overview

We see corneal abrasions from just a few causes - most seem to be from nasal cannulas inadvertently dragged across the eye from whatever cause, and eyes not being taped well while the patient is asleep, resulting in a horizontal line where the cornea dried out intra-op. I've seen this happen both with and without eye lube.

 

[Apollyon]

Tetracaine please (my ophtho buddies say a few drops of Lido is fine also). These things hurt like the dickens (from a former hard contact lense wearer). Nothing like the relief of a bit of local until it heals.

The tetracaine give brief relief. Do NOT give it to patients to take with them. It is going to hurt longer than the tetracaine effect. If they take it, and the reason for the abrasion is something under the eyelid, they will keep putting the drops in until they wear away the cornea.

Erythro ointment q6h is also dually effective - preventing infection, and providing relief. You can also go with PO opiates.

My experience is from the ED side.

 

[pgg]

Tetracaine please (my ophtho buddies say a few drops of Lido is fine also). These things hurt like the dickens (from a former hard contact lense wearer). Nothing like the relief of a bit of local until it heals.

I was taught that sending patients home with topical ophtho -caine drops is never OK, both for LA toxicity worries and because patients won't seek f/u care for ongoing problems if they can make the eye feel better at will.

 

[BADMD]

See the pt, evaluate for any gross abnormalities, known eye disease or obvious foreign body, and if the symptoms are c/w abrasion then Tobramycin drops q6 x 24 hrs then consult ophthalmology if it persists. That routine has served me well.

Tobra is probably overkill and a bit hard on the cornea. Bacitracin ointment is typically fine unless there is a corneal abscess. I typically give NSAIDs for pain control although the ointment actually does a pretty good job at pain control by itself. I see these semi frequently in the ED.

 

[urge]

The tetracaine give brief relief. Do NOT give it to patients to take with them. It is going to hurt longer than the tetracaine effect. If they take it, and the reason for the abrasion is something under the eyelid, they will keep putting the drops in until they wear away the cornea.

Erythro ointment q6h is also dually effective - preventing infection, and providing relief. You can also go with PO opiates.

My experience is from the ED side.

I second the erythro ointment.

 

[Planktonmd]

Irrigate with normal saline and bandage the affected eye overnight.
Next day if they are still hurting get an ophthalmology consult.
If they are out patients then send them home with a bandaged eye with instructions to return to the ER if they are having severe pain next day.
Using Tetracaine to mask the symptoms is not a very smart approach and it can cause more injury to the anesthetized eye.
Antibiotic eye drops are not necessary unless there is an infection.

 

[Hamhock]

Next day if they are still hurting get an ophthalmology consult.
If they are out patients then send them home with a bandaged eye with instructions to return to the ER if they are having severe pain next day.

Why send to the ER? Why not refer to ophtho or optometry?

HH

 

[Planktonmd]

Why send to the ER? Why not refer to ophtho or optometry?

HH

Because at that point in time they are not under the care of the anesthesiologist anymore (they were already discharged) and the ER Doc will be the one who decides if they need to be referred and to whom they should be referred.


.

 

[BADMD]

Because at that point in time they are not under the care of the anesthesiologist anymore (they were already discharged) and the ER Doc will be the one who decides if they need to be referred and to whom they should be referred.

Honestly, that doesn't make any sense. An urgent outpatient optho appointment would be far more effective at treating the problem and would be substantially cheaper. Plus, most ER docs are going to recommend Optho follow up, regardless. You are already sending them home with the diagnosis, just alter your discharge instructions and cut out the middle man.

 

[periopdoc]

Try getting ophtho to see them at 6 at night for such a minor condition. Hell I don't even want to come back in for these if I have already gone home

- pod

 

[BADMD]

Try getting ophtho to see them at 6 at night for such a minor condition. Hell I don't even want to come back in for these if I have already gone home

- pod

If they can wait until the next day to go the ED, they wait until the next day to see the ophthalmologist.

 

[Planktonmd]

Honestly, that doesn't make any sense. An urgent outpatient optho appointment would be far more effective at treating the problem and would be substantially cheaper. Plus, most ER docs are going to recommend Optho follow up, regardless. You are already sending them home with the diagnosis, just alter your discharge instructions and cut out the middle man.

Telling a patient that if the eye gets worse they need to get an appointment with an ophthalmologist is basically telling the patient that they are now on their own and you don't want to be part of their care anymore, although you caused the complication!
A patient with severe eye pain might not be able to wait a couple of days to see an ophthalmologist.

 

[pgg]

Telling a patient that if the eye gets worse they need to get an appointment with an ophthalmologist is basically telling the patient that they are now on their own and you don't want to be part of their care anymore, although you caused the complication!

This is different than dumping them on the ER ... how?

I know ER dumps are common. My brother is an ER physician, and he tells me the anesthesiologists at his hospital tell their PDPHs to go to the ER and then never show their faces to assess or manage the complication they caused. This is particularly inappropriate since anesthesia caused and should manage that complication to completion, but dumping a corneal abrasion on the ER is almost as bad.

A patient with severe eye pain might not be able to wait a couple of days to see an ophthalmologist.

What's the ER guy going to do that you can't for those couple of days?

 

[tkim]

Irrigate with normal saline and bandage the affected eye overnight.
Next day if they are still hurting get an ophthalmology consult.
If they are out patients then send them home with a bandaged eye with instructions to return to the ER if they are having severe pain next day.
Using Tetracaine to mask the symptoms is not a very smart approach and it can cause more injury to the anesthetized eye.
Antibiotic eye drops are not necessary unless there is an infection.

Patching the eye has not been shown to promote healing, reduce pain, and in high risk populations, i.e., contact-lens wearers, will increase the chance of infection.

In fact, if you decide to patch the eye, you should absolutely rx abx gtts because of the increased risk of infection.

Tetracaine at time of exam +/- flourescein to confirm abrasion will reduce pain immediately and allow a better exam.

 

[Birdstrike]

.

 

[dhb]

Why not just keep them intubated for 3 days waiting for it to heal?

 

[Frank Rizzo]

Work with a lot of optho docs. I've talked to many of them about said topic... ask 5 different docs, get 5 different answers, which tells me it doesn't matter all that much. Only thing they agree on is IF you use tetracaine, it should be a one time thing in PACU then no more, for the exact reasons already discussed in this thread. Iced saline opthalmic gtts can be very helpful in relieving the pain.

 

[Jay K]

My brother is an ER physician, and he tells me the anesthesiologists at his hospital tell their PDPHs to go to the ER and then never show their faces to assess or manage the complication they caused. This is particularly inappropriate since anesthesia caused and should manage that complication to completion

Interesting, this is the complete reverse at my practice locations. We're always being consulted for epidural blood patches for PDPH days out as a result of lumbar punctures performed in the ED for meningitis workups.

Do the ED docs at your brother's place of work perform epidural blood patches?

One logistics issue, at our practice sites, is that irrespective of cause, PDPH patients must be admitted properly to the hospital (not necessarily hospital admission), but must have an entry site into "the system." So, people calling in about PDPH must either come in via the ER for initial eval, and then the ED requests our consult for PDPH eval and treatment, or they're "admitted" via "preop" from the floor as a add-on.

Also, patients should receive a w/u first to determine/rule out other causes of "headache" so that other etiologies aren't missed; As you well know, many complaints blamed as PDPH don't pan out to really be PDPH. Those are some reasons I can see why an anesthesia service would have patients show up first to the ER for a, sometimes very brief yet appropriately so, w/u then the appropriate consult to anesthesia for eval and treatment.

Not ragging on your brother's ED dept or defending the anesthesia dept there, just commenting on our practice.

ON TOPIC - I appreciate reading everyone's responses (esp ED responses) re: corneal abrasion Rx; Haven't had to deal with one, but my residency program's knee-jerk response was always opthalmology consult.

 

[Dusn]

Yeah, I'd agree with most of what was said. Erythromycin ophthalmic ointment (ointment blurs the vision but helps provide some relief), or vigamox eye drops (but vigamox is expensive).

Most consults I've had in residency (I'm ophtho) are annoying because we're required to do a full consult even though we could tell you the diagnosis and treatment over the phone. It really almost always ends up being that nice horizontal linear corneal abrasion from a lid that wasn't fully taped closed. The patient always feels like something is in the eye when it's really an abrasion.

The corneal epithelium heals very quickly and should be about healed by the next day. Tetracaine slows the corneal healing and if they take it home with them and use it chronically it will make them lose their cornea and can lead to blindness. Like Birdstrike said before, even if you did nothing the patient would almost always be fine -- the only truly bad mistake is letting them take home a bottle of tetracaine, lido or proparacaine. I only use 1 drop of proparacaine in the PACU to do the exam.

When I'm an attending in private practice, I'm sure I'd be more than happy to be sent your corneal abrasion. Sending a corneal abrasion to the ER sounds ridiculous.