ER docs pushing for tetracaine for corneal abrasions!

[Slide]

Recently our ER staff have been suggesting topical tetracaine for patients to take home short term for corneal abrasions. In the past, when consulted for this, I would educate them on what tetracaine toxicity could do to the cornea. However, they are now touting an ER publication from New Zealand suggesting that it's ok to send patients home on this. There are a few flaws with the study but it's not stopping their enthusiasm for this study. Has anyone encountered similar experiences, and what have you said to them to discourage them from doing this practice? To me this sounds like an extremely dangerous move on their part.

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[TheLesPaul]

I would document "NO TETRACAINE Rx to be given" in your note if you get consulted. Someone is bound to get an ulcer from this, it's only a matter of time.

 

[MstaKing10]

how bout you quote articles discussing the risk of topical anesthetic abuse and resultant corneal ulcers, melts etc. Leave it in the chart if need be. Seems like they need to be schooled on the risks involved with this recommendation. I'm surprised really. Not a good idea.

 

[ophthope]

Tell the ER doc that if you ever see a corneal melt on a patient they put on a topical anesthetic, you'll testify against them in the lawsuit that you're helping the patient file.

Seriously what the heck, there is a known risk of ulcers and corneal melt from this.

 

[cme2c]

There are plenty of refractive surgeons who prescribe dilute tetracaine for their PRK patients. But it is dilute and they will provide a limited quantity of the drops. If the ER is going to use dilute agents and only provide enough for a day of use, fine. But, I have recently seen patients prescribed tetracaine or proparacaine and given 15ml bottles, most were from urgent cares without slit lamps. Not to mention the fact that many providers who see patients in the ED are not properly trained on the slit lamp exam. If I had an abrasion, I would want a bandage contact lens and and a decent broad spectrum antibiotic drop.

 

[TheLesPaul]

If I had an abrasion, I would want a bandage contact lens and and a decent broad spectrum antibiotic drop.

That's pretty silly of you then. Unless you have some predisposing process like corneal anesthesia or recurrent neurotrophic ulcers, it doesn't make any sense to a) slap a BCTL on especially if it's relatively smaller like most abrasions, or b) give Vigamox and breed FQ resistance. PSP works just as well to prevent infection.

I agree with you about possibly providing very dilute tetracaine, perhaps in one of those "single-use" droppers like PFATs come in.

 

[MstaKing10]

There are plenty of refractive surgeons who prescribe dilute tetracaine for their PRK patients. But it is dilute and they will provide a limited quantity of the drops. If the ER is going to use dilute agents and only provide enough for a day of use, fine. But, I have recently seen patients prescribed tetracaine or proparacaine and given 15ml bottles, most were from urgent cares without slit lamps. Not to mention the fact that many providers who see patients in the ED are not properly trained on the slit lamp exam. If I had an abrasion, I would want a bandage contact lens and and a decent broad spectrum antibiotic drop.

I don't mind a trained ophthalmologist prescribing these dilute agents in the post operative period under careful follow up and observation. I have a HUGE problem with ER docs doing so. What if the patient has a corneal ulcer, viral keratitis or autoimmune issue causing the "abrasion"? ER and primary care docs are not properly trained to diagnose or treat these conditions and starting the patient on tetracaine would only excacerbate this and lead to possible complications. Especially in the ER setting where the patient does not have appropriate follow up, this is particularly irresponsible. Still horrified by this practice and hope it is stopped.

More than one way to manage an abrasion. If its large and edges irregular/rolled, a contact lens makes sense. Otherwise, several drops/antibiotics and ointments work well. Can even patch the eye for 24h if need be (I don't do this but some good docs I work with do). Topical tetracaine is not a good "treatment" for this condition.

 

[Slide]

Well I'm not surprised other people are experiencing this too. I'm a senior resident now and I've known since the start of residency you don't treat K abrasions with tetracaine. The reason I'm more alarmed is that in our department, ER docs are starting to push this paper as proof that it's ok:

Waldman N et al. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the
treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med. 2014
Apr;21(4):374-82.

The paper has flaws and it has unreasonable expectations that would not fly in the real world. I can't find this paper on PubMed so I believe this journal probably will not have much impact long term but it's still concerning that ER physicians are trying to use this one paper to justify giving patients tetracaine (which they will sometimes even despite our recs). The fact as Cme2c said, most ER docs don't know how to turn on a slit lamp on, much less use one properly ("Oh yeah I saw the corneal abrasion under the Wood's lamp! Use the cobalt blue what?),

 

[Apollyon]

I'm just a dumb ER doc, so I want people to name names, at least in the city where these docs in the ED are pushing aggressively to give the tetracaine to the patients. I've been out of residency for 8 years, and I learned in residency to not give the bottle to the patients, because, as I tell them, "You'll keep putting the drops in and your cornea will scratch away, and you won't know it". I am not a cowboy, by any means, and this thread is another example of one group of extremists that are painted as indicative of the whole. There was an article about this topic in one of our throwaways, and I told myself "I don't care what they say - I am not giving that bottle to the patients".

As far as "not knowing how to use the slit lamp", well, whatever. I do it. It's a required skill for EM residency. If you are a resident or in academics, and the EM program is failing, then take it upon yourself to help us out. That's a lot better than just MFing us and throwing us under the bus en bloc.

 

[RustedFox]

EM attending here; 2.5 years out in practice.

EVERYONE at my three sites, even the MLPs, knows not to give the tetracaine out.

 

[WilcoWorld]

Do you folks know that the data on tetracaine toxicity comes mostly from animal studies? The human literature against tetracaine is a series of case reports, and in this series 14/15 who developed toxicity used excessive amounts of the drug. Also, are you aware that there are multiple studies in the Ophtho literature supporting the use of tetracaine or proparicaine for post op pain?

-Verma S et al. A comparative study of the duration and efficacy of tetracaine 1% and bupivacaine 0.75% in controlling pain following photorefractive keratectomy (PRK). Eur J Ophthalmol. 1997 Oct-Dec; 7(4):327-33
-Brilakis HS and Deutsch TA. Topical tetracaine with ban- dage soft contact lens pain control after photorefractive keratectomy. J Refract Surg. 2000 Jul-Aug;16(4):444-7
-Shahinian L Jr et al. Dilute topical proparacaine for pain relief after photorefractive keratectomy. Ophthalmol- ogy. 1997 Aug;104(8):1327-32

All of these studies found topical anesthetics to be safe, when given appropriately, for post op pain.

Now, before we generalize these findings to treating corneal abrasions in the ED, we should look at literature on that population in particular. Fortunately, Dr. Ball has done just that:
-Ball IM et al. Dilute proparacaine for the management of acute corneal injuries in the emergency department. CJEM. 2010 Sep;12(5):389-96

This study had promising results. But it is worth noting that this was done with dilute proparicanie, and it was a small study. A larger study would be needed if it were to be powered to detect a small, but significant danger. As Slide mentioned above, a study published in 2014 found no difference in wound healing when tetracaine was used in a double-blind RCT study of 116 patients with corneal abrasion (BTW it is available on PubMed - here's a link.)

So should "ER Docs" start sending people out with high-concentration tetracaine for corneal ulcers? No!
Should we question the received dogma that topical anesthetics should NEVER be used for corneal abrasions? Yes.

But don't listen to me, I'm just a dumb ER Doc (who reads the literature and, surprisingly, knows how to turn on the slit lamp and calibrate the tonopen).

 

[Slide]

Whoa no reason to take my comments personally as an attack to you. No one is saying ER docs are dumb. You guys do an important service and I respect the job you guys do in dealing with all types of emergencies. I couldn't do it, and I'm glad there are physicians that can handle that sort of stress.

That said, I was posting this thread to see what experiences other places with ophtho support were experiencing. I am still standing by my assertion that tetracaine, regular or dilute strength, is right now not appropriate for corneal abrasions in the ER. I stand by it because I've seen the complications from patients using tetracaine for corneal abrasions and I've had to manage them. I've asked cornea specialists about this issue and they too agree this should not be done in the ER. You may see some cornea specialists use a dilute solution of proparacaine, but that's only select patients that will follow up in 24 hours, and in post-refractive cases because the abrasion/wound is a clean wound with a known mechanism, and that is definitely not the norm. However, after 24 hours, the drops are stopped. They also are comfortable doing it because they can manage the complications that can come with topical anesthetics. There aren't many studies in ophthalmology journals that are double blind studying this because corneal abrasions often heal in 1-3 days as long as the abrasion does not get infected and there is no mechanical reason for it. The animal studies may not be as strong as clinical studies, but there's not much effort going into it because the general consensus in ophthalmology is to discourage such practices. As a result, we thankfully do not see topical anesthetic usage complications because the general consensus in ophthalmology is to discourage it.

As far as that paper cited, there are several issues with it. First, the patients appear to be aggressively called to make sure they followed up quickly. Such a practice may not be realistic, especially if there's no way to contact the patient. Another is that visual acuities were not recorded. A pain scale is NOT the best way to assess if a corneal abrasion has improved. Last, I did not see any mention of confirmation by an optometrist or ophthalmologist that the abrasions were indeed simple corneal abrasions.

Yes I'm a lowly resident, so you can disregard anything I say because I'm in "training." But, my issues are that:
1) if A patient seen in the ER is getting pain relief and is told to follow up tomorrow, will he/she? If they're feeling better, they may not show up because they think the abrasion has healed, which leads to....
2) a corneal ulcer! The main reason abrasions are seen daily is not for pain but to make sure there's not an ulcer. If an ulcer isn't caught early the patient may then be getting Q1hour vanc and tobramycin.
3) some corneal abrasions may have subtle but important clues that means different treatment may be needed. If there's a pseudomembrane or something under the eyelid that's causing the mechanical mechanism for the abrasion, topical anesthetics may make it worse by weakening the corneal epithelium and stroma. If the abrasion is from neurotrophic keratopathy, then that cornea is going to be in big trouble with constant topical anesthetics (not to mention they can't feel their corneas very well).
4) antibiotics and lubrication work well, it may hurt for several hours but it heals fast if treated properly. A corneal abrasion may be painful but lots of injuries can be painful, that doesn't mean we always give enough pain relief so there is no pain felt during the healing period.
5) some cornea specialists are also concerned about possible corneal melt with prolonged use. I don't know what evidence they are using but I'm not going to argue with a cornea specialist about corneal management.

My concern isn't because of ER docs going against our recs; I have no problem with disagreement. My issue is that this could potentially cause harm to patients in the future and require costly treatments or surgeries in the future. Oh, and to those ER docs that know how to properly use a slit lamp, I thank you for taking the time and effort to use one properly. My comment above wasn't meant to be snide, it was based on many night in the ER with residents unable to use the slit lamp. I'd say we as ophthalmologists should try to educate them more, but we let them rotate with us and give them lots of lectures on it, but some of them just ignore us.

 

[nyr77]

Read WIlco's reply. There are now two studies, a canadian and an australian which show no harm from use of topical anesthetics in corneal abrasions, this dogma is based on animal studies using incredibly high dosage, and word of mouth, not actual evidence based medicine. We currently have more literature for use of topical anesthetics in human trials than against it.

 

[Slide]

Read WIlco's reply. There are now two studies, a canadian and an australian which show no harm from use of topical anesthetics in corneal abrasions, this dogma is based on animal studies using incredibly high dosage, and word of mouth, not actual evidence based medicine. We currently have more literature for use of topical anesthetics in human trials than against it.

I did, and my response was partly due to that. The evidence in ophthalmology are mainly case reports and animal models. There's little interest right now, partly because for regular corneal abrasions it's considered somewhat unethical to do it, but if tetracaine dispensing is being more commonly done, you may see some being done in the future. Though there are small clinical studies that may support tetracaine, it is still scant, and does not fit with the physiology of corneal healing (that corneal sensation is necessary for good epithelial healing, which is well documented). EBM is not perfect, especially when weighed in against the clinical experiences of ophthalmologists and the physiology of corneal healing.

In addition, tetracaine only lasts for about 15-30 minutes before it wears off. If you want to keep a patient pain-free, the patients may be putting at least 4 drops in every hour. That adds up to a lot. My issue is that we have a reliable and safe way to treat abrasions, we don't need to change what we know works very well.

The other thing as other posters alluded to is that corneal abrasions aren't just diagnoses, they may also be symptoms of an underlying disease. I'm not saying for an ophthalmology consult for every corneal abrasion, but to abstain from potentially risky medications if you're not 100% sure how to diagnose and manage the complications from using it.

 

[backrow]

I'm a risks/benefits kind of guy.

Risk: although likely on the small side is a vision threatening condition that could potentially be the cause for a patient to need a corneal transplant.

Benefit: according to the most recent study a perceived increase in the efficacy of the drug over placebo, BUT no change in pain scales.

Does the small (yes my opinion) benefit outweigh the risks, albeit likely small, of a vision threatening condition.

To me, no.

 

[MstaKing10]

Lets throw out the papers regarding post operative PRK patients, that's a totally different patient population under different circumstances...apples and oranges.

There are plenty of papers discussing the risk of topical anesthetics in humans. Do yourself a favor and Pubmed keywords: topical, anasthetic, abuse, cornea.

The Canadian Paper:
- Excluded any patients that could not follow up or those having prior eye pathology. That may be very difficult to discern in the ER setting.
- The proparacaine was diluted in the hospitals pharmacy. Not sure that is cost effective or even possible in most non-academic centers.
- All patients followed up on day 1,3, and 5 of the study with an ophthalmologist. In the real world, it is difficult to predict which patients will follow up and which will not. This type of careful follow up may not work in many situations.
- The numbers were really small (15 and 18 patients in each group) with short follow up. Are there potential complications that the study is not powered enough to pick up? Yes, the writers acknowledge this.

The New Zealand Paper:
- Excluded high risk patients (infection, complications). Again, hard to discern in ER setting.
- Patients were re-assessed at 48hours, and called at one week and one month. I don't believe many ER docs would follow this protocol.
- Didn't show ANY difference in pain scores between the two groups. REALLY?? Isn't that the whole point?

This is overall pretty weak evidence to use as a rationalization for changing your practice and quite frankly diverging from standard of care. This is potentially a medical-legal issue. If someone melts their cornea or has a blinding condition that the tetracaine drops masked, will you step up to the stand and quote these papers as your defense? I hope not.

Lets look at the bigger picture: what's the downside of prescribing a wide spectrum antibiotic in the ER and sending the patient on their way with instructions to follow up the next day with an ophthalmologist? None really. So why take the risk? To relieve their pain? According to the New Zealand paper, it doesn't even do that!!!

I've taken care of two patients who were blinded by: 1. persistent corneal ulcer leading to infection and 2. corneal melt both associated with topical anesthetic abuse from topical anesthetics that the patients stole from an eye doctors office. Not good.

 

[dantt]

2) a corneal ulcer! The main reason abrasions are seen daily is not for pain but to make sure there's not an ulcer. If an ulcer isn't caught early the patient may then be getting Q1hour vanc and tobramycin.

Do you guys see corneal abrasions daily? Seems rather excessive if you've seen the patient and know the mechanism...

 

[Slide]

Unfortunately we do. At least here we've been burned for not doing so, especially with some of the patients we have. It's only daily for 1-2 days so it's not too bad. At first I thought it was excessive, but then I had a few patients who didn't follow up and ended up a week later with an ulcer. For kids it's an absolute must, especially from a medicolegal standpoint.

 

[backrow]

Do you guys see corneal abrasions daily? Seems rather excessive if you've seen the patient and know the mechanism...

Yes, they get seen daily until the epithelium heals at some institutions.