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Slide 1 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine
Slide 2 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid
Slide 3 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours
Slide 4 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence
Slide 5 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers
Slide 6 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers
Slide 7 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers
Slide 8 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background
Slide 9 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background
Slide 10 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background
Slide 11 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background
Slide 12 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background
Slide 13 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background
Slide 14 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background
Slide 15 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background
Slide 16 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 17 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 18 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 19 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 20 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 21 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 22 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 23 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 24 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 25 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 26 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal
Slide 27 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background
Slide 28 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 29 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 30 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 31 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 32 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 33 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 34 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 35 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 36 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background
Slide 37 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background
Slide 38 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background
Slide 39 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter
Slide 40 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management
Slide 41 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management
Slide 42 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management
Slide 43 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily
Slide 44 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily
Slide 45 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty
Slide 46 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management
Slide 47 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search
Slide 48 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing
Slide 49 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion?
Slide 50 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion?
Slide 51 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588
Slide 52 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742
Slide 53 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury.
Slide 54 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing
Slide 55 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing
Slide 56 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades
Slide 57 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299
Slide 58 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511
Slide 59 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000)
Slide 60 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion?
Slide 61 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion?
Slide 62 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion?
Slide 63 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort.
Slide 64 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group.
Slide 65 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion?
Slide 66 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion?
Slide 67 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion?
Slide 68 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.”
Slide 69 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions
Slide 70 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions
Slide 71 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil
Slide 72 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion?
Slide 73 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE]
Slide 74 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE]
Slide 75 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE]
Slide 76 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE]
Slide 77 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE]
Slide 78 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE]
Slide 79 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE] Is cycloplegia indicated for corneal abrasion? – glare + relieves pain – blocks accomodation Bottom line No evidence for cycloplegia, weak evidence against it Ophthalmologists use it Jerry Hoffman uses it – acute angle closure glaucoma Does the patient have ciliary spasm? Important negatives precluded by a patch One application is probably enough If ciliary spasm, two drops cyclopentolate or homatropine in the ED x 1 No scopolamine, atropine, or phenylephrine
Slide 80 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions. Medical College of Wisconsin, Waukesha, USA. PMID- 9789511 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 This review was clearly written and presented. Aims and inclusion criteria were stated. Results from two independent literature searches were compared. Relevant information on the included studies was presented in tabular format. Validity criteria were defined and results from the validity assessment and the meta-analysis clearly tabulated. Details were given of methods used to assess validity and statistical heterogeneity assessed and clinical heterogeneity reviewed. The discussion includes consideration of the following limitations of the review: small number of studies with small number of participants; the inability to combine all studies statistically; potential for publication bias; and inter study variations including cause and size of abrasion, setting, and methods used for evaluation of healing. By limiting the search to English language studies identified in one database, albeit with advice sought from experts, some other relevant studies may have been omitted. No details were given of methods used to select primary studies or extract data and validity was assessed by only one reviewer. The authors conclusions were supported by the evidence presented, though more details of methods used in the review and the use of more than one researcher to assess validity would improve the quality of the review. Should we patch corneal abrasions: a meta-analysis (Structured abstract) NHS Centre for Reviews and Dissemination (2000) Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? LeSage, N., et al, Ann Emerg Med 38(2):129, August 2001. Efficacy of Eye Patching for Traumatic Corneal Abrasions: A Controlled Trial. BACKGROUND: Corneal abrasions generally heal within several days. Eye patching is commonly used in these patients based on the belief that it reduces discomfort and might accelerate healing. However patching impairs vision and may foster conditions for the development of infection. Several small and unblinded studies have not reported that patching is beneficial (or harmful). METHODS In this single-blind, prospective study, from Laval University in Quebec, 163 patients presenting to the ED with a traumatic corneal abrasion were randomized to patching or no patching treatment groups. Additional treatment included application of erythromycin ointment, with or without mydriatic agents and/or opioid analgesics at the discretion of the managing physician. On serial follow-up visits, patients were evaluated by a clinician blinded to group assignment RESULTS: There were no differences between the groups in the cumulative rate of healing or reduction of discomfort over time in the total study group or In subgroups of patients with or without a corneal foreign body, or with greater or lesser degrees of initial pain. Rates of healing in the patched and non-patched group were 51% and 60% after 24 hours, and 92% and 88 respectively, after three days. Median discomfort scores on a 12cm visual analogue scale were 6.0 and 5.7 in the patched and non-patched groups on presentation, and 4.7 and 3.7, respectively during the first 24 hours, indicating that both groups experienced substantial discomfort during this period CONCLUSIONS: These results confirm that patching has no apparent benefit (or harm) in patients with a traumatic corneal abrasion, and suggest that greater attention should be focused on effective methods of relieving early discomfort. Is patching indicated for corneal abrasion? Michael JG. Management of corneal abrasion in children: a randomized clinical trial Annals of Emergency Medicine July 2002 STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group. Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Is patching indicated for corneal abrasion? Cochrane Review in progress Expected publication – Second quarter 2005 Angus Turner “About the larger abrasions... I have not found any study that specifically looks at the larger ones. Kaiser 1995 does divide the patients into two groups... those with large abrasions don't have any significant differences with patch or no patch... however, the numbers are small and lacking the power to detect any difference. So, it seems to me, there is no evidence as to what we should do for a large abrasion. In my limited personal experience for what it is worth, I have found contact bandage lenses to really help patients with large abrasions.” Is patching indicated for corneal abrasion? + promotes healing – discomfort + relieves pain – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Bottom Line Patching is indicated for large corneal abrasions Patient wishes, severe pain Never patch high-risk corneal abrasions Is cycloplegia indicated for corneal abrasion? + relieves pain – glare – blocks accomodation Cycloplegia is Mydriasis is Evidence Loss of power in the ciliary muscle of the eye Dilation of the pupil Is cycloplegia indicated for corneal abrasion? Is cycloplegia indicated for corneal abrasion? Brahma AK. Topical analgesia for superficial corneal injuries Journal of Accident and Emergency Medicine 1996 May; 13(3):186-8 Royal Eye Hospital, Manchester, United Kingdom. OBJECTIVE – To assess the analgesic effects of a topical non-steroidal anti-inflammatory agent, flurbiprofen 0.03%, during healing after superficial corneal injuries. METHODS – 401 patients treated for corneal abrasion in a five month period were randomly allocated to one of four treatment groups: polyvinyl alcohol alone (control), homatropine 2%, flurbiprofen 0.03%, or homatropine 2% followed by flurbiprofen 0.03%. Treatments were given for 48 h. Ocular pain was recorded on a visual analogue scale by the patients over the first 24 h, and use of oral analgesics was also recorded. Usable responses were received from 224 patients (55.8%). RESULTS – Patients treated with flurbiprofen had significantly lower pain scores for the 24 h duration of the study than controls (P < 0.05). CONCLUSIONS – Flurbiprofen eye drops provide more effective pain relief than traditional treatments for superficial corneal injuries. PMID: 8733656 [PubMed - indexed for MEDLINE] Is cycloplegia indicated for corneal abrasion? – glare + relieves pain – blocks accomodation Bottom line No evidence for cycloplegia, weak evidence against it Ophthalmologists use it Jerry Hoffman uses it – acute angle closure glaucoma Does the patient have ciliary spasm? Important negatives precluded by a patch One application is probably enough If ciliary spasm, two drops cyclopentolate or homatropine in the ED x 1 No scopolamine, atropine, or phenylephrine
Slide 81 - Management of Corneal Abrasion A Review of the Literature October 27, 2004 Reuben J. Strayer McGill Emergency Medicine Raison d’etre Common Controvercial It’s the eye, stupid Survey *I think that a presssure patch is obsolete. A soft bandage contact lens is more tolerant and the epithelium will heal under this lens in 24 hours Objectives The noncontrovercial The controvercial The background The evidence Background Corneal abrasion vs. corneal epithelial defect Five Layers Corneal abrasion vs. corneal epithelial defect Five Layers Etiologies Trauma / FB Contact lens Spontaneous Background EP Hard Skills management of cardinal presentations management of specific diagnoses EP Soft Skills management of flow documentation billing teaching/taking signout publishing dealing with coworkers reassessment altered mental status abdominal pain cardiac arrest ventricular fibrillation acute appendicitis anticholinergic toxicity corneal abrasion decreased VA red eye eye trauma eye pain Background Differential Diagnosis Blepharitis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Background Differential Diagnosis Background Differential Diagnosis Blepharitis Conjunctivitis Iritis Glaucoma Penetrating eye injury Infectious infiltrate / ulcer Recurrent erosion syndrome (DDx crying baby) Background Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Infectious infiltrate / ulcer Differential Diagnosis Penetrating eye injury Seidel Test Penlight exam hyphema irregular pupil Background High velocity mechanism metal on metal Diagnosis Positive fluorescein exam Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Injection Background Fluorescein Exam Background Diagnosis Pain exacerbated by eye movement Epiphora Blepharospasm Foreign body sensation Photophobia Positive fluorescein exam Response to topical anesthesia Background Diagnosis Sklar, D.P., et al, Ann Emerg Med 18(11):1209, November 1989. Topical Anesthesia of the Eye as a Diagnostic Test The authors, from the University of New Mexico School of Medicine, examined the response to a local anesthetic in patients with eye pain as a predictor of the nature of the injury. Seventy-one patients presenting with eye pain assessed their degree of pain on a visual analogue scale before and after application of one drop of 0.5% proparacaine to the affected eye. Fifty patients had an ultimate slit lamp diagnosis of simple corneal abrasion or foreign body, and 21 had other causes of eye pain (e.g., conjunctivitis, corneal ulcers or abrasions or foreign bodies with iritis, hyphema, glaucoma, subconjunctival hemorrhage). Examination by direct vision with fluorescein and ultraviolet light was inaccurate in diagnosing 24% of the patients with simple corneal abrasions or foreign bodies, and 29% of the patients with other diagnoses. Patients with simple corneal abrasions or foreign bodies had a mean initial pain score that was significantly higher than those with other conditions (6.3 vs. 4.8 on a scale of 1-10), and exhibited a mean change in pain score after application of topical anesthesia that was significantly greater than those with other conditions (5.2 vs. 1.3, p0.001). A decrease in pain score of more than five points or a final pain score of less than one point as an indicator of simple corneal abrasion or foreign body had a sensitivity and specificity of 80% and 86%, respectively. It is suggested that pain due to simple corneal lesions appears to be more responsive to application of a topical anesthetic than pain due to other ocular conditions. The response to topical anesthesia may be useful in the evaluation of patients presenting with eye pain, particularly when slit lamp examination is not immediately available. Background Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA contact lens organic matter Schein, O.D., et al, Am J Emerg Med 11(6):606, November 1993. Contact Lens Abrasions and the Nonophthalmologist About 25 million persons in the U.S. wear contact lenses. Users of contact lenses who sustain corneal abrasions often initially present to primary care physicians. The authors, from the Johns Hopkins University in Baltimore, discuss the management of corneal abrasions in these individuals. Contact lens-associated ulcerative keratitis, a break in the corneal epithelium with underlying suppuration of the corneal stroma, is usually due to bacterial infection and is most commonly caused by Pseudomonas species. The risk of contact lens-associated ulcerative keratitis is increased 10- to 15-fold with overnight use of extended-wear soft lenses as compared with daily wear soft lenses. Appropriate management differs from that of the patient presenting with a corneal abrasion not associated with contact lens use. Erythromycin and sulfas that are frequently employed in patients with other types of mechanical corneal abrasion are inadequate in these cases. Aminoglycoside ointments (e.g., tobramycin or gentamicin) or combination products such as Polymyxin B and Bacitracin, which are effective against Pseudomonas, should be utilized. Routine patching is discouraged, as this intervention limits tearing and increases the temperature and humidity of the ocular surface, favoring bacterial replication. Topical steroids also promote bacterial replication. Since the patient will not experience the pain relief produced by patching, adequate oral analgesics should be employed. Early follow-up should be scheduled (typically within 24 hours), when reexamination with a slit- lamp biomicroscope should be performed. Three cases are discussed in which initial mismanagement resulted in significant sequelae (and litigation in two cases). If no infiltrate, Rx antipseudomonal abx (flouroquinalone or aminoglycoside) drops Ophthalmology followup 24 hours Analgesia Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch high risk CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Benson, W.H., et al, J Emerg Med 11:677, 1993. Tetanus Prophylaxis Following ocular Injuries BACKGROUND: Tetanus prophylaxis is often routinely administered to patients with corneal abrasions. However, development of tetanus following ocular injuries appears to be extremely rare. Only 38 cases have been reported between 1847 and 1993; 33 of these cases involved perforation through the cornea or sclera, and none of the remaining five occurred in patients with simple corneal abrasions. METHODS: This study, from the Medical College of Virginia and West Virginia University Health Sciences Center, assessed the appropriateness of tetanus prophylaxis following eye injuries. Mice were passively immunized with tetanus antitoxin 24 hours prior to instrumentation or received no antitoxin. They were then subjected to three different types of eye injuries (abrasion, penetration or perforation) followed by injection of C. tetani organisms or toxin into the anterior chamber. RESULTS: The frequency of clinical tetanus or death following perforating injuries in unimmunized animals was high (29% [6/21] and 67% [4/6] in mice injected with organisms or toxin, respectively). There were no cases of clinical tetanus or death in the 24 immunized animals subjected to perforating injury, the nine unimmunized animals or nine immunized animals subjected to injection of tetanus organisms or toxin following corneal stroma scarification (penetrating injury), or in the nine unimmunized and nine immunized animals subjected to injection of tetanus organisms or toxin following corneal abrasion. CONCLUSIONS: The authors suggest that tetanus prophylaxis is warranted following perforating ocular injuries, but does not appear to be routinely necessary following uncomplicated corneal abrasions or other nonperforating ocular injuries. Management Undebated Approaches Do not prescribe topical anesthetics for any reason Do not patch contact lens-associated CA A patch should not be left in place for more than 24 hours No steroids If the patient sleeps, most CA’s will have healed by the morning Rx po analgesia Tetanus prophylaxis is indicated for penetrating eye injuries, not for abrasions. Management Follow daily • Original studies, review articles, editorials • Literature interpretation clearinghouses/systematic reviews: Cochrane, BestBETs, infoPOEMs, Clinical Evidence • Opinion clearinghouses: EMA, ACP Journal Club, EM Reports • Paper textbooks (Rosen's Emergency Medicine, Yanoff's Ophthalmology) • Online textbooks (UpToDate, eMedicine, Jeff Mann's EM Guidemaps, ReviewOfOptometry.com) • Guidelines - local, national • Local practice • Personal experience Where does information for the emergency physician come from? Challenge unique to the emergency physician: Relevant information can come from literature in any specialty Textbook Approaches *"The decision to patch a corneal injury is made on a case-by-case evaluation. Patching of the eye may slow healing and may increase the rate of infection and is rarely done. However, it still may be used briefly for patients with significant ciliary spasm and photophobia." **"The practice of pressure patching eyes with corneal epithelial defects has no merit." ***Tetanus toxoid recommended Management • Cochrane • BestBets • EMA Database • infoPOEMs - [several articles I already knew about] • ACP Journal Club, Clinical Evidence [no relevant info] • National Guideline Clearinghouse, Ontario Guidelines Advisory Committee, ACEP Clinical Policies & Policy Statements, CAEP Policies & Guidelines, GuideEM, Primary Care CPG's. [no relevant info] • EM Reports - Eye emergencies and Eye trauma reviews • Journal Watch EM - [two articles I already knew about] • PubMed The Search Are topical antibiotics indicated for simple corneal abrasion? + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983. Antibiotics and Corneal Epithelial Wound Healing. Alfonso E. Effects of gentamicin on healing of transdifferentiating conjunctival epithelium in rabbit eyes. Am J Ophthalmol. 1988 Feb 15;105(2):198-202. Petroutsos G. Int Ophthalmol. 1984 Jun;7(2):65-9. The effect of concentrated antibiotics on the rabbit's corneal epithelium. Petroutsos G. Arch Ophthalmol. 1983 Nov;101(11):1775-8. Antibiotics and corneal epithelial wound healing. Stern GA. Arch Ophthalmol. 1983 Apr;101(4):644-7. Effect of topical antibiotic solutions on corneal epithelial wound healing. Are topical antibiotics indicated for simple corneal abrasion? The authors of this controlled French study evaluated the effect of different concentrations of antibiotic eyedrops on corneal epithelial wound healing in rabbit eyes subjected to corneal wounding. Beginning six hours after wounding, two drops of each test preparation were instilled into both eyes of groups of five animals six times daily. A control group was treated with saline drops. The remaining animals were treated with bacitracin (500U/ml or 10,000U/ml), gentamicin sulfate (3mg/ml or 10mg/ml), neomycin (3.5mg/ml or 8mg/ml), or chloramphenicol (4mg/ml). Serial evaluation of healing rates, indicated that the mean healing rates of animals treated with saline, chloramphenicol, or the lower concentrations of bacitracin, gentamicin, and neomycin did not differ significantly. However when compared to control eyes, corneal healing in animals treated with the higher concentrations of bacitracin, gentamicin, and neomycin was significantly delayed, although the delay in animals treated with 10mg/ml gentamicin and 8mg/ml neomycin was most likely clinically acceptable. Histological examination of four eyes from each treatment group four days after wounding demonstrated that epithelial thickness in eyes treated with saline, 500U/ml bacitracin, 3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml chloramphenicol was similar (three to four layers). Epithelial thickness in eyes treated with 10mg/ml gentamicin and 8mg/ml neomycin was two to three layers. In eyes treated with 10,000U/ml bacitracin, maximum epithelial thickness was two layers. These data confirm the toxicity of the 10,000U/ml bacitracin preparation and demonstrate that healing rate may be influenced by the concentration of antibiotic eyedrop solutions. Petroutsos, G., et al, Arch Ophthalmol 101(11):1775, November 1983 Antibiotics and Corneal Epithelial Wound Healing. Are topical antibiotics indicated for simple corneal abrasion? Are topical antibiotics indicated for simple corneal abrasion? Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R . Emergency eye injuries. Aust Fam Physician. 1990 Jun;19(6):934-8. Accident and Emergency Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland. This study analyses all patients presenting with eye complaints to the casualty section of a Brisbane Hospital during a one month period. Eye complaints constituted 3.6 per cent of all patients. A foreign body was involved in 57 per cent of all eye injuries. The patients were subject to a trial assessing the effectiveness of antibiotic treatment following removal of the foreign body. There was no significant difference between antibiotic and placebo (sterile saline). PMID: 2248588 Are topical antibiotics indicated for simple corneal abrasion? King JW, Brison RJ. Do topical antibiotics help corneal epithelial trauma? Can Fam Physician. 1993 Nov;39:2349-52. Topical antibiotics are routinely used in emergency rooms to treat corneal trauma, although no published evidence supports this treatment. In a noncomparative clinical trial, 351 patients with corneal epithelial injuries were treated without antibiotics. The infection rate was 0.7%, suggesting that such injuries can be safely and effectively managed without antibiotics. A comparative clinical trial is neither warranted nor feasible. Department of Surgery, Queen's University's Faculty of Medicine, Kingston. PMID: 8268742 Are topical antibiotics indicated for simple corneal abrasion? Upadhyay, PC. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85:388–392. Aims—To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. Methods—A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. Results—Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18–24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24–48 hours subsequently developed corneal ulceration. Conclusions—Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury. Are topical antibiotics indicated for simple corneal abrasion? Bottom line: Lemmings Erythromycin .5% ointment 1/2 inch ribbon to eye tid x 3 days Ointments are universally recommended over drops + prevents infection Recommended by most authorities, many of whom admit data is lacking Evidence – resistance – inconvenience – expense – may prevent healing Is patching indicated for corneal abrasion? + promotes healing + relieves pain – discomfort – loss of vision/depth perception – may conceal symptoms of disease progression – retards healing – increases risk of infection Evidence Patching has been the standard of care for decades Is patching indicated for corneal abrasion? Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936. PURPOSE: To evaluate the effectiveness of pressure patching in the treatment of noninfected, noncontact lens-related traumatic corneal abrasions and abrasions secondary to removal of corneal foreign bodies. METHODS: Two hundred twenty-three patients with noninfected, noncontact lens-related traumatic or foreign body removal-related corneal abrasions were followed daily after receiving topical antibiotics and mydriatics and after being randomized to receive either a pressure patch or no patch. RESULTS: Twenty-two patients were excluded from the study. For data analysis, the remaining patients were split into two sections: those with traumatic corneal abrasions (120 patients) and those with corneal abrasions secondary to removal of corneal foreign bodies (81 patients). Patients with traumatic corneal abrasions healed significantly faster, had less pain, and had fewer reports of blurred vision" when they were not wearing a patch. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no-patch groups. Similarly, for corneal abrasions due to removal of foreign bodies, patients healed significantly faster and had less pain when they were not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision. Finally, there was better compliance in the no-patch group. CONCLUSIONS: Noninfected, noncontact lens-related traumatic corneal abrasions as well as abrasions secondary to foreign body removal can be treated with antibiotic ointment and mydriatics alone without the need for a pressure patch. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston 02114, USA. PMID- 9098299 Is patching indicated for corneal abrasion? Flynn, CA, D'Amico, F, Smith, G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1998; 47:264 BACKGROUND: Eye patching is commonly recommended for tr