Transcript Corneal Abrasions

Symptoms noted on presentation at Sibley Memorial
Emergency Department on August 26, 201 included:
This is the cover of a brochure published in the summer of 2011 by Sibley Hospital. Featured on the cover is Dr. Cope’s
photograph along with an introductory heading to a new fast track initiative to move patients in and out of the ER at an
accelerated pace. I was at the ER for a total of 35 minutes and one wonders how much of that had to do with this
financially motivated “imitative”.
This presentation includes salient points about the injury, infection and subsequent
Pain and suffering that I sustained as a result of misdiagnosis and mistreatment that
Exacerbated or caused a melting corneal ulcer. The mismanagement of my
Heathcare on August 25th occurred at Sibley Memorial Hospital by attending physian
Gregory Cope, MD.
Corneal abrasions`(From HCP LIVE published in 2007)
The management of corneal abrasions involves pain relief
and prevention of secondary infection. The decision to patch an eye after
a corneal abrasion is very controversial.13 Patching the eye closed will alleviate
some pain, but it does not accelerate corneal healing.14 Eye patching should be
avoided if the corneal abrasion was caused by organic trauma or contact lenses
because the patching can allow microbial contaminants to proliferate overnight
Soft contact lens use It is also important to ask about the use of soft
contact lenses. A soft contact lens wearer with a red eye should be
presumed to have an infectious corneal ulcer (bacterial keratitis)
until proven otherwise. There is a high incidence of gram-negative corneal
ulcers (ie, Pseudomonas aeruginosa infection) in patients who sleep
while wearing their contact lenses.6 Any corneal epithelial defect with an
underlying "white" corneal opacity noted on examination should be assumed to be a
corneal ulcer (Figure 3). Such a patient should urgently be referred to an ophthalmologist.
If not properly diagnosed and treated, the risk of developing a visually debilitating scar
or a corneal perforation is high because the microbial enzymes can rapidly melt the
cornea.7 Treatment consists of topical fortified broad-spectrum antibiotics applied to the
eye at hourly intervals. Topical corticosteroids are contraindicated in the presence of
infectious corneal ulcers because they may accelerate further melting of the cornea.
Where does information for the emergency physician come
from?
Challenge unique to the emergency physician:
Relevant information can come from literature in any specialty
•
Original studies, review articles, editorials •
Literature interpretation
clearinghouses/systematic reviews: Cochrane, BestBETs, I
nfo POEMs,
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,
review Of Optometry.com)
•
Guidelines - local, national
•
Local practice
•
Personal experience
Management
Note when
This was
published
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
Analgesia
Ophthalmology followup 24 hours
Management
Undebated Approaches
Do not prescribe topical anesthetics for any reason
Do not patch high risk corneal abrasions, meaning:
The person presenting is a contact lens wearer
organic matter such as a tree limb is a possible cause
Emergency protocol should be implemented if there is no
Improvement in symptoms four hours after removal of the contact
lens. The assumption of microbial keratitis is standard and an
Emergency consult with an ophthalmologist is necessary for
Immediate evaluation and treatment.
Management
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 10to 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
Analgesia
Ophthalmology followup 24 hours
Management
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 10to 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
Analgesia
Ophthalmology followup 24 hours
The Search
•
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
Applying the Patch
Had I not been a contact lens wearer and not removed my lens the night
before (and seen improvement in the hours since removal) and if the
abrasion was considered large 10 mm in diameter then a minority of
physicians may have patched the eye. The key is that they would have
patched the eye, not given me the materials and written and verbal
instructions to do so myself when I got home. This was presumably because
I was driving however, I should have been advised not to drive. Note, the
time spent in the ER was 35 minutes exactly and discharge was at 7:00 pm.
In the interim it had grown to dusk outdoors. My visual acuity without
correction in the left eye was legally blind. All facts known and noted by Dr.
Cope. Below is a description of how patching was formerly done in non
contact lens wearers:
Two gauze eye pads and three strips of tape are required for patching. Antibiotic ointment is applied
to the eye by instilling a small amount (1/2" to 1" ribbon) in the inferior cul-de-sac. One pad is folded
in half. The patient is asked to close both eyes gently. There should be no squeezing of the
orbicularis muscles. The folded patch is used to occupy the space over the globe in the orbit and
apply pressure to the globe. The second pad is then placed over the folded pad. The patient or an
assistant is asked to apply firm pressure to the second pad, while it is being taped firmly with the
three strips of tape. These strips are most effective if place obliquely from the midline over the nose
toward the cheekbone. The patient is then asked to open the eyes and report if the lid under the
patch can be raised. If it can then the patch has not been applied successfully and must be redone.
The patch is left in place overnight, and no more than 24 hours. A patch that is worn too long may
interfere with the diagnosis of infection because the patient cannot monitor vision and discharge.
Pseudomonas Ulcers Following Patching of
Corneal Abrasions Associated with Contact
•
•
•
Lens Wear
Clemons, Carol S. MD; Cohen, Elisabeth J. MD; Arentsen, Juan J. MD; Donnenfeld, Eric
D. MD; Laibson, Peter R. MD
: We report our experience with six patients-each with a history of contact lens use-who
were diagnosed as having Pseudomonas corneal ulcers after having been pressure
patched in treatment for apparent corneal abrasions. Four of these six patients (67%)
required penetrating keratoplasty due to marked central corneal scarring following healing
of their corneal ulcers. By comparison, among the 44 patients with a history of contact
lens use hospitalized at Wills Eye Hospital between January 1978 and June 1986 with
Pseudomonas corneal ulcers, only 11 (25%) required corneal transplantation. It is
important to be aware that serious ulcers associated with the use of contact lenses can
present initially as sterile-appearing erosions. Pressure patching should be avoided in
patients with corneal abrasions and a history of contact lens use. Note: Even
unweighted, this represents an increase by 42 percent in the percentage of patients
who developed P. Aeruginosa infections soley because they were pressure
patched, with no other variations in treatment, presentation or etiology. In reality
the percentage is much greater because of the number of cases involved in the
unpatched group.
(C) 1987 The Contact Lens Association of Ophthalmologists,
Inc.
Vance Wilson was planning to leave on a vacation to the Black Hills of South Dakota on Friday, August 26 th, 2011 (labor day weekend. He had
just purchased a Canon p95 camera and was testing it on the evening of August 24th, 2011. This photo was taken with the self timer function at
about 10 pm. A few hours earlier, Mr. Wilson had removed his left contact lens due to a scratching or irritated feeling; as this photo shows, his
left eye appears fairly clear at that time. Twenty hours later, he presented at the Sibley Memorial Hospital Emergency department because of
increased redness, photophobia, tearing, pain, and spasm. He had not put the contact lens in since its removal before this photo was taken.
Mr. Wilson followed The instructions and Used the materials given to him by
Dr. Gregory Cope; patching his left eye after applying a ribbon of the erythromycin
ointment from the sample tube obtained from the physician at bed time which that evening
was at 12:30 am. Nine or ten hours later
he awoke to blindness, copious blue-green discharge, eyes crusted shut and in debilitating
pain. Shocked, he called Washington Eye Physicians and Surgeons and scheduled an
Exam for that afternoon. This photo was taken by Dr. Neil Martin at Washington Eye on
September 1, 2011 at approximately 3:00 PM, following a week of harrowing treatment
At Johns Hopkins University in Baltimore, MD. Prior to this the eye was completely obscured By a white mucous substance. Mr. Wilson’s vision at
this stage was hand movement at 4 feet.
Wilson, Vance
left eye on September 1, 2011 (photographed by
Dr. Neil Martin – Washington Eye Physcians and
Surgeons.
Vance Wilson on May 25th, 2012 following corneal transplant surgery; note this surgery was needed to correct the
scarring that resulted from Sibley’s mistreatment and performed almost exactly nine months after the injury and
infection
inflicted at Sibley Memorial Hospital. The following are issues resulting from the August, 26 th, 2011 incident noted
in Mr. Wilson’s left eye as of October 15, 2012:
Posterior Synechiae (scarring of the posterior chamber
Unevenly shaped Iris due to melding of pupil and iris tissue during infection.
+2 Cataract formed during infection
Neovascularization formed during
infection.
Exaggerated astigmatism
uneven topography. Each
of these conditions has a
cumulative negative impact in
increasing the risk for future
rejection of the transplant and
additional complications, some
eye threatening. (evisceration of the eye.)
The surgeon who perfomred the transplant
has stated that the prognosis is unknown due
to the deeply scarred eye tissue; current vision
in left eye is 20’70 to 20’100 (fluctuating). Mr.
Wilson is still using steriod drops every four
hours in his left eye.
There are eleven
stitches' still in the
eye (originally there
were 18.)
Comparison photo showing scar taken on April 30th, 2012 –left eye
Is at right in photograph. The Corneal transplant was performed on
May 23rd, 2012.
Pseudomonas Ulcers Following Patching of
Corneal Abrasions Associated with Contact
•
•
•
Lens Wear
Clemons, Carol S. MD; Cohen, Elisabeth J. MD; Arentsen, Juan J. MD;
Donnenfeld, Eric D. MD; Laibson, Peter R. MD
: We report our experience with six patients-each with a history of contact
lens use-who were diagnosed as having Pseudomonas corneal ulcers after
having been pressure patched in treatment for apparent corneal abrasions.
Four of these six patients (67%) required penetrating keratoplasty due to
marked central corneal scarring following healing of their corneal ulcers. By
comparison, among the 44 patients with a history of contact lens use
hospitalized at Wills Eye Hospital between January 1978 and June 1986 with
Pseudomonas corneal ulcers, only 11 (25%) required corneal
transplantation. It is important to be aware that serious ulcers associated with
the use of contact lenses can present initially as sterile-appearing erosions.
Pressure patching should be avoided in patients with corneal abrasions and
a history of contact lens use. Note: This represents an increase by 42
percent in the percentage of patients who developed P. Aeruginosa
infections soley because they were pressure patched, with no other
variations in treatment, presentation or etiology.
(C) 1987 The Contact Lens Association of Ophthalmologists, Inc.
Dr. Cope noted a centrally located “defect”
on my left cornea. He also noted that I had
removed my left contact lens the evening
before and seen in the hours since then
(about sixteen hours) worsening or
progressing symptoms, warranting an
emergency ophthalmological consult
(standard of practice, nationally)
Symptoms noted: photophobia, pain
FBS, clear discharge, loss of vision
Was not noted but that is inexplicable becaus
a) I was not wearing glasses and my vision
was very poor and b) an epithelial defect was
Centrally on my left cornea. I do not recall
And there is not mention of a visual
Acuity exam.
***
***I think this alone says it all.
algorithm
Abrasion was not large; the ulcer
Was measured at 4.5 cm D the next
Day at Washington Eye. I verbally rated
Pain as a “7” on a 1-10 scale noted in chart.
Corneal Abrasions
Corneal abrasions are defects of the normal corneal epithelium caused by trauma from small objects
(often a fingernail, twig, hairbrush, or comb). They also occur after removal of a foreign body. Corneal
abrasions from contact lenses represent a separate category with a unique set of clinical problems. In
a one-year survey of admissions to a British emergency eye clinic, corneal abrasions accounted for
10% of the visits.54
Corneal abrasions are quite painful, and most people do not return to full functioning until the abrasion
is healed. Patients describe immediate, sharp pain followed rapidly by tearing, photophobia, a
decrease in visual acuity, and a persistent foreign body sensation. The eye will appear injected.
Topical anesthetic drops will often significantly improve the pain, reduce blepharospasm, and allow a
full examination. Fluorescein staining reveals the corneal defect. The magnification provided by a slit
lamp allows a detailed quantification of the size as well as the depth of the lesion. The natural history of
most abrasions is full healing in 2-3 days. Except in the cases of abrasions associated with contact
lens use, infection occurs in fewer than 1% of cases. Until the mid-1990s, accepted therapy involved
occlusive eye patches, antibiotic ointments (felt to be more soothing than drops), oral analgesics, and
optional cycloplegics. The theory behind the occlusive patches was to provide a stable corneal
environment to promote rapid reepithelialization. Patches were also thought to reduce pain.
A meta-analysis by Flynn et al in 1998 that combined five randomized clinical trials showed no
statistical difference in healing between patched and un-patched eyes, and no reduction in pain in
patients whose eyes were patched.55 These trials, however, enrolled only patients with small- to
moderatesized abrasions (< 10 mm2). Large abrasions seem to enjoy improved healing if patched.56
Unlike eye patching, topical NSAID drops may improve patient comfort. In one randomized, doubleblind, placebo-controlled trial of 100 patients with corneal abrasions, topical ketorolac 0.5% (Acular)
was shown to reduce pain and photophobia significantly at the one-day mark. The ketorolac group was
also able to return to function one day sooner, on average, than the placebo group. There was no
difference in rates of healing or complications.56 A smaller study using diclofenac 0.3% (Voltaren)
showed a small but statistically significant improvement in pain scale at two hours.57 The exact
mechanism of action of these topical NSAIDs has not yet been delineated. It is probably some
combination of reduction in pain sensation and antiinflammatory effect.56 For traumatic, non-contact
lens abrasions with significant pain, Kaiser et al recommendketorolac 0.3% QID for three days or until
the patient is comfortable, a broad-spectrum antibiotic ointment TID for three days or until the abrasion
is healed, an optional shortacting cycloplegic such as cyclopentolate, and no patch (unless the
abrasion is > 10 mm2).56 Many emergency physicians prescribe narcotic pain medicines for patients
with corneal abrasions; these drugs are especially appreciated when the patient tries to go to sleep.
Corneal abrasions in contact lens users represent a distinct problem. There are approximately 25
million contact lens wearers in the U.S. They are all at increased risk of developing infected
abrasions—referred to as ulcerative keratitis. Overnight, extended-wear soft lenses carry a 10- to 15fold risk of infection. The causative organism is most often Pseudomonas species. The course can be
fulminant, leading to permanent vision loss from corneal scarring.
Do not patch corneal abrasions secondary to contact lens use. In 1987, Clemons et al reported six
cases of Pseudomonas keratitis following pressure patching for contact-lensassociated corneal
abrasions.58 The occlusive patch favors bacterial replication by raising corneal temperature and
interfering in the normal protective effects of routine eye blinking, tear exchange, and tear movement.
The treatment of contact-lens-associated abrasions should begin with an antibiotic ointment that
covers Pseudomonas (such as gentamicin [Genoptic] or combination polymixin/bacitracin). Steroid
combinations should be avoided, as they may favor bacterial replication. Follow-up within 24 hours
should be arranged, because suppuration of the abrasions can occur rapidly. Contact lens use should
not resume until the abrasion is fully healed.59 The offending lenses should be replaced or inspected
carefully for evidence of damage. Note the pressure patching accelerated suppuration sot that it had
occurred within 15 hours and probably much sooner.