corneal emergencies

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A summary of emergency management of common anterior segment emergencies

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  • 1.Corneal EmergenciesCorneal Emergencies Dr Laurence SullivanDr Laurence Sullivan Corneal Clinic, RVEEHCorneal Clinic, RVEEH Bayside Eye Specialists, BrightonBayside Eye Specialists, Brighton 100 Victoria Parade East Melbourne100 Victoria Parade East Melbourne LasersightLasersight

2. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal AnatomyCorneal Anatomy 3. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Useful ToolsUseful Tools Slit lamp / magnificationSlit lamp / magnification Fluorescein stain [either strips orFluorescein stain [either strips or drops (2%)]. Stains corneal stroma,drops (2%)]. Stains corneal stroma, i.e. epithelial defect.i.e. epithelial defect. Local anaesthetic dropsLocal anaesthetic drops cotton buds, fine (25G)cotton buds, fine (25G) needleneedle Telephone!Telephone! 4. Fluorescein stainFluorescein stain Stains stroma (=defect in theStains stroma (=defect in the epithelium)epithelium) Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 5. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Minor EmergenciesMinor Emergencies Corneal or subtarsal foreign bodyCorneal or subtarsal foreign body Welding flash burnWelding flash burn Corneal abrasion/recurrent erosionsCorneal abrasion/recurrent erosions Corneal exposure e.g. Bells palsyCorneal exposure e.g. Bells palsy HSV dendriteHSV dendrite HZOHZO May treat and review, depending onMay treat and review, depending on circumstancescircumstances 6. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Major emergenciesMajor emergencies Chemical burns (Alkali, or Lime)Chemical burns (Alkali, or Lime) Microbial (bacterial) keratitisMicrobial (bacterial) keratitis Also fungal, HSV, acanthamoebaAlso fungal, HSV, acanthamoeba Trauma / laceration / perforationTrauma / laceration / perforation Corneal graft rejectionCorneal graft rejection Autoimmune melts / scleritis / vasculitisAutoimmune melts / scleritis / vasculitis LASIK flap shiftLASIK flap shift All require urgent referralAll require urgent referral 7. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Chemical burnsChemical burns Alkali (lime), acid, alcohol, otherAlkali (lime), acid, alcohol, other solventssolvents Alkali worse because of increasedAlkali worse because of increased penetration into corneal tissuepenetration into corneal tissue First Aid at site: Irrigation, irrigation,First Aid at site: Irrigation, irrigation, irrigation! 1-2L of normal saline, tapirrigation! 1-2L of normal saline, tap water, soft drink, milk, beer, (?water, soft drink, milk, beer, (? urine?).urine?). 8. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Chemical burns - signsChemical burns - signs Epithelial defect (fluorescein stain)Epithelial defect (fluorescein stain) Cloudy corneaCloudy cornea Conj.Conj. hyperaemiahyperaemia Beware if conj.Beware if conj. is blanchedis blanched (ischaemic)(ischaemic) Non-healing ulcer Acute ulcer 9. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal Stromal haze andCorneal Stromal haze and fluorescein stainfluorescein stain 10. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Alkali burns -Alkali burns - mild and moderatemild and moderate Limbal ischaemia 11. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Chemical burnsChemical burns The long term problem is damage toThe long term problem is damage to corneal limbal stem cells (>270corneal limbal stem cells (>270)), or, or stromal damage which makes thestromal damage which makes the cornea unable to produce/support ancornea unable to produce/support an epitheliumepithelium Leads to chronic epithelial defect,Leads to chronic epithelial defect, stromal lysis, scarring andstromal lysis, scarring and vascularisation (conj.).vascularisation (conj.). 12. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Chemical burnsChemical burns A&E: Irrigation, irrigation, irrigation!A&E: Irrigation, irrigation, irrigation! 1-2L normal saline.1-2L normal saline. LA drops will help for exam &LA drops will help for exam & irrigation (Benoxinate/Oxybuprocaineirrigation (Benoxinate/Oxybuprocaine or Amethocaine, or Xylocaine 1%)or Amethocaine, or Xylocaine 1%) Analgesia. Dilate pupil (for comfort:Analgesia. Dilate pupil (for comfort: Mydriacyl/Tropicamide, HomatropineMydriacyl/Tropicamide, Homatropine they all have red tops)they all have red tops) Check pH (7-8 OK)Check pH (7-8 OK) 13. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Chemical burnsChemical burns Slit lamp exam (LA) - extent ofSlit lamp exam (LA) - extent of epithelial loss (fluorescein stain).epithelial loss (fluorescein stain). Limbal involvement?Limbal involvement? (whitening+ischaemia)(whitening+ischaemia) Evert upper lid, remove particulateEvert upper lid, remove particulate matter with cotton bud, forceps.matter with cotton bud, forceps. Conj. may be white if ischaemic (badConj. may be white if ischaemic (bad sign).sign). 14. Chemical burns a bad oneChemical burns a bad one Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 15. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Chemical burnsChemical burns ReferRefer allall with epithelial defect.with epithelial defect. On arrival at RVEEH, irrigation isOn arrival at RVEEH, irrigation is often repeated!often repeated! Then, topical antibiotics, steroids,Then, topical antibiotics, steroids, citrate and ascorbate (buffer alkalicitrate and ascorbate (buffer alkali and inhibit PMN proteinase enzymes,and inhibit PMN proteinase enzymes, support new collagen fromsupport new collagen from keratocytes), antiglaucoma Rx.keratocytes), antiglaucoma Rx. AMTAMT 16. Microbial keratitisMicrobial keratitis A soggy white spot (PMNs) on theA soggy white spot (PMNs) on the cornea of an inflamed eyecornea of an inflamed eye Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 17. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Microbial KeratitisMicrobial Keratitis Risk factors: contact lens wear, trauma,Risk factors: contact lens wear, trauma, organic contamination, topical steroid droporganic contamination, topical steroid drop use.use. Red eyeRed eye Ulcer (fl. Stain)Ulcer (fl. Stain) Corneal infiltrate (white spot) = PMNsCorneal infiltrate (white spot) = PMNs Hypopyon (pus level in anterior chamber)Hypopyon (pus level in anterior chamber) PainPain 18. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Microbial KeratitisMicrobial Keratitis - Management- Management Refer for corneal scraping ->Refer for corneal scraping -> Microscopy, culture, sensitivities.Microscopy, culture, sensitivities. Admit (often)Admit (often) Intensive topical broad spectrumIntensive topical broad spectrum antibiotic drops (Ciprofloxacin q1hantibiotic drops (Ciprofloxacin q1h D&N)D&N) Modify Rx according to micro resultsModify Rx according to micro results 19. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Fungal scleritis/keratitisFungal scleritis/keratitis 20. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Microbial keratitis - post LASIKMicrobial keratitis - post LASIK 21. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Microbial keratitis, hypopyonMicrobial keratitis, hypopyon 22. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal infiltratesCorneal infiltrates 23. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 DDxDDx Old scar in a quiet eyeOld scar in a quiet eye (herpes)(herpes) Band keratopathyBand keratopathy (Calcium deposition)(Calcium deposition) 24. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal Perforation in ContactCorneal Perforation in Contact Lens-related MicrobialLens-related Microbial KeratitisKeratitis Seidels test - 2% Fluorescein dropsSeidels test - 2% Fluorescein drops 25. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 TraumaTrauma Laceration, perforationLaceration, perforation If full thickness, usually -> urgentIf full thickness, usually -> urgent surgery under GA (suture or graft)surgery under GA (suture or graft) Fasting, eye shield, analgesia, anti-Fasting, eye shield, analgesia, anti- emeticsemetics No drops if perforatedNo drops if perforated 26. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal lacerationCorneal laceration 27. Corneal lacerationCorneal laceration Consider IOFBConsider IOFB CT ScanCT Scan Needs surgicalNeeds surgical repairrepair Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 28. Shield, Analgesia,Antiemesis,Shield, Analgesia,Antiemesis, ReferRefer Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 29. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Traumatic HyphaemaTraumatic Hyphaema Blunt traumaBlunt trauma Rx bed rest, admit?Rx bed rest, admit? AnalgesiaAnalgesia pupil dilatationpupil dilatation (Atropine 1%)(Atropine 1%) Topical steroidTopical steroid dropsdrops no aspirinno aspirin 30. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal transplant rejectionCorneal transplant rejection Setting: Corneal transplant, red eye,Setting: Corneal transplant, red eye, blurred vision, photophobia.blurred vision, photophobia. Keratic precipitates - PMNs &Keratic precipitates - PMNs & macrophages on back surface of corneamacrophages on back surface of cornea Exclude suture and wound problems,Exclude suture and wound problems, infection.infection. Intensive potent topical steroidsIntensive potent topical steroids (Prednefrin forte or Dexamethasone 1%(Prednefrin forte or Dexamethasone 1% q1h).q1h). 31. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal transplant rejectionCorneal transplant rejection 32. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Loose corneal transplant sutureLoose corneal transplant suture 33. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Autoimmune ulcers, scleritisAutoimmune ulcers, scleritis vasculitisvasculitis Rheumatoid arthritis, SLE w/Rheumatoid arthritis, SLE w/ vasculitis, Wegenersvasculitis, Wegeners granulomatosis.granulomatosis. Rx corneaRx cornea Rx underlyingRx underlying condition systemiccondition systemic steroids,steroids, immunosupp