Download - Corneal emergencies

Corneal EmergenciesCorneal Emergencies

Dr Laurence SullivanDr Laurence SullivanCorneal Clinic, RVEEHCorneal Clinic, RVEEH

Bayside Eye Specialists, BrightonBayside Eye Specialists, Brighton100 Victoria Parade East Melbourne100 Victoria Parade East Melbourne

LasersightLasersight

Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

Corneal AnatomyCorneal Anatomy


Useful ToolsUseful Tools

Slit lamp / magnificationSlit lamp / magnification Fluorescein stain [either strips or Fluorescein 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!

Fluorescein stainFluorescein stain

Stains stroma (=defect in the Stains stroma (=defect in the epithelium)epithelium)



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. Bell’s palsyCorneal exposure e.g. Bell’s palsy HSV dendriteHSV dendrite HZO HZO May treat and review, depending on May treat and review, depending on

circumstancescircumstances


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


Chemical burnsChemical burns

Alkali (lime), acid, alcohol, other Alkali (lime), acid, alcohol, other solventssolvents

Alkali worse because of increased Alkali 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, tap irrigation! 1-2L of normal saline, tap water, soft drink, milk, beer, (?water, soft drink, milk, beer, (?urine?).urine?).


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 blanched is blanched

(ischaemic)(ischaemic)Non-healing ulcer

Acute ulcer


Corneal Stromal haze and Corneal Stromal haze and fluorescein stainfluorescein stain


Alkali burns -Alkali burns - mild and moderate mild and moderate

Limbal ischaemia



The long term problem is damage to The long term problem is damage to corneal limbal stem cells (>270corneal limbal stem cells (>270°)°), or , or stromal damage which makes the stromal damage which makes the cornea unable to produce/support an cornea unable to produce/support an epitheliumepithelium

Leads to chronic epithelial defect, Leads to chronic epithelial defect, stromal lysis, scarring and stromal lysis, scarring and vascularisation (conj.).vascularisation (conj.).



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/Oxybuprocaine irrigation (Benoxinate/Oxybuprocaine or Amethocaine, or Xylocaine 1%) or Amethocaine, or Xylocaine 1%) Analgesia. Dilate pupil (for comfort: Analgesia. Dilate pupil (for comfort: Mydriacyl/Tropicamide, Homatropine Mydriacyl/Tropicamide, Homatropine they all have red tops)they all have red tops)

Check pH (7-8 OK)Check pH (7-8 OK)



Slit lamp exam (LA) - extent of Slit 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 particulate Evert upper lid, remove particulate matter with cotton bud, forceps.matter with cotton bud, forceps.

Conj. may be white if ischaemic (bad Conj. may be white if ischaemic (bad sign).sign).

Chemical burns – a bad oneChemical burns – a bad one




Refer Refer allall with epithelial defect. with epithelial defect. On arrival at RVEEH, irrigation is often On arrival at RVEEH, irrigation is often

repeated!repeated! Then, topical antibiotics, steroids, Then, topical antibiotics, steroids,

citrate and ascorbate (buffer alkali citrate and ascorbate (buffer alkali and inhibit PMN proteinase enzymes, and inhibit PMN proteinase enzymes, support new collagen from support new collagen from keratocytes), antiglaucoma Rx.keratocytes), antiglaucoma Rx.

AMT AMT

Microbial keratitisMicrobial keratitis

A soggy white spot (PMNs) on the A soggy white spot (PMNs) on the cornea of an inflamed eyecornea of an inflamed eye



Microbial KeratitisMicrobial Keratitis

Risk factors: contact lens wear, trauma, Risk factors: contact lens wear, trauma, organic contamination, topical steroid drop organic 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


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 spectrum Intensive topical broad spectrum

antibiotic drops (Ciprofloxacin q1h antibiotic drops (Ciprofloxacin q1h D&N)D&N)

Modify Rx according to micro resultsModify Rx according to micro results


Fungal scleritis/keratitisFungal scleritis/keratitis


Microbial keratitis - post LASIKMicrobial keratitis - post LASIK


Microbial keratitis, hypopyonMicrobial keratitis, hypopyon


Corneal infiltratesCorneal infiltrates


DDxDDxOld scar in a quiet eye Old scar in a quiet eye (herpes)(herpes)

Band keratopathy Band keratopathy (Calcium deposition)(Calcium deposition)


Corneal Perforation in Contact Corneal Perforation in Contact Lens-related Microbial Lens-related Microbial Keratitis Keratitis Seidel’s test - 2% Fluorescein dropsSeidel’s test - 2% Fluorescein drops


TraumaTrauma

Laceration, perforationLaceration, perforation If full thickness, usually -> urgent If 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


Corneal lacerationCorneal laceration

Corneal lacerationCorneal laceration

Consider IOFBConsider IOFB CT ScanCT Scan Needs surgical Needs surgical

repairrepair


Shield, Analgesia,Antiemesis, Shield, Analgesia,Antiemesis, ReferRefer



Traumatic HyphaemaTraumatic Hyphaema

Blunt traumaBlunt trauma

Rx bed rest, admit?Rx bed rest, admit? AnalgesiaAnalgesia pupil dilatation pupil dilatation

(Atropine 1%)(Atropine 1%) Topical steroid Topical steroid

dropsdrops no aspirinno aspirin


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 steroids Intensive potent topical steroids (Prednefrin forte or Dexamethasone 1% (Prednefrin forte or Dexamethasone 1% q1h).q1h).


Corneal transplant rejectionCorneal transplant rejection


Loose corneal transplant sutureLoose corneal transplant suture


Autoimmune ulcers, scleritis Autoimmune ulcers, scleritis vasculitisvasculitis

Rheumatoid arthritis, SLE w/ Rheumatoid arthritis, SLE w/ vasculitis, Wegener’s vasculitis, Wegener’s granulomatosis.granulomatosis.

Rx corneaRx cornea Rx underlying Rx underlying

condition – systemic condition – systemic

steroids, steroids,

immunosuppressionimmunosuppression


Rheumatoid melt (ulcer)Rheumatoid melt (ulcer)


Rheumatoid melt - glue and CLRheumatoid melt - glue and CL


Rheumatoid melt – inferior Rheumatoid melt – inferior arcuate patch graftarcuate patch graft


Nodular scleritisNodular scleritis

Lasik Flap shiftLasik Flap shift

Relatively minor trauma but poor VARelatively minor trauma but poor VA



Questions?Questions?


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. Bell’s palsyCorneal exposure e.g. Bell’s palsy HSV dendriteHSV dendrite HZO HZO May treat and review, depending on May treat and review, depending on

circumstancescircumstances


Corneal foreign bodyCorneal foreign body Metallic (grinding)Metallic (grinding) Beware organic (infection)Beware organic (infection) Beware hammering metal-on-metal – high Beware hammering metal-on-metal – high

impact, IOFB -> CT scanimpact, IOFB -> CT scan LA dropLA drop 25 G needle on a cotton bud to lift off or dig out 25 G needle on a cotton bud to lift off or dig out

FBFB Oc Chloramphenicol, double padOc Chloramphenicol, double pad Dilate homatropine 2 or 5% statDilate homatropine 2 or 5% stat

?rust ring removal (next day)?rust ring removal (next day)


Corneal Foreign BodyCorneal Foreign Body

Removing a CFBRemoving a CFB

LA (oxybuprocaine,LA (oxybuprocaine,

Alcaine)Alcaine)

25G needle on a 25G needle on a cotton budcotton bud



CFB and rust ringCFB and rust ring

Subtarsal FBSubtarsal FB



Corneal ExposureCorneal Exposure

Facial nerve palsy, acute CVA, LOCFacial nerve palsy, acute CVA, LOC Inability to blink, close lids. May -> Inability to blink, close lids. May ->

ulceration of inferior corneaulceration of inferior cornea Chloramphenicol ointmentChloramphenicol ointment Padding, Lid tapingPadding, Lid taping May need lid suture (tarsorraphy), May need lid suture (tarsorraphy),

Botulinum toxin ptosisBotulinum toxin ptosis

Facial palsyFacial palsy



Inferior punctate epithelial Inferior punctate epithelial erosions (exposure)erosions (exposure)


Lateral tarsorraphy and lower lid Lateral tarsorraphy and lower lid tighteningtightening


Corneal abrasion / erosions / Corneal abrasion / erosions / welding flash burnwelding flash burn

Large or small (punctate) epithelial Large or small (punctate) epithelial defectsdefects

Oc. ChloramphenicolOc. Chloramphenicol +/- double pad+/- double pad +/- pupil dilatation+/- pupil dilatation

Corneal abrasion / erosionCorneal abrasion / erosion



Welding flash burnWelding flash burn(“photokeratitis”)(“photokeratitis”)


Healing corneal abrasionHealing corneal abrasion


HSV dendritic ulcerHSV dendritic ulcer

Branching ulcer (superficial) - base Branching ulcer (superficial) - base stains with Fluorescein, edges with stains with Fluorescein, edges with Rose Bengal (red)Rose Bengal (red)

wipe off infected cells w/ cotton bud -wipe off infected cells w/ cotton bud -> send for HSV PCR> send for HSV PCR

Oc Acyclovir q3h (5x/day) for 7 daysOc Acyclovir q3h (5x/day) for 7 days review in 2 days to check response review in 2 days to check response

to Rxto Rx


Herpes Simplex Herpes Simplex dendritic ulcersdendritic ulcers


HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus

Oral acyclovir 800mg 5 x a day (or Oral acyclovir 800mg 5 x a day (or famcyclovir, valacyclovir)famcyclovir, valacyclovir)

Ophthalmic review to detect Ophthalmic review to detect intraocular inflammation, increased intraocular inflammation, increased IOPIOP

Can have late corneal and Can have late corneal and inflammatory problemsinflammatory problems


HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus

Late Neurotrophic corneal ulcer and scar.

V1 rash of HZO



Thank YouThank You

Download - Corneal emergencies

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