Superficial Trauma

SUBCONJUNCTIVAL HEMORRHAGE The fragile conjunctival vessels can rupture from trauma, sudden Valsalva pressure spikes (sneezing, coughing, vomiting, straining), hypertension, or spontaneously with no discernible etiology. No treatment is necessary, and the hemorrhage usually resolves within 2 weeks. If multiple recurrent episodes occur, coagulation studies and further investigation are warranted.

CONJUNCTIVAL ABRASION Superficial conjunctival abrasions without any other associated ocular injury only requires erythromycin ointment bid for 2 to 3 days or no treatment if very small. The lid should be everted and the fornix inspected under magnification for any residual particulate matter or organic debris.

CORNEAL ABRASION Abrasions of the cornea are associated with pain, photophobia, and tearing. They can be the result of trauma or contact-lens wear. Visual acuity assessment can be difficult because of the patient's extreme discomfort. A drop of a topical anesthetic will often reduce the discomfort temporarily and facilitate visual acuity testing. A corneal epithelial defect will be present and is best seen with fluorescein staining and examination with a cobalt-blue light. The eyelid should be everted and inspected for foreign bodies. Examine the cornea for possible full-thickness injury (optical sectioning) and assess the anterior chamber with the slit lamp, looking for any associated injury. Adequate and persistent cycloplegia is essential to controlling pain. Reduction of ciliary spasm contributes significantly to pain relief and in most cases eliminates the need for narcotic pain medication. By the same token, inadequate cycloplegia almost mandates the need for oral analgesics. If an abrasion is larger than 2 mm or very painful, consider having the patient instill a cycloplegic agent (cyclopentolate 1%, homatropine 5%, or scopolamine 0.25%), one drop every 6 to 8 h at home to help control discomfort. Scopolamine dilates the pupil for several days and is usually reserved for very large, painful abrasions. Cyclopentolate 1% (Cyclogyl) one drop tid does an excellent job of providing cycloplegia and wears off within 24 h of discontinuation. Erythromycin ophthalmic ointment should be instilled and an eye patch may be placed, if desired, provided that the abrasion was not from an organic source or from the wearing of soft contact lenses. Abrasions will heal with or without a patch and ophthalmologists will treat patients either way. Some patients appear to be more comfortable with an eye patch for the first 12 to 18 h, but this is not uniform and the physician can make an individual decision with the patient. Abrasions from organic sources have fungal potential and should not be patched. Abrasions related to the wearing of soft contact lenses pose a risk of Pseudomonas infection and likewise should not be patched. These patients should be treated with tobramycin ointment qid, followed by a fluoroquinolone (Ciloxan, Ocuflox) drop or tobramycin drop qid once the epithelial defect starts to close. Do not prescribe a topical anesthetic for pain relief, most anesthetics cause corneal toxicity when recurrently dosed and can lead to blinding complications.

Documenting the Dimensions of a Corneal Abrasion Some slit lamps (Haag-Streit) have a measuring dial attached to the mechanism that varies the length of the slit beam (Fig.. ,230-11, Plate 1.3)- If your slit lamp is equipped with this feature, you can vary the length of the slit beam on the cornea until it corresponds to the length or width of the abrasion. The reading on the wheel equals the length of the slit beam in millimeters. This additional feature allows you to document the dimensions of the abrasion precisely, thereby enabling subsequent examiners to evaluate the wound's healing response objectively.

Corneal Abrasion Slit Lamp

FIG. 230-11. (Plate_13). Slit-lamp measuring wheel. The length of the light beam on the cornea can be varied and the reading on the dial represents the length in millimeters. Useful in measuring corneal abrasion dimensions.

Treatment:

1. Identify source of abrasion if possible.

2. Cycloplegia (cyclopentolate 1%, or homatropine 5%) one drop now and repeat q 6-8 h as needed for pain. Warn patient that the pupil will dilate, lose its ability to focus at near, and that the drop will burn for 10 to 15 s when placed in the eye.

3. Not related to contact-lens wear: Erythryomycin ophthalmic ointment and eye patch, or no patch and erythromycin ointment qid.

4. Related to contact-lens wear: Tobramycin ophthalmic ointment qid. No patch.

5. Organic source: Erythromycin ophthalmic ointment qid. No patch.

6. Ophthalmology referral or reexamine next day.

CONJUNCTIVAL FOREIGN BODIES Conjunctival foreign bodies can usually be removed with a moistened, cotton-tipped applicator after anesthetizing the eye with a topical anesthetic. The upper eyelid should be everted and inspected under the highest magnification available to avoid missing any additional foreign bodies. Frequently small wooden particles such as sawdust will blend into the conjunctiva when moistened by the tears and be difficult to find without slit-lamp magnification. Small, fine vertical corneal abrasions seen only with fluorescein staining will often alert the physician to the presence of a foreign body embedded in the tarsal conjunctiva of the upper lid.

CORNEAL FOREIGN BODIES Foreign bodies should be removed carefully under the best magnification available. The slit lamp provides sufficient magnification and allows both hands to be free for use. A history consistent with high-velocity ocular impact (i.e., hammering metal on metal) should alert you to the possibility of a penetrating injury. The cornea should be inspected using "optical sectioning" (see Fig, 23.0.-11) to assess depth of penetration prior to removal. Full-thickness foreign bodies should not be removed in the ED and require an ophthalmology consult. Fortunately most corneal foreign bodies are superficial and can be removed easily and safely. A "golf-club spud" is a handy tool for this task, but a small 30- to 25-gauge needle under slit lamp magnification, or moistened, cotton-tipped applicator will work most of the time. A topical anesthetic should be instilled prior to removal, and it is helpful to also instill an anesthetic drop in the unaffected eye to suppress reflex blinking during removal. Many slit lamps have an attached "fixation light" that is mobile and can be moved in front of the unaffected eye to give the patient a steady target to concentrate on. This reduces the random movements that can occur when you are trying to remove the foreign body. The eyelids can be held open with your fingers, or a wire eyelid speculum can provide excellent support during the procedure. Metallic foreign bodies can create rust rings that are toxic to the corneal tissue. If a rust ring is present, the spud or an ophthalmic burr can be used to remove most of the rust. Even if a thorough job is done initially, the next day more rust can often be seen, requiring additional burring. It is therefore not necessary to go after all the rust aggressively in the ED if the patient can be seen by an ophthalmologist the next day. The rust-ring area can soften overnight and be removed in the office the next day. The deeper the stromal involvement, the higher the risk of corneal scarring; therefore, only a superficial burring should take place in the ED. No ED drill burring should take place if the rust ring is located in the visual axis (pupil) owing to the risk of causing visually significant scarring. These patients should have an ophthalmologist remove the stromal rust in the office within 24 h. As with any foreign body of the eye, the lid should be everted and inspected under magnification to ensure that no additional foreign bodies are present. The corneal abrasion that will be present after the removal of a foreign body should be treated as previously discussed, with adequate cycloplegia, antibiotic ointment, and optional patching.

Treatment:

1. Instill topical anesthetic in both eyes to suppress the blink reflex.

2. Test visual acuity (sometimes easier after an anesthetic drop is administered).

3. Assess if this is a full-thickness or penetrating injury.

4. Remove the foreign body under slit-lamp magnification and remove superficial rust if possible. Use burr if available, but avoid burring in visual axis.

5. Evert lid to rule out additional foreign bodies.

6. Treat resultant corneal abrasion with topical cycloplegia, erythromycin ointment, and optional patching (see " Conjunctiv§l,A.bra.sio.O," above).

7. Referral to ophthalmologist, to be seen the next day.

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