Corneal emergencies

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

Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal AnatomyCorneal Anatomy

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!

Fluorescein stainFluorescein stain
 Stains stroma (=defect in theStains 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
 HZOHZO
May treat and review, depending onMay 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, 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?).

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

Corneal Stromal haze andCorneal Stromal haze and
fluorescein stainfluorescein stain

Alkali burns -Alkali burns -
mild and moderatemild and moderate
Limbal
ischaemia

 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.).

 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)

 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).

Chemical burns – a bad oneChemical burns – a bad one

 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

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

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

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

Fungal scleritis/keratitisFungal scleritis/keratitis

Microbial keratitis - post LASIKMicrobial keratitis - post LASIK

Microbial keratitis, hypopyonMicrobial keratitis, hypopyon

Corneal infiltratesCorneal infiltrates

DDxDDx
Old scar in a quiet eyeOld scar in a quiet eye
(herpes)(herpes)
Band keratopathyBand keratopathy
(Calcium deposition)(Calcium deposition)

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

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

Corneal lacerationCorneal laceration

Corneal lacerationCorneal laceration
 Consider IOFBConsider IOFB  CT ScanCT Scan
 Needs surgicalNeeds 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 dilatationpupil dilatation
(Atropine 1%)(Atropine 1%)
 Topical steroidTopical 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 steroidsIntensive 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, scleritisAutoimmune ulcers, scleritis
vasculitisvasculitis
 Rheumatoid arthritis, SLE w/Rheumatoid arthritis, SLE w/
vasculitis, Wegener’svasculitis, Wegener’s
granulomatosis.granulomatosis.
 Rx corneaRx cornea
 Rx underlyingRx underlying
condition – systemiccondition – systemic
steroids,steroids,
immunosuppressionimmunosuppression

Rheumatoid melt (ulcer)Rheumatoid melt (ulcer)

Rheumatoid melt - glue and CLRheumatoid melt - glue and CL

Rheumatoid melt – inferiorRheumatoid 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
 HZOHZO
 May treat and review, depending onMay 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 – highBeware 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 out25 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 a25G 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 epithelialInferior punctate epithelial
erosions (exposure)erosions (exposure)

Lateral tarsorraphy and lower lidLateral tarsorraphy and lower lid
tighteningtightening

Corneal abrasion / erosions /Corneal abrasion / erosions /
welding flash burnwelding flash burn
 Large or small (punctate) epithelialLarge 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) - baseBranching ulcer (superficial) - base
stains with Fluorescein, edges withstains with Fluorescein, edges with
Rose Bengal (red)Rose Bengal (red)
 wipe off infected cells w/ cotton budwipe 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 responsereview in 2 days to check response
to Rxto Rx

Herpes SimplexHerpes Simplex
dendritic ulcersdendritic ulcers

HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus
 Oral acyclovir 800mg 5 x a day (orOral acyclovir 800mg 5 x a day (or
famcyclovir, valacyclovir)famcyclovir, valacyclovir)
 Ophthalmic review to detectOphthalmic review to detect
intraocular inflammation, increasedintraocular inflammation, increased
IOPIOP
 Can have late corneal andCan have late corneal and
inflammatory problemsinflammatory problems

HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus
Late Neurotrophic corneal
ulcer and scar.
V1 rash of
HZO

Questions?Questions?
Thank YouThank You

Corneal emergencies

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