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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
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!
Fluorescein stainFluorescein stain
 Stains stroma (=defect in theStains stroma (=defect in the
epithelium)epithelium)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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. 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
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
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?).
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal Stromal haze andCorneal Stromal haze and
fluorescein stainfluorescein stain
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Alkali burns -Alkali burns -
mild and moderatemild and moderate
Limbal
ischaemia
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.).
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)
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).
Chemical burns – a bad oneChemical burns – a bad one
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
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
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
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Fungal scleritis/keratitisFungal scleritis/keratitis
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Microbial keratitis - post LASIKMicrobial keratitis - post LASIK
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Microbial keratitis, hypopyonMicrobial keratitis, hypopyon
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal infiltratesCorneal infiltrates
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)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal Perforation in ContactCorneal Perforation in Contact
Lens-related MicrobialLens-related Microbial
KeratitisKeratitis
Seidel’s test - 2% Fluorescein dropsSeidel’s test - 2% Fluorescein drops
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal lacerationCorneal laceration
Corneal lacerationCorneal laceration
 Consider IOFBConsider IOFB  CT ScanCT Scan
 Needs surgicalNeeds surgical
repairrepair
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Shield, Analgesia,Antiemesis,Shield, Analgesia,Antiemesis,
ReferRefer
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
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).
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal transplant rejectionCorneal transplant rejection
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Loose corneal transplant sutureLoose corneal transplant suture
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Rheumatoid melt (ulcer)Rheumatoid melt (ulcer)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Rheumatoid melt - glue and CLRheumatoid melt - glue and CL
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Rheumatoid melt – inferiorRheumatoid melt – inferior
arcuate patch graftarcuate patch graft
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Nodular scleritisNodular scleritis
Lasik Flap shiftLasik Flap shift
 Relatively minor trauma but poor VARelatively minor trauma but poor VA
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Questions?Questions?
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. 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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
CFB and rust ringCFB and rust ring
Subtarsal FBSubtarsal FB
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Inferior punctate epithelialInferior punctate epithelial
erosions (exposure)erosions (exposure)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Lateral tarsorraphy and lower lidLateral tarsorraphy and lower lid
tighteningtightening
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Welding flash burnWelding flash burn
(“photokeratitis”)(“photokeratitis”)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Healing corneal abrasionHealing corneal abrasion
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Questions?Questions?
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Herpes SimplexHerpes Simplex
dendritic ulcersdendritic ulcers
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Herpes SimplexHerpes Simplex
dendritic ulcersdendritic ulcers
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
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
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus
Late Neurotrophic corneal
ulcer and scar.
V1 rash of
HZO
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Questions?Questions?
Thank YouThank You

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Corneal emergencies

  • 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. 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
  • 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 Seidel’s test - 2% Fluorescein dropsSeidel’s 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
  • 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, Wegener’svasculitis, Wegener’s granulomatosis.granulomatosis.  Rx corneaRx cornea  Rx underlyingRx underlying condition – systemiccondition – systemic steroids,steroids, immunosuppressionimmunosuppression
  • 34. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Rheumatoid melt (ulcer)Rheumatoid melt (ulcer)
  • 35. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Rheumatoid melt - glue and CLRheumatoid melt - glue and CL
  • 36. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Rheumatoid melt – inferiorRheumatoid melt – inferior arcuate patch graftarcuate patch graft
  • 37. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Nodular scleritisNodular scleritis
  • 38. Lasik Flap shiftLasik Flap shift  Relatively minor trauma but poor VARelatively minor trauma but poor VA Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
  • 39. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Questions?Questions?
  • 40. 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. 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
  • 41. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 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)
  • 42. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Corneal Foreign BodyCorneal Foreign Body
  • 43. Removing a CFBRemoving a CFB  LA (oxybuprocaine,LA (oxybuprocaine, Alcaine)Alcaine)  25G needle on a25G needle on a cotton budcotton bud Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
  • 44. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 CFB and rust ringCFB and rust ring
  • 45. Subtarsal FBSubtarsal FB Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
  • 46. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 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
  • 47. Facial palsyFacial palsy Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
  • 48. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Inferior punctate epithelialInferior punctate epithelial erosions (exposure)erosions (exposure)
  • 49. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Lateral tarsorraphy and lower lidLateral tarsorraphy and lower lid tighteningtightening
  • 50. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 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
  • 51. Corneal abrasion / erosionCorneal abrasion / erosion Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
  • 52. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Welding flash burnWelding flash burn (“photokeratitis”)(“photokeratitis”)
  • 53. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Healing corneal abrasionHealing corneal abrasion
  • 54. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Questions?Questions?
  • 55. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 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
  • 56. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Herpes SimplexHerpes Simplex dendritic ulcersdendritic ulcers
  • 57. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Herpes SimplexHerpes Simplex dendritic ulcersdendritic ulcers
  • 58. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 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
  • 59. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus Late Neurotrophic corneal ulcer and scar. V1 rash of HZO
  • 60. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011 Questions?Questions? Thank YouThank You