By Dr Steven Lam, Specsavers Sunbury, VIC
Px: 58-year-old male who works in a plant nursery
Reason for visit: The patient’s RE was stabbed by a branch when he was picking up a medium-sized tree at work two days prior to presentation. Was prescribed chloramphenicol q.i.d. by the pharmacist on the same day, however the pain did not resolve. There was no significant family, ocular or general health history.
Ocular motility: Full
Pupils: PERRLA DCN
VA: RE: 6/9.5 LE: 6/6
Slit lamp examination
Anterior segment: Large superior corneal abrasion on RE not crossing the pupil. Anterior chamber was clear and quiet (Figure 1).
Posterior segment: NAD
Diagnosis & Management
- Corneal abrasion
- Herpes simplex keratitis
- Fungal keratitis
- Acute angle closure
Diagnosis: Corneal abrasion secondary to trauma in the RE
- Bandage contact lens (Opteyes / Biofinity Monthly -0.50)
- Prophylaxis minims chloramphenicol q.i.d.
Corneal abrasions typically involve damage to the corneal epithelium due to mechanical trauma, foreign bodies, contact lenses, or chemical and flash burns. Patients normally present with a detailed history of the incident, symptoms of pain, conjunctival hyperaemia, epiphora, photophobia, blurred vision, inability to open eyelids, and a foreign body sensation in the involved eye.
Examination of patients with corneal abrasions will require initial local anaesthetic such as one drop of Alcaine 0.5% in the affected eye for compliance. Once the patient’s VA is measured, a diagnosis can be made on slit lamp examination with fluorescein staining and a cobalt blue filter. Upon examination, clinicians will see an area of pooled fluorescein at the site of injury. It is important that clinicians also rule out foreign bodies with lid eversion and corneal perforations with the Siedel test.
Management of severe corneal abrasions may involve pain relief with a SiHy monthly bandage contact lens to prevent further mechanical rubbing from the eyelids on the area, and topical analgesics such as ketorolac 0.5%, diclofenac 0.1% or oral, over-the-counter analgesics. Prophylactic antibiotics such as chloramphenicol should also be applied four times a day. If the patient is a frequent contact lens wearer, amino glycosides that provide gram-negative bacteria cover should be considered to prevent infections from Pseudomonas aeruginosa.
Review periods for corneal abrasions should be 24 hours then every 2-3 days until full resolution. The lesion should show signs of healing within 24 hours. However, if no improvement or worsening is seen, other differential diagnoses and urgent referral to rule these out should be considered.
The patient was managed with an Opteyes monthly -0.50DS contact lens, although any SiHy monthly lens can act as a bandage. When reviewed 24 hours later, the abrasion had almost completely healed (Figure 2). The bandage contact lens was removed and all antibiotics stopped. Since the injury originated from plant matter, the patient was reviewed a week later to exclude delayed fungal keratitis.
This case highlights how a bandage contact lens can significantly help improve corneal healing and pain symptoms after severe injury.
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