Another Poke in the Eye

Corneal abrasion — there is an epithelial defect that takes up fluorescein.

Corneal abrasion (+/- foreign body) is the most common form of eye trauma presenting to the emergency department.

History:

• History of trauma: scratching or hitting the eye, nature of the object, could a foreign body still be present?
• Symptoms: sharp pain, photophobia, foreign body sensation, tearing, discomfort with blinking.
• Contact lens use?

Examination:

• Visual acuity: may be reduced if central
• Slit lamp:
  • Use topical anesthesia and identify an epithelial defect that stains with fluorescein.Assess size, depth, and location.Other features – conjunctival injection, edematous eyelid, mild AC reaction.
• Look for evidence of: infection — significant infiltrate, marked AC reaction, purulent discharge penetrating eye injury

Evert the eyelids to look for a foreign body!

Consider the possibility of:

• HSV keratitis
• recurrent corneal erosions
• superficial punctate keratopathy (SPK)

Management:

• oral analgesia and topical cycloplegics
• topical antibiotic
  • There is little evidence of efficacy
  • The Australian Therapeutic Guidelines (2010) suggests chloramphenicol drops
  • The Will’s Eye Manual suggests covering injuries due to fingernail scratches and vegetable matter with fluoroquinolones
    contact lens wearers need anti-pseudomonal coverage (among other nasty bugs) and are best discussed with an ophthalmologist.
• consider removal of loose or hanging epithelium that may impair healing.
• tetanus prophylaxis if indicated.

Review until healed. A small, peripheral lesion can be reviewed after about 3 days. A large or central lesion is best reviewed the next day.

Contact lens wearers should be reviewed daily. Contact lenses should not be used until the defect is healed and the eye has felt back to normal for at least a week.

To rule out the presence of an occult foreign body hidden under the upper eyelid. If missed ongoing trauma to the surface of the eye may occur.

Here are 3 methods:

Method 1:

• Folding the upper eyelid on itself, using the tip of a cotton bud or similar device to help flex the lid ten hold it in place. This takes a surprising amount of skill and can make the novice look like, well, a novice.
• ask the patient to look down.
• place the cotton bud about 5 mm from the lid crease and apply light pressure.
• evert the over the cotton bud using the eyelashes to lift the eyelid up and away from the globe.
• hold in in the everted position with the tip of your cotton bud so that the eyelid doesn’t flick back, leaving you back where you started…

Method 2:

• Double-eversion using an eyelid retractor.
• If the upper eyelid is thoroughly anesthetised with topical anesthetic, the everted eyelid can be further everted using a modified paper clip (e.g. bed in half at 90 degrees and slide under the everted eyelid).
• It can give a great view, but its not always tolerated by the patient — despite what evangelists for the technique may say…
• Furthermore, flakes of metal from the paper clip can result in corneal abrasions.

Method 3 (ALIEM trick of the trade)

• An ingenious method I learned from Michelle Lin’s ‘Tricks of the Trade’ on Academic Life in Emergency Medicine is to use a cotton bud to roll the upper eyelid back on itself — too easy!

• Ehlers JP, Shah CP, Fenton GL, Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease Lippincott Williams & Wilkins
• NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide. [Free PDF]