History
Patient: 58 year old male, Works in a plant nursery
Reason for Visit: Picked up a medium sized tree at work and a branch stabbed his right eye 2 days ago. Was provided g.chlorisig qid by the pharmacist on the same day, however the pain has not resolved.
There was no significant family, ocular or general health history.
Clinical Assessment
Pretest
Ocular Motility: Full
Pupils. PERRLA DCN
Acuity
Visual acuity: R. 6/9.5 L. 6/6
Slit Lamp Examination
Anterior Segment: Large superior corneal abrasion on the right eye not crossing the pupil. Anterior chamber was clear and quiet. Posterior Segment: NAD
Differential Diagnosis
- Corneal Abrasion
- Herpes Simplex Keratitis
- Fungal Keratitis
-
Acute angle closure
Management
Dx. Corneal abrasion secondary to plant trauma in the RE.
1. Bandage Contact Lens (Optyes/Bioinfinity Monthly -0.50)
2. Prophylaxis g.Chlorsig minums qid
Discussion
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 eye lids and a foreign body like 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 visual acuity 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 for foreign bodies with lid eversion and corneal perforations with the siedel test.
Management of severe corneal abrasions typically involves pain relief with a silicon hydrogel, monthly bandage contact lens to prevent further mechanical rubbing from the eye lids on the area and topical analgesics such as Ketorolac (Acular)/Diclofenac (Voltaren) 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 such as Tobramycin or Gentamycin 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 in 24 hours, however, if it has become worse, a different differential diagnosis should be considered.
Conclusion
The patient was managed with a opteyes monthly -0.50DS contact lens, although any silicon hydrogen monthly lens can act as a bandage. He was reviewed in 24 hours and almost made a full recovery. The bandage contact lens was removed and all antibiotics was stopped. Since his injury originated from plant matter, he was reviewed in 1 week to exclude delayed fungal keratitis. This case highlights how a bandage contact lens can significantly help improve corneal healing after severe injury.
References
- Donnenfeld E, Selkin B, Perry H, Moadel K, Selkin G, Cohen A, Sperber L. Controlled Evaluation of a Bandage Contact Lens and a Topical Nonsteroidal Anti-inflammatory Drug in Treating Traumatic Corneal Abrasions. AAO. 1995:102(6):979-984
- Punjabi S, Bedi N. A Clinical Study to Evaluate Tehrapeutic Efficacy of Soft Contact Lenses in Corneal Disease. Int J Res Med Sci. 2016:4(10):4632-4636
- Shi D, Song H, Ding T, Qiu W, Wang W. Evaluation of the safety and efficacy of therapeutic bandage contact lenses on post cataract surgery patients. Int J Ophthalmology. 2018:11(2):230-234