Corneal Abrasions

Written by: Julian Richardson, MD, MBA (NUEM PGY-2) Edited by: Andrew Moore, MD (NUEM ‘18) Expert commentary by: Brad Sobolewski, MD, MEd

---

A 40 yo construction worker comes to Emergency Department with a foreign body sensation in his left eye for two days. He states that he forgot to wear his eye protection while sanding a plank of wood the other day and felt like something has been scratching his eye ever since. Upon entering the room, his left eye is hyperemic and the patient appears to be in discomfort.

Approach to the painful red eye with foreign body sensation

The initial differential diagnosis to a painful red eye is broad and includes entities such as keratitis, corneal abrasions, corneal ulceration, acute angle glaucoma, iritis, chemical burn, scleritis, subconjunctival hemorrhage, and conjunctivitis. The patient’s history is particularly concerning for corneal abrasion, corneal ulceration, or globe rupture. A simple test to distinguish these diagnoses is the fluorescein exam.

Fluorescein exam

Fluorescein has been used in ophthalmology since the 1880s. This exam should be included for all patients where there is a suspicion of abrasion, foreign body, or infection. Fluorescein absorbs light in blue-wavelengths and emits energy in green wavelengths. It fluoresces in alkaline environments, for example Bowman’s membrane which is located below the corneal epithelium. It does not fluoresce in acidic environments such as the tear film over intact cornea.  Because of this, defects in the cornea increase fluorescein uptake and assist in locating corneal damage.

The eye should first be numbed usually with the use of a topical anesthetic drop, such as tetracaine. Next, take a fluorescein strip and place one drop of saline or local anesthetic to the strip. Place this strip inside the lower lid, remove, and ask the patient to blink. The key to a good exam is to produce a thin layer covering the surface of the eye. If too much is applied, the excess can easily be removed by asking the patient to blot their eye while closed with a tissue. The eye should then be examined using a Wood’s lamp, blue filter of a slit lamp, or penlight with a blue filter

Warning! this dye will permanently stain soft contact lenses and clothing. Be sure to remove any contacts and have plenty of gauze or other absorbant material available prior to instillation. Irrigating the excess dye out the eye after examination will help minimize staining the patient’s clothing.

Corneal Abrasion

Definition

• Scratch to the epithelium that comprises the cornea and exposes the basement membrane. Patients generally complain of a foreign body sensation, pain, photophobia, and some vision loss. On physical exam, the clinician may find injected conjunctiva, and decreased visual acuity (if the defect is large or lies in the visual axis).

 Fluorescein Exam

• Typically, abrasions are seen at the central part of the cornea due to limited protection of closure of the patient’s eyelids. The margins are sharp and linear in the first 24hrs. Circular defects suggests an embedded foreign body is present and may persist for greater than 48hrs. Foreign bodies can also produce vertical linear lesions and the upper lid should be lifter up to look for a foreign body under the eyelid

Management

• Treatment with antibiotics have become the standard of care. Antibiotics are particularly indicated for abrasions caused by contacts (cover for pseudomonas), foreign bodies, or history of trauma with infectious or vegetative matter due to a higher risk of infection. Ophthalmic antibiotic therapy include: erythromycin ointment or sulfacetamide 10%, polymyxin/trimethoprim, ciprofloxacin, or ofloxacin drops (4 times a day for 3-5 days). Pain relief can be provided with oral or topical pain meds. Topical NSAIDs include .1% indomethacin, .03% flubiprofen, .5% ketorolac, 1% indomethacin, and .1% diclofenac.  If symptoms persist greater than 24 hours after treatment the patient should follow-up with a physician. If the abrasion has not healed in 3-4 days the patient should be evaluated by an ophthalmologist.

Corneal Ulceration

Definition

• When a defect in the corneal epithelium becomes infected with bacteria or fungi it is defined as a corneal ulceration. This is a common complication of corneal abrasions and if left untreated can result in a corneal perforation.

Fluorescein Exam

• Corneal staining with infiltrate or opacification around the lesion should raise suspicion for ulceration. Contact lens wearers raise the suspicion of a Pseudomonal infection. Many Pseudomonal organisms fluoresce when exposed to UV light and fluoresce prior to fluorescein application.

Management

• Concern for ulceration requires an urgent ophthalmology consultation within 24hrs. Discharged patients should be treated with antibiotic drops or ointment.

Globe Rupture

Definition

• Full thickness injury to the cornea, sclera, or both secondary to penetrating of blunt trauma.

Fluorescein Exam

• Seidel test: instill a large amount of fluorescein onto eye and looking for small stream of fluorescent blue or green fluid leaking from the globe.

Management

• Once suspected, avoid further examination or manipulation, make the patient NPO, and place an emergent ophthalmology consultation. These patients also require broad spectrum IV antibiotic coverage with a 3rd generation cephalosporin or aminoglycoside and vancomycin to prevent post-traumatic endophthalmitis.

In summary, all patients with eye pain, particularly with a foreign body sensation, warrant a fluorescein exam. A wealth of information can be gained by this simple test and will guide the management of the patient.

---

Expert Commentary

This is a very comprehensive review of a common complaint in the Emergency Department. You correctly identified that one must be careful to avoid instilling too much fluorescein so as to cause a false positive result. Though a drop of tetracaine or saline dilutes the fluorescein from the strip somewhat the quantity is hard to control at times – especially in noncompliant patients (like the children I usually examine in the Pediatric Emergency Department). Excess fluorescein can collect across the eye making identification of small abrasions challenging. If you put too much in rinse the eye and try again. It is also incredibly important to not sent the patient home with tetracaine drops, as too frequent use may lead to further corneal injury. The evidence is based on animal models and case series and is far from complete. Read more on this great R.E.B.E.L. EM post (link: http://rebelem.com/topical-anesthetic-use-corneal-abrasions/).

One of the main pitfalls to the use of fluorescein strips is the risk of actually causing an abrasion. The method noted in this article – placing the strip inside the lower lid margin and asking the patient to blink – can cause an abrasion if the edge of the strip touches the cornea. This is particularly challenging to do in children, since even with proper restraint the blink reflex and their tendency to recoil is high. Therefore I recommend doing one of the following:

1. Hold the patient’s eyelids open. Drip the tetracaine or saline down the strip and allow it to drip into the eye, being careful to avoid touching the strip to the eye.

2. Make a fluorescein dropper. This is well detailed in the Tricks of the Trade: Fluorescein application techniques for the eye form Academic Life in Emergency Medicine (link: https://www.aliem.com/2015/06/tricks-of-the-trade-fluorescein-eye/). The Angiocath dropper allows for better control of droplet size and makes it easier to instill fluorescein into the squinting eye without the risk of touching the cornea.

You could just touch the fluorescein strip to the patient's inner eyelid when trying to diagnose a corneal abrasion. But then you could cause a corneal abrasion, which is an ouroboros of terribleness from which there is no escape. So why don't you try making a dropper instead, as detailed in this PEMBLOG SHORTS video.

PEMBlog.com - https://wp.me/p2EBRt-1je

Vimeo.com - https://vimeo.com/287706199

Brad Sobolewski, MD, MEd

Associate Professor, Assistant Director - Pediatric Residency Training Program

Division of Emergency Medicine

Cincinnati Children's Hospital Medical Center

---

How To Cite This Post

[Peer-Reviewed, Web Publication] Richardson J, Moore A. (2019, May 20). Corneal Abrasions [NUEM Blog. Expert Commentary by Sobolewski]. Retrieved from http://www.nuemblog.com/blog/corneal-abrasion

---

Other Posts You May Enjoy

---

References

1. Images courtesy of http://www.tedmontgomery.com/the_eye/

2. Marx, J. A., & Rosen, P. (2014). Rosen's emergency medicine: Concepts and clinical practice (8th ed.) Ch. 71. Opthamology. Philadelphia, PA: Elsevier/Saunders

3. Yanoff, M., Duker, J. S., & Augsburger, J. J. (2009). Ophthalmology. Ch 4, Corneal anatomy, physiology, and wound healing. Edinburgh: Mosby Elsevier.

4. Roberts, J. R., In Custalow, C. B., In Thomsen, T. W., & In Hedges, J. R. (2014). Roberts and Hedges' clinical procedures in emergency medicine. Ch 62. Opthalmologic procedures.

5. Gardiner, M. F. Overview of eye injuries in the emergency department. Retrieved September 16, 2017, from https://www.uptodate.com/contents/overview-of-eye-injuries-in-the-emergency-department.

6. Jacobs, D. S. Corneal abrasions and corneal foreign bodies: management. Retrieved September 16, 2017, from https://www.uptodate.com/contents/corneal-abrasions-and-corneal-foreign-bodies-management.

7. Waldman, N., Winrow, B., Denise, I., Gray, A., McMAster, S., Giddings, G., & Meanley, J. (2017). An observational study to determine whether routinely sending patients home with a 24-hour supply of topical tetracaine from the emergency department for simple corneal abrasion pain is potentially safe. Annals of Emergency Medicine, 02(016).

A Deep "Seeded" Cough

Written by: Laurie Nosbusch, MD (NUEM PGY-2) Edited by: Jon Andereck, MD, (NUEM PGY-4) Expert commentary by: Viren Kaul, MD

---

The Case

Chief Complaint: Cough for 3 weeks

History of Present Illness: An 18 month old male patient presents to the emergency department for a cough that has persisted for 3 weeks. He had a runny nose for one week, but the cough has persisted for two weeks beyond resolution of his congestion. The cough is non-productive and is worse at night when lying down. Parents deny fever, shortness of breath, wheezing, vomiting, choking, change in energy level, change in appetite, or weight loss.

Physical Exam:

Vitals: T 37.2, HR 103, BP 92/palp, RR 35, Sat 97% on room air

General: Well-appearing, interactive, sitting with parents

Pulmonary: Tachypneic but no signs of respiratory distress, no stridor, no accessory muscle use, no retractions, no tracheal tugging, no nasal flaring. Right lung is clear to auscultation. Left lung has decreased breath sounds at the base.

The rest of the physical exam is unremarkable.

 

Chest X- Ray [1]:

Figure 1. Radiology interpretation: Hyperlucency of left lung with mediastinal shift to right

Differential Diagnosis: Bronchial mass, congenital lobar emphysema, foreign body aspiration

Case Resolution: Bronchoscopy was performed and food debris (possibly a seed or popcorn) was removed from the left lower bronchus. The left mainstem bronchus was inflamed. The patient was treated for post-obstruction inflammation and pneumonia with steroids and antibiotics.

Final Diagnosis: Foreign body aspiration

---

Discussion:

Foreign Body Aspiration Causing Partial Airway Obstruction  

Epidemiology: Foreign body aspiration is a common presentation in the emergency department. Nearly 80% of these events occur in children younger than 3 years and they are more common in males. [2]

Presentation: These patients may have variable presentations depending on timing:

Common Chest X-Ray Findings:

• Visualization of radio-opaque foreign body

• Normal chest x-ray (30%) [7,8]

• Lower airway obstruction: hyperinflated lung, hyperlucent lung, atelectasis, mediastinal shift, pneumonia, abscess [7,9] (See Figure 1 Above)

• Lower airway obstruction: hyperinflated lung, hyperlucent lung, atelectasis, mediastinal shift, pneumonia, abscess [7,9] (See Figure 1 Above)

• Lateral decubitus films: air trapping due to foreign body in bronchus prevents collapse of affected lung [9] (Compare Figures 2 and 3 Below)

Figure 2. Left Lateral Decubitus Film [9]

Left lung collapses when in dependent position. This is normal and does not suggest foreign body or air trapping in left lung.

Figure 3. Right Lateral Decubitus Film [9]

Right lung does not collapse when in dependent position. This is abnormal and suggests foreign body in right bronchus causing air trapping in right lung.

Management:

• Address the ABCs

• Obtain a history, specifically asking about choking events

• If the history is concerning for foreign body aspiration or if breath sounds are asymmetric, order x-ray

  • PA/lateral chest views

  • Consider expiratory phase chest x-ray (in cooperative patients) or bilateral decubitus chest x-rays (for younger, less cooperative patients) as these can enhance detection of unilateral air trapping [9]

  • If there is concern for laryngotracheal foreign body, obtain neck PA/lateral x-rays

  • If the x-rays are negative, order CT or proceed directly to bronchoscopy depending on clinical suspicion [9]

• Bronchoscopy is performed to remove the foreign body

• If there is evidence of inflammation or infection, give steroids and/or antibiotics

• Initial empiric antibiotics should cover oral anaerobes, ex. ampicillin-sulbactam [10]

---

Key Points:

• Consider foreign body aspiration for any pediatric patient with a respiratory complaint

• The H&P is important for diagnosis because chest x-rays can be normal 30% of the time

• Think about foreign body aspiration when you see an x-ray suggestive of air trapping

---

Expert Commentary

Thank you for the opportunity to review this well summarized article on partial tracheobronchial foreign body aspiration (FBA) in pediatric patients.

Here are my TOP TEN TIPS:

1. Beware the unwitnessed FBA!

2. Ask for presence of an older sibling, they often provide the foreign body (FB) to the younger sibling.

3. > 60% FBs land on the right side and > 80% are organic.

4. Having an iron will is a good thing. Having an iron pill in your airway: bad! Iron and potassium tablets dissolve in the airway, cause severe inflammation and result in stenosis.

5. Smaller the child, smaller the airway, more likelihood of obstruction.

6. Which FBs are most likely to cause obstruction and be fatal? MNEMONIC: They reach the RIBS!!

   1. Round

   2. Incompressible

   3. Don’t Break easily

   4. Smooth

7. Peanuts are commonest single food item responsible for FBA.

8. DO NOT conduct blind sweeps of the mouth as it can lead to complete airway obstruction.

9. What to do should the child stop speaking or coughing i.e. develop a complete central airway obstruction?

   1. Ask for help!

   2. Infants: Alternating back blows and compressions

   3. Older children/adults: Heimlich maneuver

   4. Follow the AHA guidelines

10. Bronchoscopy is recommended in all cases where the suspicion for FBA is high. In children, rigid bronchoscopy is recommended. Flexible bronchoscopy can be used for diagnosis in uncertain situations but having a rigid bronchoscope in standby is strongly advised.

Viren Kaul, MD

Fellow, Pulmonary and Critical Care Medicine

Mount Sinai School of Medicine at Elmhurst

---

Posts you may also enjoy

---

How to cite this post

[Peer-Reviewed, Web Publication]   Nosbusch L, Andereck J (2018, July 23). A deep "seeded" cough.  [NUEM Blog. Expert Commentary by Kaul V]. Retrieved from http://www.nuemblog.com/blog/pediatric-cough

---

References:

1. Case courtesy of Dr Jeremy Jones, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/26866">rID: 26866</a>

2. Tan HK, Brown K, McGill T, et al. Airway foreign bodies (FB): a 10-year review. Int J Pediatr Otorhinolaryngol 2000; 56:91.

3. Wiseman NE. The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 1984; 19:531.

4. Laks Y, Barzilay Z. Foreign body aspiration in childhood. Pediatr Emerg Care 1988; 4:102.

5. Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Child 1980; 134:68.

6. Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol Head Neck Surg 1991; 117:876.

7. Sahin A, Meteroglu F, Eren S, Celik Y. Inhalation of foreign bodies in children: experience of 22 years. J Trauma Acute Care Surg 2013; 74:658.

8. Svedstrom E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol 1989;19:520.

9. Laya BF, Restrepo R, Lee EY. Practical imaging evaluation of foreign bodies in children: an update. Radiol Clin N Am 2017; 55:845

10. Sandora TJ, Harper MB. Pneumonia in hospitalized children. Pediatr Clin North Am 2005; 52:1059.