Case Study 3 - CC: Acute left eye pain and blurry vision

Patient History

HPI:
The patient is a 70 year-old male, retired building contractor, who presents with severe left eye pain, tearing, photophobia and blurry vision after being kicked in the eye by his grandson 2 hours ago. He also reports foreign-body sensation in his left eye. He denies any flashing lights or floaters or mucous discharge from the eye.

Past Ocular History:
Cataract surgery OU 3 years ago. No hx contact lens use, no other hx of eye trauma, amblyopia or other eye diseases.

Ocular Medications:
None

Past Medical History:
Hypertension - treated

Surgical History:
Prior appendectomy

Past Family Ocular History:
No history of macular degeneration, glaucoma or other blinding diseases.

Social History:
He denies alcohol, tobacco, or illicit drug use.

Medications:
Hydrochlorothiazide

Allergies:
None

ROS:
Denies recent illnesses, CNS, heart, lung, GI, skin or joint problems.

Ocular Exam

Visual Acuity (cc):
OD: 20/20
OS: 20/50 PH NI

IOP (tonoapplantation):
OD: 13 mmHg
OS: 15 mmHg

Pupils:
Equal, round and reactive OU, no APD

Extraocular Movements:
Full OU. No nystagmus.

Confrontational Visual Fields:
Full to finger counting OU

External:
Mild periorbital erythema most prominent in the inferior lid and cheek on the L side.

Slit Lamp:

Diagnosis
Traumatic corneal abrasion

Discussion

Differential Diagnosis:
The patient has a superficial, traumatic corneal abrasion based on clinical signs and symptoms. The differential diagnosis would include infectious keratitis (including herpetic keratitis), recurrent corneal erosion, neurotrophic epithelial defect or contact lens-associated keratopathy (but we know in this case that the patient does not have a history of contact lens use).

Definition:
A corneal abrasion is a disruption in the epithelium of the cornea. This is caused most commonly by trauma, contact lens use or foreign body. Typical symptoms include intense irritation, foreign-body sensation, eye pain, excessive tearing, and/or an inability to open the eye due to pain and light sensitivity. Most abrasions result in significant discomfort to the patient due to the high level of corneal innervation.

Examination:
Obtaining a careful history, including the possibility of trauma or contact lens use, is important in evaluating patients with possible corneal abrasions. Some of the most common signs of a corneal abrasion include mild lid margin swelling and hyperemia, conjunctival hyperemia, increased tearing and lack of epithelium in the cornea (best visualized with fluorescein). Visual acuity might be decreased if the corneal abrasion is in the visual axis. Ensure to examine the fornix and evert the lids to rule out the presence of a foreign body. Fluorescein will stain the corneal epithelial basement membrane or the corneal stroma, which are exposed when the epithelial cells are removed with an abrasion. To apply fluorescein to the eye, use a drop that contains both fluorescein and an anesthetic agent or apply a drop of anesthetic to the tip of a fluorescein strip and gently place the orange drop on the inferior conjunctiva by pulling the eyelid down. View the cornea under a cobalt blue light. A bright green stain highlights the areas of corneal abrasion. Fluorescein can also help demonstrate a full thickness corneal laceration with leakage of aqueous humor to the exterior of the eye, the Seidel sign. Use a drop of anesthetic early in the eye examination; this will make the patient feel more comfortable and able to open the eye. However, NEVER GIVE A PATIENT A BOTTLE OF ANESTHETIC DROPS TO TAKE HOME. A persistent epithelial defect and corneal melt can occur resulting in permanent vision loss.

Treatment:
A simple corneal abrasion can be treated with lubrication and antibiotic prophylaxis. Antibiotic drops or ointment formulation, and artificial tears or ointment can be used (ex. erythromycin ointment four times per day for five days or until the abrasion is healed). Symptoms should start to improve within 24-48 hours. Severe corneal abrasions can result in corneal scars, epithelial irregularity or recurrent erosion syndrome. Patients should NOT use their contact lenses until the epithelium is completely healed. The patient should be examined in one or two days by an eye care provider to ensure that the abrasion is resolving without pathology.

1.    Which symptom would typically not be present in a patient who has a corneal abrasion
   • pain
   • redness
   • tearing
   • ptosis
   • flashes
2. What medicated drop should NEVER be given to a patient to be used at home or regularly when patients present with a corneal abrasion and why?
   • proparacaine drops, it anesthetizes the cornea and can cause a corneal melt if used for too long
   • gentamycin drops, it can cause surface irritation and redness
   • tropicamide drops, it can cause persistent dilation and decrease focusing
   • timolol drops, it can cause hypotension in frail elderly patients
3. How would you test for the presence of a corneal abrasion in the Emergency Room?
   • add a fluorescein drop to the affected eye and examine the eye in white light
   • add a drop of proparacaine and examine the eye at the slit lamp
   • check visual acuity at near, one eye at a time
   • add a drop of proparacaine to a fluorescein strip and put a drop in the eye, examine eye with a blue light lamp

1. Which symptom would typically not be present in a patient who has a corneal abrasion

e. flashes

Flashes are usually produced by disruption of normal retinal function. A simple corneal abrasion would not be affecting the retina.

2. What medicated drop should NEVER be given to a patient to be used at home or regularly when patients present with a corneal abrasion and why?

a. proparacaine drops, it anesthetizes the cornea and can cause a corneal melt if used for too long

The numbness of the cornea inhibits normal healing to devastating consequences.

3. How would you test for the presence of a corneal abrasion in the Emergency Room?

d. add a drop of proparacaine to a fluorescein strip and put a drop in the eye, examine eye with a blue light lamp

One should use proparacaine to make the eye comfortable, fluorescein to highlight the area of the cornea with denuded epithelium and a lamp with blue light to look for the defect (the area would be stained bright green).