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Questions Answered: 300

Final Score 76%

229
71

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Ophthalmology

Question 74 of 300

A 32 year old presents to the Emergency Department with a 3 hour history of pain to the left eye. What examination finding is seen?

Answer:

There is an area of fluorescein stain uptake suggesting a corneal defect.

Corneal Abrasion

Ophthalmology

Last Updated: 12th February 2021

Corneal abrasions are defects in the epithelial surface of the cornea. The cornea is susceptible to injury as it is the most anterior part of the eye. Relatively minor superficial injuries can cause significant pain as the cornea is densely innervated with sensory fibres from the ophthalmic branch of the trigeminal nerve.

Causes

  • Mechanical trauma from external objects
  • Foreign bodies (lodged under the eyelid or on the corneal surface)
  • Chemical, radiation or flash burns
  • Contact lens use during insertion or removal
  • Recurrent erosions - spontaneous abrasions which can develop in people with structural defects of the corneal epithelium due to a previous injury

Clinical features

  • History of precipitating event (e.g. object striking eye, foreign body entering eye, difficult contacts lens removal)
  • Sudden onset of eye pain on blinking
  • Foreign body sensation (may be described as 'gritty' or 'scratching')
  • Lacrimation
  • Photophobia
  • Decreased or blurred vision due to epithelial disruption and stromal oedema
  • Conjunctival injection
  • Blepharospasm (abnormal contraction of eyelid)

Assessment

  • The eye should be carefully examined
  • A topical anaesthetic may ease examination
  • Inspect for conjunctival or corneal foreign body (eversion of the eyelid may reveal a subtarsal foreign body)
  • Visual acuity should be tested and documented
  • Fluorescein examination
    • Fluorescein stains basement membrane which is exposed in the area of the epithelial defect
    • The stained abrasion appears yellow with the naked eye
    • Visualisation is enhanced by the use of a cobalt blue filter on an opthalmoscope or slit lamp, whereby the fluorescein fluoresces bright green
    • Vertical linear scratches on cornea suggest subtarsal foreign body due to repeated scratching with blinking

Management

  • Exclude retained foreign body
  • Consider analgesia (oral paracetamol, ocular lubricants)
  • Prescribe topical antibiotics (e.g. chloramphenicol)
  • Prognosis
    • Most uncomplicated small corneal abrasions will heal rapidly within 1–2 days without visual impairment
    • Larger defects, or those associated with contact lens use, should have ophthalmological follow-up in 1 to 2 days to ensure healing

Referral

Refer the person immediately to the emergency eye service if:

  • A suspected penetrating eye injury has occurred or an intraocular foreign body is suspected — all high-velocity injuries (such as from drilling, lawn mowing or hammering) or injuries caused by sharp objects (such as glass, knives, pencils or thorns) should be treated as penetrating injuries until proven otherwise
  • Significant orbital or periocular trauma has occurred
  • A chemical injury has occurred
  • A retained foreign body that cannot be removed safely is present
  • Infection or corneal ulcer is suspected
  • Any of the following red flag clinical features are present:
    • Severe pain
    • Irregular, dilated or non-reactive pupils
    • Significant reduction in visual acuity
    • Hyphaema (blood in the anterior chamber) or hypopyon (pus in the anterior chamber)
    • Large or deep abrasions
    • Corneal opacity

Complications

  • Corneal ulceration
  • Infective keratitis
  • Iritis
  • Recurrent erosion syndrome

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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