Australian Doctor 14th February 2025

34 HOW TO TREAT : ACUTE CORNEAL CONDITIONS

14 FEBRUARY 2025 ausdoc . com . au using a slit lamp , the suture is removed with fine plain forceps ( see figure 9B ).

Carlos is prescribed topical chloramphenicol qid for five days . The eye settles well with no development of keratitis or graft rejection .

Case study two

Olivia , a 37-year-old female , presents complaining of irritation in her left eye for the past two days . There is no associated discharge . She has a history of many years of intermittent redness and eye discomfort , but this has always resolved with no specific treatment .

On examination , her visual acuity is 6 / 6 unaided . There is a peripheral corneal opacity at 6.30 o ’ clock with an adjacent intense limbal injection , but otherwise the eye is quiet and there is no anterior uveitis ( see figure 10 ). Fluorescein staining shows minimal overlying epithelial defect . The eyelids demonstrate blepharitis with meibomian inspissation . Because of the focal nature of the condition and the absence of a history of contact lenses or trauma , marginal keratitis is diagnosed . Infectious keratitis is the main differential diagnosis ; however , this is usually associated with more diffuse conjunctival injection and pain . Scraping of the infiltrate is undertaken for microscopy / culture and sensitivity to exclude infection . Topical dexamethasone 0.1 % qid for one week is started .

Olivia is reviewed after two days and the infiltrate is clearing with the inflammation settling . There is no growth from the corneal scraping .

How to Treat Quiz .

1 . Which THREE statements regarding the cornea are correct ? a Damage to the cornea can result in scarring , with a loss of clarity and reduction in vision . b The cornea has the highest density of nerve fibre endings of any tissue in the body , which acts as a protective mechanism . c The cornea cannot be examined without a slit lamp . d Loss of corneal sensitivity results in increased risk of trauma and poorer healing response .

2 . Which TWO statements regarding corneal foreign bodies are correct ? a Organic materials , such as plant or insect , carry a lower risk of infection . b The common cause of ocular FBs is a combination of inadequate use of protective eyewear and engaging in high-risk activities such as grinding , hammering , drilling and welding . c MRI may provide valuable information regarding the location and extent of a metallic FB . d A more recent corneal FB is typically easier to remove .

3 . Which THREE statements regarding the treatment of corneal foreign bodies are correct ?

a Removal of a metallic FB requires the use of a magnet . b Post-procedural management encompasses pain control , prophylactic antibiotics and follow-up care . c Do not prescribe local anaesthetic as it delays healing and can mask the development of complications . d If there are any signs of infection or progressive inflammation on follow-up , urgently refer the patient for ophthalmic care .

4 . Which THREE are appropriate in the management of a corneal abrasion ? a Instilling local anaesthetic before examination . b Fluorescein staining and cobalt blue light to determine the size and location of the epithelial defect . c Pupillary dilation with atropine . d Urgent referral if intraocular trauma is suspected .

5 . Which THREE statements regarding sharp trauma to the cornea are correct ? a Higher velocity injuries with harder and sharper objects are more likely to result in perforation .

CONCLUSION

THE GP has a pivotal role as the primary care provider . EDs are often crowded , with precedence given to more life-threatening conditions than ophthalmic ones . The authors feel that a lack of training in ophthalmology in medical schools may

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b It is critical to document the level of vision for both prognostic and medicolegal reasons . c If a penetrating eye injury is suspected , keep the patient calm and quiet , with the eye covered by a hard shield to avoid any pressure on the eye . d Patients with non-penetrating injuries always have better vision .

6 . Which TWO are appropriate management in traumatic hyphaema ? a Sleeping flat . b Limit physical activity and wear an eye shield . c Topical steroids for inflammation . d Pupil is constricted to immobilise the iris and stabilise clots .

7 . Which THREE are signs of more severe burns ? a Total epithelial defect . b Conjunctival injection . c Corneal opacity . d Limbal ischaemia .

8 . Which TWO statements regarding corneal burns are correct ? a Corneal burns are acid or alkali related .

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ACUTE CORNEAL CONDITIONS

contribute to hesitancy from ED resident staff in assessing ophthalmic conditions . With a good history , careful examination measuring the visual acuity , using a good source of illumination and magnification , most acute corneal conditions can be managed in general practice or

b Irrigate the eye with saline or water for 20-30 minutes , with the simultaneous application of topical anaesthetics , before examination . c Alkali burns typically are more severe . d Symptoms of flash burns occur 48 hours postexposure .

9 . Which THREE are features of infective keratitis ? a Purulent discharge in bacterial and fungal keratitis . b Unilateral pain , intense redness , photophobia , sensation of an FB and reduced vision . c Worsening photophobia over several weeks in acanthamoebal keratitis . d Severe pain in HSV keratitis .

10 . Which THREE statements regarding infective keratitis are correct ? a It is easy to clinically distinguish between the infiltrates of bacterial or fungal keratitis . b Bacterial keratitis is commonly caused by poor contact lens hygiene practice . c HSV keratitis demonstrates a characteristic dendritiform ulcer that stains with fluorescein and cobalt blue light . d Delayed or ineffective treatment can result in permanent vision loss . referred appropriately for more urgent ophthalmic care . With further knowledge and basic skills , the range of scope can be extended , with mutual benefits to the patient and practitioner .

Any acute opacity of the cornea is a red flag for severity . Oedema , denaturation of stromal proteins , white cell infiltration and microbial infection all result in loss of corneal clarity ; if left untreated this will potentially result in permanent scarring and vision loss . Although the cornea has remodelling capability over many months , visually significant scarring , especially if overlying the central visual axis , will require removal by phototherapeutic keratectomy , if superficial , or corneal transplantation , if deeper . This option is less likely to be successful if there is vascularisation , which increases the risks of rejection of the transplant . Thus timely and appropriate management of corneal conditions is the key to preserving vision .

Australian Doctor 14th February 2025 | Page 34

34 HOW TO TREAT : ACUTE CORNEAL CONDITIONS

34 HOW TO TREAT : ACUTE CORNEAL CONDITIONS

How to Treat Quiz .