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is seen in patients with underlying eye disease [33]. Signs and symptoms are similar to that of bacterial keratitis, and fungal infections are often treated as bacterial until culture results are available. Topical therapy is used for mild keratitis and systemic antifungal therapy is added in more severe cases. Patients are usually admitted to the hospital for hourly dosing of topical antifungal therapy, which may be required for several days [33]. Topical steroids are contraindicated. Anterior uveitis is a common finding and cycloplegics are often used in these cases. Improvement usually occurs over weeks; corneal transplant is reserved for refractory cases.
Amoebic
The first case of Acanthamoeba keratitis was described in 1973 [34]. Infection with this amoeba, which is abundant in the environment, usually occurs in young, healthy adults and the majority of cases are contact lens related. Symptoms are similar to bacterial keratitis, although the pain seems to be more severe and the infection progresses more slowly in the case of Ancanthamoeba keratitis [34]. Slit lamp examination may reveal dendritiform lesions that can be confused with HSV keratitis. Ancanthamoeba keratitis should be suspected in any contact lens wearer with dendriform keratitis, and cultures of the corneal epithelium and contact lenses should be sent in such cases. Treatment typically involves combination therapy with topical amoebicidal agents after consultation with an ophthalmologist.
Corneal abrasion
Patients with corneal abrasions are commonly seen in the emergency department. A corneal abrasion is a traumatic defect in the corneal epithelium, which may result from direct mechanical trauma, contact lens related injury, foreign bodies, or motor vehicle accidents with airbag deployment [35]. Patients complain of pain, sensitivity to light, and excessive tearing following trauma to the eye. The patient may recollect injury from a fingernail, makeup applicator, or excessive rubbing of the eyes. In other cases the trauma may be so minor that it is not remembered by the patient at all. Trauma to the eye of a machine worker or as a result of metal striking metal should raise suspicion for penetrating globe injury. In contact lens wearers, specific history about poorly fitting lenses and prolonged wearing should be elicited.
Application of a short-acting topical anesthetic, such as proparacaine, will facilitate examination of the painful eye. Visual acuity is typically normal unless the abrasion involves the visual axis or there is significant corneal edema. There may be blepharospasm of the a ected eye as a result of photophobia. Ciliary spasm may cause miosis. The cornea can appear hazy if there is edema. Conjunctival injection is classically present and is most pronounced at the limbus. The diagnosis is confirmed by green fluorescence in
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damaged areas of the cornea seen under Wood’s lamp or cobalt blue light on slit lamp examination after the application of fluorescein (Fig. 5). Contact lens-related abrasions may be punctate or coalesce to form a larger, round central abrasion. Multiple vertical abrasions suggest a foreign body and should prompt the examiner to flip the upper eye lid for careful examination. Siedel’s sign or the presence of a hyphema on slit lamp examination suggests penetrating trauma to the globe.
Current treatment for corneal abrasions is largely based on theoretical benefit and general consensus rather than on rigorous study. Primary goals of therapy are pain control, prevention of infection, and rapid healing of the corneal epithelium. In a systematic review of five randomized controlled trials, topical NSAIDs, such as ketorolac, diclofenac, and indomethacin, resulted in a modest decrease in pain without a delay in wound healing or an increased risk of infection [36]. Patients who use topical NSAIDs may also return to work earlier and require fewer oral analgesics, including narcotics. Topical NSAIDs are, however, relatively expensive. Cycloplegics should theoretically relieve pain and photophobia related to ciliary spasm, but a systematic review showed no clear evidence to support their use in corneal abrasion [37]. Patching of the eye following a corneal abrasion has been shown to be of no benefit in pain relief or rate of healing, and is no longer recommended [38]. Concerns over the safety of patching have also been raised, as this treatment leaves the patient e ectively monocular, thus impairing ambulation and driving. Contact lens-related abrasions in particular are at increased risk of infection when patched, and the eye should not be covered in these cases. Patients with contact lens-related abrasions should be instructed to discontinue contact lens use until the defect heals and symptoms resolve. Oral analgesics, such as acetaminophen, ibuprofen, or opoids,
Fig. 5. Large corneal abrasion confirmed by fluorescein illumination under cobalt blue light. (Reprinted from Goldman L, Ausiello D. Cecil text book of medicine, 22nd edition. Philadelphia: WB Saunders; 2004. Fig. 465–8; with permission.)
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are typically prescribed for pain control. The decision to use oral NSAIDs or opioids should be made on an individual patient basis. In cases where oral analgesics are contraindicated, topical NSAIDs may be of benefit. A topical antibiotic, such as erythromycin, is commonly prescribed four times per day for 3 to 5 days to prevent infection, although there is no strong evidence to support this practice. Because of their lubricating e ect, antibiotic ointments are generally preferred over drops. Patients with contact lens abrasions should be treated with prophylactic topical antibiotics to cover Pseudomonas, such as gentamycin or ciprofloxacin. There is no convincing evidence in the literature to support tetanus prophylaxis in patients with nonpenetrating corneal abrasions [39].
Most abrasions heal within 1 to 3 days, although defects involving greater than half of the surface of cornea may require 4 to 5 days to fully heal [40]. Patients with small corneal abrasions will heal quickly and generally require only a single 24-hour follow-up examination to ensure healing. Patients with contact lens-related corneal abrasions should be reexamined daily to ensure prompt healing and to exclude infection. Referral to an ophthalmologist is indicated for large abrasions, defects over the visual axis, abrasions that become larger or more symptomatic the next day, or for patients who develop a corneal infiltrate or ulcer.
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