This document discusses various corneal emergencies and their management. Minor emergencies including foreign bodies, abrasions, and exposures can often be treated and reviewed depending on the circumstances. Major emergencies such as chemical burns, infections, trauma, and transplant rejection require urgent referral. Proper examination, culturing, antibiotic treatment, and surgery are important for managing different corneal conditions.

1. Corneal EmergenciesCorneal Emergencies
Dr Laurence SullivanDr Laurence Sullivan
Corneal Clinic, RVEEHCorneal Clinic, RVEEH
Bayside Eye Specialists, BrightonBayside Eye Specialists, Brighton
100 Victoria Parade East Melbourne100 Victoria Parade East Melbourne
LasersightLasersight

2. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal AnatomyCorneal Anatomy

3. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Useful ToolsUseful Tools
 Slit lamp / magnificationSlit lamp / magnification
 Fluorescein stain [either strips orFluorescein stain [either strips or
drops (2%)]. Stains corneal stroma,drops (2%)]. Stains corneal stroma,
i.e. epithelial defect.i.e. epithelial defect.
 Local anaesthetic dropsLocal anaesthetic drops
 cotton buds, fine (25G)cotton buds, fine (25G)
needleneedle
 Telephone!Telephone!

4. Fluorescein stainFluorescein stain
 Stains stroma (=defect in theStains stroma (=defect in the
epithelium)epithelium)
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

5. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Minor EmergenciesMinor Emergencies
 Corneal or subtarsal foreign bodyCorneal or subtarsal foreign body
 Welding flash burnWelding flash burn
 Corneal abrasion/recurrent erosionsCorneal abrasion/recurrent erosions
 Corneal exposure e.g. Bell’s palsyCorneal exposure e.g. Bell’s palsy
 HSV dendriteHSV dendrite
 HZOHZO
May treat and review, depending onMay treat and review, depending on
circumstancescircumstances

6. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Major emergenciesMajor emergencies
 Chemical burns (“Alkali”, or “Lime”)Chemical burns (“Alkali”, or “Lime”)
 Microbial (bacterial) keratitisMicrobial (bacterial) keratitis
– Also fungal, HSV, acanthamoebaAlso fungal, HSV, acanthamoeba
 Trauma / laceration / perforationTrauma / laceration / perforation
 Corneal graft rejectionCorneal graft rejection
 Autoimmune melts / scleritis / vasculitisAutoimmune melts / scleritis / vasculitis
 LASIK flap shiftLASIK flap shift
All require urgent referralAll require urgent referral

7. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Chemical burnsChemical burns
 Alkali (lime), acid, alcohol, otherAlkali (lime), acid, alcohol, other
solventssolvents
 Alkali worse because of increasedAlkali worse because of increased
penetration into corneal tissuepenetration into corneal tissue
 First Aid at site: Irrigation, irrigation,First Aid at site: Irrigation, irrigation,
irrigation! 1-2L of normal saline, tapirrigation! 1-2L of normal saline, tap
water, soft drink, milk, beer, (?water, soft drink, milk, beer, (?
urine?).urine?).

8. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Chemical burns - signsChemical burns - signs
 Epithelial defect (fluorescein stain)Epithelial defect (fluorescein stain)
 Cloudy corneaCloudy cornea
 Conj.Conj.
hyperaemiahyperaemia
 Beware if conj.Beware if conj.
is blanchedis blanched
(ischaemic)(ischaemic)
Non-healing
ulcer
Acute ulcer

9. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal Stromal haze andCorneal Stromal haze and
fluorescein stainfluorescein stain

10. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Alkali burns -Alkali burns -
mild and moderatemild and moderate
Limbal
ischaemia

11. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Chemical burnsChemical burns
 The long term problem is damage toThe long term problem is damage to
corneal limbal stem cells (>270corneal limbal stem cells (>270°)°), or, or
stromal damage which makes thestromal damage which makes the
cornea unable to produce/support ancornea unable to produce/support an
epitheliumepithelium
 Leads to chronic epithelial defect,Leads to chronic epithelial defect,
stromal lysis, scarring andstromal lysis, scarring and
vascularisation (conj.).vascularisation (conj.).

12. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Chemical burnsChemical burns
 A&E: Irrigation, irrigation, irrigation!A&E: Irrigation, irrigation, irrigation!
 1-2L normal saline.1-2L normal saline.
 LA drops will help for exam &LA drops will help for exam &
irrigation (Benoxinate/Oxybuprocaineirrigation (Benoxinate/Oxybuprocaine
or Amethocaine, or Xylocaine 1%)or Amethocaine, or Xylocaine 1%)
Analgesia. Dilate pupil (for comfort:Analgesia. Dilate pupil (for comfort:
Mydriacyl/Tropicamide, HomatropineMydriacyl/Tropicamide, Homatropine
they all have red tops)they all have red tops)
 Check pH (7-8 OK)Check pH (7-8 OK)

13. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Chemical burnsChemical burns
 Slit lamp exam (LA) - extent ofSlit lamp exam (LA) - extent of
epithelial loss (fluorescein stain).epithelial loss (fluorescein stain).
 Limbal involvement?Limbal involvement?
(whitening+ischaemia)(whitening+ischaemia)
 Evert upper lid, remove particulateEvert upper lid, remove particulate
matter with cotton bud, forceps.matter with cotton bud, forceps.
 Conj. may be white if ischaemic (badConj. may be white if ischaemic (bad
sign).sign).

14. Chemical burns – a bad oneChemical burns – a bad one
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

15. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Chemical burnsChemical burns
 ReferRefer allall with epithelial defect.with epithelial defect.
 On arrival at RVEEH, irrigation isOn arrival at RVEEH, irrigation is
often repeated!often repeated!
 Then, topical antibiotics, steroids,Then, topical antibiotics, steroids,
citrate and ascorbate (buffer alkalicitrate and ascorbate (buffer alkali
and inhibit PMN proteinase enzymes,and inhibit PMN proteinase enzymes,
support new collagen fromsupport new collagen from
keratocytes), antiglaucoma Rx.keratocytes), antiglaucoma Rx.
 AMTAMT

16. Microbial keratitisMicrobial keratitis
 A soggy white spot (PMNs) on theA soggy white spot (PMNs) on the
cornea of an inflamed eyecornea of an inflamed eye
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

17. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Microbial KeratitisMicrobial Keratitis
 Risk factors: contact lens wear, trauma,Risk factors: contact lens wear, trauma,
organic contamination, topical steroid droporganic contamination, topical steroid drop
use.use.
 Red eyeRed eye
 Ulcer (fl. Stain)Ulcer (fl. Stain)
 Corneal infiltrate (white spot) = PMNsCorneal infiltrate (white spot) = PMNs
 Hypopyon (pus level in anterior chamber)Hypopyon (pus level in anterior chamber)
 PainPain

18. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Microbial KeratitisMicrobial Keratitis
- Management- Management
 Refer for corneal scraping ->Refer for corneal scraping ->
Microscopy, culture, sensitivities.Microscopy, culture, sensitivities.
 Admit (often)Admit (often)
 Intensive topical broad spectrumIntensive topical broad spectrum
antibiotic drops (Ciprofloxacin q1hantibiotic drops (Ciprofloxacin q1h
D&N)D&N)
 Modify Rx according to micro resultsModify Rx according to micro results

19. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Fungal scleritis/keratitisFungal scleritis/keratitis

20. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Microbial keratitis - post LASIKMicrobial keratitis - post LASIK

21. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Microbial keratitis, hypopyonMicrobial keratitis, hypopyon

22. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal infiltratesCorneal infiltrates

23. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
DDxDDx
Old scar in a quiet eyeOld scar in a quiet eye
(herpes)(herpes)
Band keratopathyBand keratopathy
(Calcium deposition)(Calcium deposition)

24. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal Perforation in ContactCorneal Perforation in Contact
Lens-related MicrobialLens-related Microbial
KeratitisKeratitis
Seidel’s test - 2% Fluorescein dropsSeidel’s test - 2% Fluorescein drops

25. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
TraumaTrauma
 Laceration, perforationLaceration, perforation
 If full thickness, usually -> urgentIf full thickness, usually -> urgent
surgery under GA (suture or graft)surgery under GA (suture or graft)
 Fasting, eye shield, analgesia, anti-Fasting, eye shield, analgesia, anti-
emeticsemetics
 No drops if perforatedNo drops if perforated

26. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal lacerationCorneal laceration

27. Corneal lacerationCorneal laceration
 Consider IOFBConsider IOFB  CT ScanCT Scan
 Needs surgicalNeeds surgical
repairrepair
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

28. Shield, Analgesia,Antiemesis,Shield, Analgesia,Antiemesis,
ReferRefer
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

29. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Traumatic HyphaemaTraumatic Hyphaema
 Blunt traumaBlunt trauma
 Rx bed rest, admit?Rx bed rest, admit?
 AnalgesiaAnalgesia
 pupil dilatationpupil dilatation
(Atropine 1%)(Atropine 1%)
 Topical steroidTopical steroid
dropsdrops
 no aspirinno aspirin

30. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal transplant rejectionCorneal transplant rejection
 Setting: Corneal transplant, red eye,Setting: Corneal transplant, red eye,
blurred vision, photophobia.blurred vision, photophobia.
 Keratic precipitates - PMNs &Keratic precipitates - PMNs &
macrophages on back surface of corneamacrophages on back surface of cornea
 Exclude suture and wound problems,Exclude suture and wound problems,
infection.infection.
 Intensive potent topical steroidsIntensive potent topical steroids
(Prednefrin forte or Dexamethasone 1%(Prednefrin forte or Dexamethasone 1%
q1h).q1h).

31. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal transplant rejectionCorneal transplant rejection

32. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Loose corneal transplant sutureLoose corneal transplant suture

33. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Autoimmune ulcers, scleritisAutoimmune ulcers, scleritis
vasculitisvasculitis
 Rheumatoid arthritis, SLE w/Rheumatoid arthritis, SLE w/
vasculitis, Wegener’svasculitis, Wegener’s
granulomatosis.granulomatosis.
 Rx corneaRx cornea
 Rx underlyingRx underlying
condition – systemiccondition – systemic
steroids,steroids,
immunosuppressionimmunosuppression

34. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Rheumatoid melt (ulcer)Rheumatoid melt (ulcer)

35. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Rheumatoid melt - glue and CLRheumatoid melt - glue and CL

36. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Rheumatoid melt – inferiorRheumatoid melt – inferior
arcuate patch graftarcuate patch graft

37. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Nodular scleritisNodular scleritis

38. Lasik Flap shiftLasik Flap shift
 Relatively minor trauma but poor VARelatively minor trauma but poor VA
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

39. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Questions?Questions?

40. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Minor EmergenciesMinor Emergencies
 Corneal or subtarsal foreign bodyCorneal or subtarsal foreign body
 Welding flash burnWelding flash burn
 Corneal abrasion/recurrent erosionsCorneal abrasion/recurrent erosions
 Corneal exposure e.g. Bell’s palsyCorneal exposure e.g. Bell’s palsy
 HSV dendriteHSV dendrite
 HZOHZO
 May treat and review, depending onMay treat and review, depending on
circumstancescircumstances

41. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal foreign bodyCorneal foreign body
 Metallic (grinding)Metallic (grinding)
 Beware organic (infection)Beware organic (infection)
 Beware hammering metal-on-metal – highBeware hammering metal-on-metal – high
impact, IOFB -> CT scanimpact, IOFB -> CT scan
 LA dropLA drop
 25 G needle on a cotton bud to lift off or dig out25 G needle on a cotton bud to lift off or dig out
FBFB
 Oc Chloramphenicol, double padOc Chloramphenicol, double pad
 Dilate homatropine 2 or 5% statDilate homatropine 2 or 5% stat
 ?rust ring removal (next day)?rust ring removal (next day)

42. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal Foreign BodyCorneal Foreign Body

43. Removing a CFBRemoving a CFB
 LA (oxybuprocaine,LA (oxybuprocaine,
Alcaine)Alcaine)
 25G needle on a25G needle on a
cotton budcotton bud
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

44. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
CFB and rust ringCFB and rust ring

45. Subtarsal FBSubtarsal FB
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

46. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal ExposureCorneal Exposure
 Facial nerve palsy, acute CVA, LOCFacial nerve palsy, acute CVA, LOC
 Inability to blink, close lids. May ->Inability to blink, close lids. May ->
ulceration of inferior corneaulceration of inferior cornea
 Chloramphenicol ointmentChloramphenicol ointment
 Padding, Lid tapingPadding, Lid taping
 May need lid suture (tarsorraphy),May need lid suture (tarsorraphy),
Botulinum toxin ptosisBotulinum toxin ptosis

47. Facial palsyFacial palsy
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

48. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Inferior punctate epithelialInferior punctate epithelial
erosions (exposure)erosions (exposure)

49. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Lateral tarsorraphy and lower lidLateral tarsorraphy and lower lid
tighteningtightening

50. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Corneal abrasion / erosions /Corneal abrasion / erosions /
welding flash burnwelding flash burn
 Large or small (punctate) epithelialLarge or small (punctate) epithelial
defectsdefects
 Oc. ChloramphenicolOc. Chloramphenicol
 +/- double pad+/- double pad
 +/- pupil dilatation+/- pupil dilatation

51. Corneal abrasion / erosionCorneal abrasion / erosion
Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011

52. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Welding flash burnWelding flash burn
(“photokeratitis”)(“photokeratitis”)

53. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Healing corneal abrasionHealing corneal abrasion

54. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Questions?Questions?

55. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
HSV dendritic ulcerHSV dendritic ulcer
 Branching ulcer (superficial) - baseBranching ulcer (superficial) - base
stains with Fluorescein, edges withstains with Fluorescein, edges with
Rose Bengal (red)Rose Bengal (red)
 wipe off infected cells w/ cotton budwipe off infected cells w/ cotton bud
-> send for HSV PCR-> send for HSV PCR
 Oc Acyclovir q3h (5x/day) for 7 daysOc Acyclovir q3h (5x/day) for 7 days
 review in 2 days to check responsereview in 2 days to check response
to Rxto Rx

56. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Herpes SimplexHerpes Simplex
dendritic ulcersdendritic ulcers

57. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Herpes SimplexHerpes Simplex
dendritic ulcersdendritic ulcers

58. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus
 Oral acyclovir 800mg 5 x a day (orOral acyclovir 800mg 5 x a day (or
famcyclovir, valacyclovir)famcyclovir, valacyclovir)
 Ophthalmic review to detectOphthalmic review to detect
intraocular inflammation, increasedintraocular inflammation, increased
IOPIOP
 Can have late corneal andCan have late corneal and
inflammatory problemsinflammatory problems

59. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
HZO - Herpes Zoster OphthalmicusHZO - Herpes Zoster Ophthalmicus
Late Neurotrophic corneal
ulcer and scar.
V1 rash of
HZO

60. Dr Laurie Sullivan 2011Dr Laurie Sullivan 2011
Questions?Questions?
Thank YouThank You