emDOCs Podcast: Episode 109 – Corneal Abrasion and DRESS

Corneal Abrasion

Epidemiology

• Ocular diagnoses comprise 8% of total ED visits with 45% of those being corneal abrasions.
• Corneal epithelium is easily damaged, however, regenerates quickly with a healing time of 24-48 hours.
• Associated findings or complications include traumatic iritis, hypopyon, or a corneal ulcer.

Risk Factors

• History of trauma
• Contact lens wearer
• Male gender
• Lack of eye protection
• Construction or manufacturing job

Clinical Presentation

• Patients often report eye pain, red eye, foreign body sensation,  eye watering/tearing, decreased visual acuity, and photophobia.
• Older children typically present like their adolescent/adult counterparts, however, infants and toddlers can present with inconsolability and a red eye.

Evaluation

• Ask specifically about patients’ work environment, materials involved, and if they are aware of the inciting event
  • Consider open globe in those with high-speed mechanism of injury (i.e. weed whacking, metal grinding, motorized vehicle involvement especially with airbag deployment etc.).
• Manage pain and blepharospasm with topical anesthetic (e.g. tetracaine, proparacaine) to facilitate the exam.
  • Pain relief with instillation is highly suggestive of corneal abrasion with appropriate clinical history.
• Conduct thorough ocular examination to include pupillary reactivity, visual acuity, extraocular motility, and lid eversion.
  • Evidence of a misshapen or peaked pupil or large, non-reactive pupil are signs concerning for open globe or evidence of intra-ocular foreign body
  • Visual acuities are likely to be normal unless the abrasion is over to visual axis or the abrasion is associated with iritis²
  • Affected eye will likely show reactive miosis
  • Patients’ conjunctiva will be injected and if presenting later will show signs of ciliary flush
  • Examination with a slit lamp and fluorescein dye is ideal.
    • Instill fluorescein by moistening the strip with a drop of saline or topical anesthetic. Pull down the patient’s lower lid and gently swipe against the bulbar conjunctiva.
      • Application of the strip directly to the eye can be challenging, especially in children and there are multiple methods for instilling fluorescein into a flush for easy application.
    • After staining, the abrasion will be apparent to the naked eye and will be enhanced with the use of a Wood’s lamp or cobalt blue filter (ophthalmoscope / slit lamp).
    • Assess for open globe with Seidel’s test: fluorescein streaming away from a noted defect/abrasion.
    • An abrasion will present as a superficial, irregular defect.
    • If presenting more than 24 hours after onset of symptoms, there may be evidence of cell and flare in the anterior chamber due to concomitant iritis.
  • Evert the upper lid to assess for foreign body (FB):
    • Maintain high suspicion in a patient whose cornea is marred by numerous vertical, linear, abrasions.
    • If found, or still high suspicion, remove by using a clean cotton tip applicator and gently sweep the palpebral conjunctiva.

Treatment:

• Prescribe a topical antibiotic
  • Non-contact lens wearers
    • Erythromycin ointment four times daily – ointment preferred to help provide comfort and lubrication.
    • Avoid ointments containing neomycin due to hypersensitivity reactions.
  • Contact lens wearers
    • Cover for Pseudomonas with topical tobramycin or fluoroquinolones four times daily (e.g. ofloxacin or moxifloxacin).
    • Fluoroquinolone drops are acceptable in children due to limited systemic absorption.
• Provide outpatient analgesia
  • Topical NSAIDs (diclofenac, ketorolac) offer little advantage for pain relief to oral NSAIDs and cost more.
  • Topical anesthetics are classically not recommended for ED patients with abrasion, but ACEP’s 2024 consensus guidelines suggest they may be used in appropriately selected patients:
    • Dispensing no more than 1.5-2 mL and having adult patients use the topical anesthetic no more than every 30 minutes for the first 24 hours is safe and will help reduce pain.
    • Must be a simple abrasion. Contraindications: large abrasion or ulcer, corneal penetration or laceration, > 2 days since it started, infection, gross contamination, retained FB, UV induced photokeratitis, damage to another part of the eye, underlying corneal pathology, previous corneal surgery or transplant in the last month, history of herpetic eye disease, and then pediatric patients.
    • Provide clear instructions for use and have patient throw it out after 24 hours. They should keep the eye drops in the refrigerator, and they need to stop the drops and come back if their symptoms worsen.
    • Of note, 5 ophthalmologists on the consensus guideline approved the science, but they ultimately withdrew their names because of pressure from the American Academy of Ophthalmology.
• Cycloplegic use showed minimal reduction in pain scores compared to placebo.
• Patching does not promote healing but can help with comfort for large abrasions.
  • Contraindicated in contact lens wearers, abrasions caused by organic materials or fingernails as this can increase risk for infection.
  • Not indicated for small abrasions.

Consult Ophthalmology:

• Findings concerning for open globe (positive Seidel test).
• Evidence of corneal infiltrate or opacity concerning for corneal ulceration
• Inability to remove retained FB
• Presence of hypopyon or hyphema

Disposition:

• Most small corneal abrasions heal within 24-48 hours and follow-up may not be necessary in the reliable patient with resolution of symptoms.
• Urgent Ophthalmology follow-up in 24-48 hours:
  • Large abrasions (< 50%) of corneal epithelium or those in the central visual axis
  • A drop in vision of > 1 line on the Snellen Chart
  • Continued symptoms after 3-4 days as this could suggest infection, FB, or progression.
  • Recent surgery to affected eye
  • Involvement of only functional eye
  • Ophthalmology Referral:
    • Recurrent corneal abrasions
    • Dry eyes

Pearls:

• In the inconsolable toddler or infant, consider a corneal abrasion.
• Keep high suspicion for open globe in the setting of high-speed mechanism of injury.
• Topical anesthetics (e.g. tetracaine) not advised for home use at this time due to safety risks.
• Topical NSAIDs offer minimal benefit compared to oral NSAIDs.
• Antibiotic recommendations include erythromycin QID for non-contact lens wearers and tobramycin or fluoroquinolone ophthalmic gtts for contact lens wearers.

Additional Reading:

Taming of the SRU: https://www.tamingthesru.com/blog/bread-butter-em/corneal-abrasions

REBEL EM: https://rebelem.com/corneal-abrasions-and-short-term-topical-tetracaine/

Ophthalmologic Medications: Pearls & Pitfalls in the ED:

Definition / Clinical Presentation: 

• Also known as Drug-Induced Hypersensitivity Syndrome
• Defined as a particular drug reaction occurring in the first 2 months after drug initiation characterized by morbilliform cutaneous eruption with fever, malaise, facial edema, lymphadenopathy.
• The presenting symptoms in almost all patients are skin rash, liver involvement, hypereosinophilia, and lymphadenopathy.
  • Consideration of the diagnosis regardless of skin eruption in patients with hypereosinophilia, liver involvement, fever, and lymphadenopathy.
• DRESS syndrome can have systemic involvement to include:
  • Acute hepatitis (most common)
  • Interstitial nephritis
  • Interstitial pneumonitis
  • Myocarditis – hypersensitivity or acute necrotizing eosinophilic myocarditis (ANEM)
• While majority cases are mild to moderate, severe DRESS can present with acute renal failure, acute respiratory distress syndrome (ARDS), liver failure, and sepsis.
• DRESS Syndrome has a 10% mortality rate with the primary cause of mortality being hepatic necrosis.

Etiology:

• Drugs most implicated in the etiology of DRESS:
  • Aromatic Anti-epileptic Drugs: carbamazepine (most common), phenytoin, phenobarbital, lamotrigine
  • Allopurinol (2^nd most common)
  • Sulfonamides: Trimethoprim- Sulfamethoxazole (TMP-SMX), dapsone, sulfasalazine
  • Minocycline
  • Vancomycin
• Pathogenesis not fully understood:
  • Theorized predominantly due to genetic mutations in drug detoxification enzymes leading to accumulation of toxic metabolites.
    • Drug is identified as the inciting agent in 80% of cases.
  • Human Herpesviridae (HHV-6, HHV-7 CMV, or EBV) infection / reactivation may be a risk factor.
  • Suspect a small subset due to delayed T-cell mediated hypersensitivity reaction.

Risk Factors:

• Previous history of a drug reaction
• A family history of DRESS in a primary relative

Evaluation:

• Assess ABCs and obtain vital signs:
  • Fever occurs in majority of patients
  • Tachypnea, hypoxia, and/or hypotension can be indicative of cardiac or pulmonary involvement.
  • Altered mentation / encephalopathy can be concerning for hepatic failure.
• Perform a thorough history:
  • Query specifically about new medications, drug allergies, and family history of DRESS.
• Perform a physical exam:
  • Skin Lesions – Rash occurs in nearly 99% of patients.
    • Early: symmetric morbilliform eruption (picture 1) on the face, upper trunk and extremities; indistinguishable from an exanthematous drug eruption
    • Late: If drug is not discontinued, the eruption can progress to generalized exfoliative dermatitis with associated sterile bullae, and lower extremity purpura.

Picture 1: Symmetric morbilliform eruption of the trunk

• Facial Edema
• Mucous Membranes: pharyngitis / tonsillar edema, cheilitis, mucosal erosions²
• Hepatomegaly
• Diffuse lymphadenopathy

• Laboratory evaluation:
  • CBC with differential
    • Eosinophilia (30% of cases)
    • Atypical lymphocytes
  • Basic Metabolic Panel
  • Liver Function Tests:
    • Elevated ALT (seen in 70% of cases), AST, and alkaline phosphatase
  • Renal function panel and urinalysis (UA) with microscopy
    • May show elevated serum creatinine.
    • UA with mild hematuria, proteinuria, and eosinophils – indicative of nephritis
  • PT/INR & PTT – if evidence of hepatic involvement
  • Cardiac enzymes – if patient has chest pain or other anginal equivalents
  • Consideration of viral hepatitis panel and serology.
    • Rule out confounding viral or autoimmune hepatitis.
  • ESR & CRP – nonspecific and typically elevated
  • Blood culture – if presenting with sepsis
• Imaging:
  • Consider a chest radiograph in patients with pulmonary symptoms to evaluate for associated pneumonitis, pleural effusions, cardiomegaly.
  • Obtain EKG if patient is presenting with chest pain.

Diagnosis:

• No reliable standard for diagnosis
• RegiSCAR Criteria identifies vast majority of cases retrospectively

*Rash suggestive of DRESS requires 2 of the following: Purpuric lesions (other than legs), infiltration, facial edema, or psoriasiform desquamation.

Treatment:

• Identify the offending agent and discontinue.
  • DRESS syndrome eruption will remain present for weeks to months following discontinuation of the inciting agent.
• Initiate systemic steroid therapy with 1 mg/kg/day prednisone when diagnosis is considered.
  • Systemic therapy may result in improvement of symptoms and labs, but may not prevent progression to or management of end-organ dysfunction.
  • Recurrence of rash and hepatitis may occur with rapid discontinuation of systemic steroids – they should be tapered over 3 – 6 months.
• Avoid empiric antibiotics as cross reactivity can aggravate presentation.
• Progression of systemic disease despite steroid administration can be managed with the addition of IVIG and consideration of plasmapheresis, immunosuppressive agents (cyclophosphamide, cyclosporin, etc.), and/or N-acetylcysteine (NAC).

Disposition:

• Admission with Dermatology consultation
  • Critical Care involvement for severe DRESS syndrome in cases of hepatic and/or renal failure.
  • Burn center transfer for management of severe exfoliative dermatitis
• Predictive factors for serious cases have yet to be identified, however allopurinol associated DRESS has a higher associated progression to serious DRESS and death rate.
• Patients should be made aware of their specific drug hypersensitivity and these drugs should never be readministered as clinical findings recur more rapidly and with increased severity.

Pearls:

• Allopurinol and carbamazepine are the most implicated drugs, however, over 50 drugs as well as viruses have been shown to precipitate DRESS syndrome.
• Differentiated from other diagnoses due to characteristic latent period of 2-6 weeks from onset of drug initiation.
• The most common visceral organ involvement is the liver with hepatomegaly or transaminase elevation.
• DRESS syndrome has a 10% mortality rate.

Additional Reading: 

• emdocs.net DRESS: what does the emergency physician need to know?
• First 10 in EM DRESS syndrome– a rapid review