The kids are back in school and hopefully everyone is settling into routines like an old man into warm bath. With our kids back to school and hopefully learning with perfect bilaterally corrected vision (having already been comprehensively examined by an optometrist), it’s time for Eye on Eyes readers to do some learning.
The case being shared in this article is not one of an unusual pathology, but the route of management. It speaks to the capability and compassion of optometrists across the country in helping one patient to feel comforted in a time of uncertainty. This 62 year old female presented for the second time in 4 months with a left corneal abrasion (see photo).
She had underlying epithelial basement membrane dystrophy and had been using hyperosmotic ointment at night once a week previous to this incident. On presentation the epithelium had a crescent-shaped break consistent with her fingernail that had accidentally brushed her cornea while rubbing her eyelid. The surrounding loose epithelium (~3mm) layed above 3+ stromal edema which created a potential for a full circumscribed abrasion with the slightest touch or blink. She was able to keep her eye closed until coming into the clinic 15 minutes after the incident.
Certainly a worrisome cornea with the potential for infection to set in, however there was no evidence of contamination of the wound and there hadn’t been a lot of time for the eye’s natural flora to cause further insult. Managing this required wound protection and prophylaxis measures to prevent infection. The monkey wrench was that this patient was flying to Calgary later the same day and I was left with a potential ulcer, scarring and related vision loss if this wasn’t followed promptly and compliance with my treatment wasn’t followed.
This scenario required some “outside of the box” thinking and in fact outside of the province thinking. Luckily, my esteemed colleague, classmate and friend Dr. Dwayne Lonsdale who practices near Calgary (North Hill Optometry) was just a facebook message away and was available to follow up and be her on-call travel optometrist while she was in his area. With the patient’s consent, I sent Dr. Lonsdale (http://www.northhilloptometry.com/) the above image (taken using my smartphone behind slitlamp) for reference and follow up until she could return to my care back in Toronto.
Once her travel-care was arranged, I placed a bandage contact lens on eye, provided her with antibiotic topical coverage and Muro 128 qid + ung qhs and sent her safely into the slit lamp of another. With recurrent corneal abrasions it is important to heal the wound first by protecting it from chronic insult. In this case repeated mechanical trauma of blinking would cause this epithelium to slide right off and leave an open wound waiting for a biological enemy to invade and infect. During this time treat with topical antibiotic coverage (4th generation qid) and hyperosmotic agent to reduce edema.
Dr. Lonsdale reported her progress and removed BCL by day 3 and wound recovery was excellent. BCVA had improved from her initial 20/40- to near 20/20. Once the wound had closed, a topical antibiotic/steroid was added to reduce inflammation further while retaining coverage.
On returning from her trip to see me, her prescribed medications were reduced to hyperosmotic ointment nightly and non-preserved 1% hyaluronic acid to replenish the epithelium. She is fully recovered and eternally grateful for the care she received at home and while travelling in Canada. We are discussing options to prevent further RCE by using oral doxycycline combined with hyperosmotic ointment nightly to reduce ocular surface inflammation.
What is interesting here is that without smartphone anterior segment photography, social network communication and the close optometric community that we have, I would not have been comfortable with this patient travelling and would have cautioned her to postpone this trip. Leaving a BCL on an eye with an open wound with the potential for an opportunist infection and sending her on a plane without confirming receptive eye care on her arrival would be a liability to say the least. But instead she travelled confidently, she healed and we all learned what is possible when people work together.
Here’s hoping our kids will learn to do the same this year!
In good health,
Dr. Richard Maharaj OD, FAAO
Director of Optometry,