treatment plan

Assessing the Damage

BY WILLIAM D. TOWNSEND, OD
April 1999

A patient presented after having a stream of boiling grease explode in his eyes. His presenting acuities without correction were 20/200 in both eyes. Pupillary reflexes were intact and there was no evidence of a relative afferent pupillary defect or EOM limitation. Pin hole did not improve vision and slit lamp examination showed multiple sites of corneal and conjunctival epithelial burn. We noted gr. II+ conjunctival injection, and on the conjunctiva were many isolated clumps of thickened grease adherent to, or in some cases, burned into the conjunctiva (Fig.1). As I surveyed the damage I asked myself, "Do we take this case or do we refer?"

Treat or Refer?

As professionals, we must address this sort of question almost every day. If the answer to a problem lies within our expertise and scope of practice, it is our duty to treat them. On the other hand, if their condition would best be treated by another doctor, we are morally and ethically obliged to refer the patient.

There are several critical issues that may help you decide the most appropriate way to deal with a given case. First consider visual acuity. This patient's acuity was severely reduced, but this was easily explained by the disruption of central epithelium. Later we discovered he had 4.00D of uncorrected astigmatism. Regard cases with reduced vision with caution unless the cause of vision loss is obvious and reversible.

Survey the extent of damage. In this patient's case, despite the terrible appearance of his anterior segment, the burns were limited to the superficial layers.

When dealing with thermal or chemical trauma, consider the nature of the chemical. In this particular case the agent, while very hot, was neutral.

In evaluating cases of trauma, also consider how far posteriorly the damage extends. When deciding whether to refer or to treat, it is essential to rule out a penetrating injury to the globe.

Another issue to consider in dealing with ocular trauma is the presence or absence of a relative afferent pupillary defect. Obviously, you should attempt to determine if there is a past history that might explain the defect, and if possible, contact any eye doctor who has previously seen the patient to determine if the relative afferent pupillary defect existed prior to the accident.

Finally, you should address the likelihood of success in treating the condition based on your experience and knowledge. This requires a thorough assessment of the damage and understanding the possible outcomes of treatment. Simply put, we gain knowledge, experience and confidence with every successful case.

We elected to manage this patient's case based on these main factors. We began by instilling a topical anesthetic and Voltaren, then used a sterile calcium alginate swab to remove the grease, and simultaneously debride away the burned tissue. We then instilled a cycloplegic drop and broad spectrum antibiotic, and instructed the patient to use Ocuflox drops every four hours. Within 48 hours, his corneas were completely re-epithelialized. Two weeks later, there was no scarring, and after correcting his considerable refractive error, he had 20/20 vision in both eyes.

The next time a patient presents with a case that challenges your comfort, ask yourself if this is a case you should manage or refer. In many instances, you'll find that you have underestimated your own ability and are able to handle the case successfully.

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. doctorbill@amaonline.com