CORNEAL ABRASIONS WHEN DO I GET MY TAPE ON?!

1. Laura Surike RN, BSN, SRNA Leah Abbott RN, BSN, SRNA CORNEAL ABRASIONSWHEN DO I GET MY TAPE ON?!

2. OBJECTIVES • AT THE END OF THIS PRESENTATION, THE LEARNER WILL BE ABLE TO: • DEFINE WHAT IS A CORNEAL ABRASION • LIST COMMON CAUSES OF CORNEAL ABRASIONS • LIST TWO WAYS TO DECREASE THE CHANCE OF CORNEAL ABRASIONS • STATE THREE WAYS TO TREAT A CORNEAL ABRASION

3. “CORNEAL WHAT?.....I’M JUST TRYING TO GET MY INTUBATION AND ALL MY MONITORS ON BEFORE THE SURGEON YELLS AT ME FOR NOT HAVING THE DRAPES UP!” ---ANONYMOUS

4. Why are We Talking About Corneal Abrasions? • While rotating through various sites for clinical, every site taped the eyes differently • Some taped the eyes before ventilating the patient, others after intubation, and some throughout the induction process • Some sites used eye lubricant and others never used it • Some sites used silk tape or opsite while others used commercial eye cut outs • What we did find was there was NO consistency

5. Currently there is no standard of care as to when to tape the eyes or how to tape the eyes • What is known is that taping the eyes while undergoing GA helps to prevent corneal abrasions

6. CORNEAL ABRASION • THE MOST COMMON OCULAR COMPLICATION OF GENERAL ANESTHESIA

8. Cornea • The cornea is an avascular structure composed of 5 histologically distinct layers • Protected by a precorneal tear film composed of 3 layers: lipid, aqueous, and mucin • Lipid layer: Prevents evaporation of the aqueous layer and acts as a lubricant • Aqueous layer: oxygenates the corneal epithelium • Mucin layer: creates a hydrophilic surface on the corneal epithelium

9. The precorneal tear film is regenerated by blinking • Absence of blinking during general anesthesia renders the cornea vulnerable to injury

10. How do Corneal Abrasions Occur? • Cornea extremely sensitive to hypoxia • Partial pressure of oxygen in cornea can decrease greatly in as little as 30 seconds of hypoxia • Corneal hypoxia leads to edema →potential for loss of the epithelial layer →causing an abrasion • Physiologic factors that alter corneal blood flow can predispose pts to corneal injury

11. This includes conditions that ↓ arterial blood flow such as ↑ IOP, head malpositioning, or pressure from an incorrectly applied face mask • ↓ venous return can also lead to corneal edema and subsequent abrasion • 2 main mechanisms of perioperative corneal injury are mechanical abrasion or exposure-induced drying of the corneal surface

12. CAUSES • Damage from anesthesia mask, surgical drapes, and spillage of solution • During Intubation: End of plastic watch bands, jewelry, hospital ID cards, stethoscopes, laryngoscope handles

13. INTRAOP: GENERAL ANESTHESIA, LONGER CASE DURATION, POSITIONING, HEAD AND NECK PROCEDURES • DURING EMERGENCE: PT RUBBING EYES (PULSE OX PROBE), MAKE-UP(MASCARA), RIGID O2 MASK THAT RIDES UP IN THE EYES

14. OCULAR INJURY CAN OCCUR D/T: • LOSS OF PAIN SENSATION • OBTUNDATION OF PROTECTIVE CORNEAL REFLEXES • ↓ TEAR PRODUCTION (BOTH BASAL AND REFLEX TEAR PRODUCTION) • SWELLING OF DEPENDENT EYES WITH POSITIONING (PRONE, LATERAL) • HIGHER INCIDENCE WITH PRONE AND LATERAL POSITIONS

15. PATIENT VERBALIZES • FOREIGN BODY SENSATION • PAIN • TEARING • PHOTOPHOBIA • ↓ VISUAL ACUITY • PAIN EXACERBATED BY BLINKING AND OCULAR MOVEMENT

16. ABRASIONS USUALLY HEAL SPONTANEOUSLY WIHTIN 72 HRS WITHOUT SCARRING • BUT SEVERE EYE INJURY CAN CAUSE CATARACT FORMATION AND IMPAIR VISION

17. CORNEAL INJURIES • CORNEAL ABRASION Complete destruction of corneal epithelium caused by trauma. (Did I check that lash reflex too hard?)

18. CORNEAL EXPOSURE Damage to corneal epithelium caused by prolonged exposure or open eye

19. Corneal exposure can also occur in pts who have difficulty closing the eyes completely (lagophythalmos or exophthalmus)

20. ACUTE ANGLE-CLOSURE GLAUCOMA Flow of aqueous humor (intra-ocular fluid) becomes blocked by an obstruction in the drainage system

22. Diagnosis • If a corneal abrasion is suspected, diagnosis is confirmed with a cobalt-blue filtered light and the application of fluorescein

26. Indications for Specialist Referral: • Hx of significant trauma • Worsening of symptoms despite tx • Erosion or infiltrate around the edges of the abrasion (possible infection) • Rare instances of healed epithelium poorly adhered to underlying layers that leads to recurrent corneal erosions

27. TREATMENT • No standard tx • Symptomatic tx can include artificial tears • Prophylactic application of antibiotic ointment (controversial but may help decrease ulcer formation) • Eye patching used in the past --- recently studies are showing that patching not helpful and may delay healing • Small abrasions often need no tx usually heal within 24-72 hrs

28. Topical NSAIDS such as diclofenac or toradol can help reduce pain • No topical anesthetics because they can hinder healing, mask worsening symptoms, and lead to keratitis and damage corneal epithelium • Symptoms usually resolve in 2 months without complication • No improvement in 24 hrs, consult ophthalmology

29. Benchmark Study • The Benchmark study that examined taping the eyes in relation to corneal abrasions was performed in 1977 by Batra & Bali • Study 0f 200 patients divided into 2 groups • Group 1 eyes were left uncovered • Group 2 eyes were deliberately closed with tape or vaseline gauze

30. Benchmark Study • In group 1, 59/100 participants had eyes that remained partially open. The other 41 had natural approximation of the eyes • Batra and Bali found that 26/59 (44%) whose eyes remained partially opened had corneal abrasions after fluorescein eye staining was performed postoperatively • Those with natural approximation of the eyelids and all those in group 2 were not found to have a corneal abrasion

31. Benchmark Study • Eyes were checked for corneal abrasions via fluorescein eye stain testing • Positive staining (which indicated a corneal abrasion) was present only in the inferior third of the cornea of those who developed corneal abrasions. This was the only area of the eye left exposed while under GA • This was the 1st study examining corneal abrasions and proved without a doubt that eyes should be taped or closed when the patient is undergoing GA

32. Ranked 6th in Importance to Avoid • Corneal abrasions are the most common ocular complication while undergoing GA, however; corneal abrasions are not one of the most common complications of undergoing GA • A study conducted by Macario, Weinger, Truong and Lee (1999) examined anesthesia outcomes that were common and important to avoid

33. Based on the ranking of 56 anesthesiologists, corneal abrasions were ranked 29th out of 33 outcomes in frequency of occurrence while undergoing routine outpatient surgery • However, when asked about what outcomes are important to avoid, corneal abrasions were ranked 6th out of 33 outcomes • Although not frequently occurring, corneal abrasions are certainly important to avoid

35. Costly • Another reason that corneal abrasions and eye injuries are important to avoid are the costly monetary rewards that can be received after eye injuries are sustained • In a closed claim analysis project performed by American Society of Anesthesiologists in 1992, 3% of all claims were related to eye injury (71/ 2,046) • Of those eye injuries, 25/71 (35%) were due to corneal abrasions and 83% occurred while under GA (Gild, Posner, Caplan & Cheney)

36. Costly • Of the 71 patients that sustained eye injuries, the patient received compensation in the form of payment in 70% of the cases • Patient rewards after sustaining eye injury from anesthesia ranged from $25.00- $1,000,000.000 (Gild, Posner, Caplan, Cheney, 1992) • Average cost of treating a corneal abrasion was $3,000.00 and permanent injury persisted in 12% of the cases

37. Costly • Standard of care for eye protection was ONLY found in 41% of the cases! • Reasons they found in their study for corneal abrasions were the following: • Patient movement • Spillage of chemicals or prep solution • Direct trauma to the eye from OR padding, needle from retrobulbar block, face mask and laryngoscope falling into the eye

38. Most Common Eye Injury in Multiple Studies • In multiple studies examining eye injuries in non- ocular surgery, corneal abrasions were the number one eye complication • A retrospective study by Roth et al. (1996) found that the most common eye injury was also corneal abrasions

39. Most Common Eye Injury in Multiple Studies • They found that 21 out of 34 (62%) patients who sustained eye injuries from a group of 60,965 patients had corneal abrasions • In Roth et al. study they found a cause of corneal abrasions in only 21% of the cases. The causes they could determine were loosening of tape covering the eyes, iodine prep dripping into the eye and trauma from a intravenous pole falling into the eye

41. Most Common Eye Injury in Multiple Studies • In another retrospective study, Yu et al. (2010) found that 10 of 24 (42%) patients, who sustained eye injuries post- operatively from a study of 75,120 operative cases, had corneal abrasions • Yu et al. in their study found corneal injury to be from incomplete closure of the eye lid, talcum powder falling in the patients’ eye from gloves and surgeons request that the eyes be left uncovered

42. Multiple Factors Can Lead to Development of Corneal Abrasions • Physiological changes • Mechanical trauma • Chemical trauma • Positioning • Duration of Surgery • Location of surgery

43. Some of these factors are preventable while other are out of our control. • As CRNA’s and SRNA’s we have a responsibility to protecting the patient and on a daily basis we perform actions that help to prevent corneal abrasions

44. Physiological Changes of the Eye Under General Anesthesia • Abolishment of normal protective eyelid reflexes • Failure of the eyelids to close (lagophthalmos) • Abolishment of blink reflex • Masking of normal perception of pain • Decreased tear production • Abolishment of the ability of the globe to turn upwards (Bells Phenomenon abolished)

45. Physiological Changes • Loss of eye lid reflex • This reflex closes the eyelid and helps to protect the eye from injury • When this is lost the eye is then at risk for incomplete closure of the eyelids (lagophthalmos) and exposure of the cornea to the dry operating room air

46. Physiological Changes • Failure of the eyelids to close is called lagophthalmos • Due to loss of blink and eye lid reflex • The study by Batra and Bali (1977) found that in their study, 59% of the patients had incomplete eyelid closure while under GA • This exposes the eye to air and drying of the cornea

48. Physiological Changes • Loss of Blink Reflex • Normally a pre-corneal tear film is present protecting the cornea. The blink reflex replenishes the pre-corneal tear film • When this reflex is obtunded, the eye is predisposed to drying • If the eye is left open, this can rupture the pre-corneal tear film and dry patches can form on the cornea

49. Physiological Changes • Pain perception is lost under GA • A insult to the eye may occur but the patient may be unable to feel it and react while being under the effects of general anesthesia

50. Physiological Changes • Decreased basal tear production • A study by Krupin, Cross & Becker (1977) found that tear production was greatly reduced by GA • In their study they measured tear production at various time intervals in 20 patients undergoing GA. Ten minutes after GA was in progress, there was a significant change in tear production (P<.001). At the 30 minute interval, tear production was further reduced (P<.001) as well as at the 60 minute interval (P<.001)