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Corneal Abrasion; problem what problem?

Well, it all depends on which side of the fence you are sitting on. Most medical definitions describe a corneal abrasion as a painful scrape or scratch on the surface of the clear part of the eye. This clear tissue of the eye is known as the cornea, the transparent window covering the iris, the circular coloured portion of the eye. Descriptions also state that in most cases the cornea heals in a couple of days and all symptoms pass.

A patient on the other hand would probably describe a corneal abrasion as painful to say the least. In fact, it may be extremely painful. This is because the cornea has a high concentration of nerve endings, so it is going to be really painful. Alongside the extreme pain they may feel as though there is something in their eye. The eye will look red, vision will be blurred and there will be excessive tearing. They may be sensitive to light but closing the eye may only cause the pain to intensify. There may be vision loss and headaches which will cause concern.

So, this can be an extremely uncomfortable situation for someone to be in and they need treatment immediately to relieve the pain and allow them to see clearly.

How does a corneal abrasion occur? The answer is, quite easily. Minor abrasions can be caused by:

  • Poking your eye with a fingernail, pen, or makeup brush.
  • Rubbing it too hard.
  • Wear poor-fitting or dirty contact lenses or wearing them for too long.
  • Walking into something like a branch of a tree.

More serious abrasions can occur from:

  • Getting chemicals in your eye.
  • Get dirt, sand, sawdust, ash, or some other foreign matter in your eye, especially at work and not wearing eye protection.
  • Play sports or engaging in high-risk physical activity without eye protection.

You may be surprised to learn that a corneal abrasion can occur when you are having an operation and are anaesthetised. How can that possibly happen, you are probably thinking. Again, the answer is quite easily. But before we consider how a corneal abrasion can occur in the operating theatre, we need to look at how the eye behaves when it is anaesthetised, and the steps taken to protect your eyes when you have an operation.

A general anaesthetic can have several effects on your eyes, including:

  • It can cause lagophthalmos which is a failure of the eyelids to fully close. During normal sleep, lid closure is maintained by the tonic contractions of the orbicularis muscle. Lagophthalmos only occurs in about 4% of people during normal sleep. However, under anaesthesia one study demonstrated that 59% of patients failed to have complete eyelid closure.(1)
  • Tear production and stability are significantly reduced which causes the cornea to dry out.
  • Bell’s phenomenon is a protective mechanism that turns the eyes upwards to protect the cornea. It occurs naturally during sleep, but this mechanism is also lost during general anaesthesia.

Therefore, you can see that the eyes are compromised when you are given a general anaesthetic and so must be protected from being damaged. But how common is getting a corneal abrasion in the operating theatre, what causes it and what is done to protect the eyes?

A corneal abrasion is the most frequent ocular complication of general anaesthesia.(2) The American Society of Anaesthesiologists’ closed claims analysis of ocular injuries associated with general anaesthesia, 35% were corneal abrasions, of which 16% resulted in permanent ocular damage.(3)

Because the eyes are compromised during general anaesthesia, almost anything can cause a corneal abrasion. The list is endless. A watch strap, name badge, the anaesthetist’s hands, facemasks, drapes, instruments laryngoscope, skin preparation solutions, or the direct irritant effect of inhalational anaesthetic agents. In recovery the eye may be injured by face masks, the patient’s fingers, or the bed linen. However, most corneal abrasions are caused by the failure of the eyelids to close properly leading to corneal drying.(4) I will return to this point later.

It’s clear that the eyes need some solid protection to prevent them from being damaged. So, what is done in today’s modern, high tech expensive operating theatre? They do this.

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Usually, a theatre technician will use some general-purpose tape that is lying on a trolley or in their pocket and your eyes will be taped shut. Prior to taping a protective ointment or gel may be applied. However, we all know that adhesiveness of tape varies and that used in the operating theatre is no different. Too little stick may not ensure or maintain complete eyelid closure, leading to moisture loss from the eye. Too much stick may cause eyelid bruising, irritation and skin tears or eyelash loss on removal. Tape used is usually opaque making it difficult to tell if the patients’ eyes are completely closed. Frequent removal and reapplication of the tape makes it less sticky and prone to falling off Additionally, the anaesthetist may need to check pupil dilation and the tape needs to be removed and reapplied whilst wearing surgical gloves. Not an easy thing to do!

So, back to our patient. Despite taping the patient’s eyes being taped during an operation, the tape was opaque, and no one spotted that the eyes opened during the operation causing the cornea to dry out. When the patient woke up, they had a really painful and sore red eye. A saline washout of the eye was tried but that didn’t work. In the end an ophthalmologist was called to examine the patient and a corneal abrasion, caused by the eye drying out was diagnosed. This required treatment including pain management, antimicrobial prophylaxis, a pressure patch, and close monitoring meaning the patient was in hospital for an extra day.

Could all this have been avoided? Could the anaesthetist have spotted that the patients’ eyes had opened during the operation and closed them? Could a corneal abrasion have been avoided and the patient not had such a painful experience? Could the hospital have avoided all those extra treatment costs such as consultant time, drugs, and bed usage?

Instead of using opaque general-purpose tape to protect the patients’ eyes, the hospital should have used EyePro™ instead.

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Why should we use EyePro™ instead of tape?  EyePro™ is a unique eyelid cover designed by an anaesthetist to maintain eyelid closure during general anaesthesia.

It ensures rapid, complete, and safe eyelid closure. By sealing around the eye circumferentially, all moisture is retained, thus preventing the eye from drying out. Additionally, a clear central window allows direct observation of eyelid closure.

EyePro™ has a patented dual zone design whereby an inner transparent window allows intra-operative assessment of eyelid closure, while an outer, more rigid, opaque zone allows for easy handling and excellent conformity to the eye socket. The inner window has a gentle adhesive which helps to maintain eyelid closure and reduces eyelid trauma and/or eyelash removal. The outer zone has slightly stronger adhesive that maintains eyelid closure for extended periods. Also, non- adhesive tabs allow for easy handling, application, and removal, even while wearing gloves.

Additionally, each pair of EyePro™ comes packaged together in a sterile wrap to decrease the risk of cross contamination. In a world where we are going to have to live with Covid-19 anything that reduces the risk of infection must be a good thing. But that will be the subject of another article.

EyePro™ is more expensive than tape I hear you say. Yes, it is. That’s because it has been specifically designed for one purpose; to protect the eyes during general anaesthesia. In doing so, EyePro™ provides a superior level of protection against corneal abrasions. And don’t forget those extra treatment costs such as consultant time, drugs, and bed usage. An extra day in hospital would cost approximately $1800/day in the USA, $AUD1000/day in Australia, £400/day in the UK and €600 in the EU.

EyePro™ is a major advance in keeping the patients’ eyes safe during general anaesthesia. Remember, most corneal abrasions are caused by the failure of the eyelids to close properly leading to corneal drying. EyePro™ allows the anaesthetist to ensure the eyes remain closed, thereby reducing the risk of corneal abrasion. This leads to a better patient experience, quicker recovery time and a reduction in the use of valuable hospital resources such as drugs, bed occupancy and clinical time. Additionally, within the overall cost of treating the patient EyePro™ could also save you money. It really is a no brainer!!!

References:

  1. Batra YK & Bali IM. Corneal abrasions during general anaesthesia. Anaesthesia and Analgesia 1977; 56: 363– 5.
  2. Terry TH, Kearns TP, Grafton‐Loue J, Orwell G. Untoward ophthalmic and neurological events of anaesthesia. Surgical Clinics of North America 1965; 45: 927– 9.
  3. Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries associated with anaesthesia. Anaesthesiology 1992; 72: 204– 8.
  4. White E, Crosse MM. The aetiology and prevention of peri‐operative corneal abrasions. Anaesthesia, 1998, 53, pages 157–161
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Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

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