eMedicine Specialties > Emergency Medicine > Ophthalmology
Corneal Laceration: Treatment & Medication
Updated: Apr 9, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Cover the patient's eye with an eye shield or polystyrene/paper cup and avoid any pressure to the globe.
- Instruct the patient to move the eyes as little as possible.
- Administer antiemetic and analgesic medication in order to reduce pressure on the globe.
Emergency Department Care
Perform an examination to ascertain the extent of the corneal, anterior chamber, ocular, and associated (eg, facial, cranial) injuries.
- Ophthalmologic consultation is indicated to convey the practitioner's findings and to decide on the appropriate evaluation, treatment, and timing of ophthalmologic evaluation.
- Place a protective eye shield (prefabricated or custom made) on the injured eye. This can be a commercial plastic eye shield or simply a polystyrene/paper cup taped over the eye.
- Administer antiemetics and systemic analgesic medication.
- Tetanus immunization or booster is indicated.
- In consultation with the ophthalmologist, discuss the administration of antibiotics including route (topical or intravenously) and frequency.
- In general, topical analgesia and antibiotics should be avoided if a corneal laceration is suspected. Use systemic analgesia and antibiotics. Topical anesthetics may be used, if needed, to facilitate visual acuity testing and the slit lamp examination.
Consultations
Ophthalmologic consultation is necessary. The two practitioners must decide and document when and where the consultation will occur.
Medication
Recommendations include a combination of a cephalosporin (eg, cefazolin) or vancomycin and an aminoglycoside (eg, gentamicin). In addition, add clindamycin if an intraocular foreign body is present or if vegetable matter has contaminated the wound. The most common organisms identified in posttraumatic endophthalmitis are Staphylococcus epidermidis, bacilli species, streptococci species, and gram-negative species. Fungal endophthalmitis is a relatively rare entity but should be considered in a patient who is recently post-surgical, immunocompromised, unresponsive to antibiotic treatment, or has a history of trauma with vegetable matter. Treatment should be discussed with the ophthalmology consultant if this is suspected.
Antibiotics
These agents are used in prophylaxis of endophthalmitis. Therapy must cover all likely pathogens in the context of the clinical setting.
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation cephalosporin antibiotic for gram-positive bacterial coverage. Commonly used in combination with an aminoglycoside to achieve broad-spectrum coverage.
Adult
500-1000 mg IV q8h; not to exceed 1 g q6h for severe infection
Pediatric
25-50 mg/kg/d IV divided tid/qid; not to exceed 100 mg/kg/d divided tid/qid for severe infection
Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test for glucose
Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; use of steroid combinations after uncomplicated removal of corneal foreign body
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside that provides coverage for most gram-negative organisms causing endophthalmitis.
Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not the antibiotic of first choice. Consider using this aminoglycoside when penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms.
Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution. May be administered IV or IM.
Adult
3 mg/kg/d IV/IM divided tid; not to exceed 5 mg/kg/d for severe infections
Dosage adjustment is based upon peak/trough levels; renal function monitoring is recommended
Pediatric
7.5 mg/kg/d IV/IM divided tid
Dosage adjustment is based upon peak/trough levels; renal function monitoring is recommended
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Clindamycin (Cleocin)
Lincosamide useful as a treatment against serious skin and soft tissue infections caused by most staphylococci. Effective against aerobic and anaerobic streptococci, except enterococci.
Use in the prophylaxis of endophthalmitis when a foreign body is present or if the injury was soil or farm related to provide an effective agent against bacilli species.
Adult
600-1200 mg/d IV divided bid/qid; not to exceed 4.8 g/d for life-threatening infections
Pediatric
20-40 mg/kg/d IV divided bid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococci species.
Can be used as an alternative to cefazolin to provide coverage for most gram-positive organisms causing endophthalmitis.
Use in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures.
To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose (drawn 0.5 h prior to next dosing). Use creatinine clearance to adjust the dose in patients with renal impairment.
Adult
2 g/d IV divided bid/qid
Pediatric
30-40 mg/kg/d IV divided bid/qid
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; concurrent use with aminoglycosides may increase risk of nephrotoxicity above that of aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; "red man" syndrome (not an allergic reaction) is caused by too rapid IV infusion (dose administered over a few min) but rarely happens when dose administered over 2-h period or PO or IP
More on Corneal Laceration |
| Overview: Corneal Laceration |
| Differential Diagnoses & Workup: Corneal Laceration |
 Treatment & Medication: Corneal Laceration |
| Follow-up: Corneal Laceration |
| References |
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References
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Further Reading
Keywords
full-thickness corneal injury, partial-thickness corneal injury, penetrating globe injury, ocular trauma, corneal laceration, corneal abrasion, ruptured globe
