CEDARS/ASPENS Debates

ER doctors and the use of topical anesthetics in corneal abrasion patients

Darrell E. White, MD, discusses his view on the practice and how pain plays a part in patient follow-up.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

One topic that has been debated over the years is the use of topical anesthetics for patients with corneal abrasions. It has become more common among ER physicians to prescribe low-dose topical anesthetics for these patients and then schedule follow-up with an ophthalmologist. Most ophthalmologists have been trained that the use of these drops will actually delay healing and lead to further complications. This month, Darrell E. White, MD, discusses this growing practice among ER physicians and gives his stance on the controversy. We hope you enjoy this discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

My Mom was raised in a traditional Roman Catholic household, and therefore so were my siblings and I. Mom has always been a student of, and highly respectful of, the mores and family customs in the homes of her friends raised by traditional Jewish parents. My siblings and I like to tell our friends that what this got us as children was a double dose of maternal guilt. For example, my brother has been married for some 30 years, and I still have guilt that I did not palm the bottle of tetracaine sitting by the slit lamp when I took my Dad to the ER with a corneal abrasion on the day of my brother’s wedding.

Darrell E. White

So powerful is the lesson learned in training that even under the direct supervision of an ophthalmologist it was simply unthinkable to use a topical anesthetic in the care of a corneal abrasion.

On the interwebs, there has been an ongoing discussion between the ER doctor authors of a paper extolling the virtues of dispensing a topical anesthetic to corneal abrasion patients and several ophthalmologists who find themselves incredulous that this is even a topic. Writing in Academic Emergency Medicine, Waldman and colleagues concluded that it is safe, effective and desirable to give corneal abrasion patients enough topical tetracaine for 24 hours of treatment. They base this claim on 64 patients treated in whom there was no difference in corneal staining at 48 hours, and roughly twice the favorable rating by patients despite no difference in pain scores between treated and untreated groups.

The initial salvo of letters from ophthalmologists pointed out the numerous incorrect diagnoses made in the ER (misdiagnosed corneal ulcers, penetrating laceration, etc.) as the most obvious problem with the study. Frankly, it is hard not to just cite their objection and call it a day. Who among us has not seen the gamut of painful anterior segment problems sent to us 24 hours after a patient was diagnosed with a corneal abrasion in the ER? Indeed, those cases are the fortunate ones for the simple fact that they were seen in follow-up by an ophthalmologist.

One hundred percent of these patients followed up because of persistent pain.

Every city that is home to an ophthalmology residency program has its own version of the corneal abrasion-topical anesthetic horror story. In the New York of the ‘80s, our story was particularly poignant because the patient was a physician. Legend had it that an academic endocrinologist suffered a scratch when her child swiped a finger across her cornea. We all know that there is no human being whose life is busier than a physician who is also a mother. With the power of the prescribing pen, she simply wrote a prescription for proparacaine and put a drop in every couple of hours. You know where this is going, of course; 5 days later she was diagnosed with a massive central corneal ulcer and eventually needed a transplant due to decreased central vision.

At this point it would be easy to fall back on our scientific training and talk about increased epithelial healing times associated with topical tetracaine, reference the use of dilute anesthetic in the perioperative period with PRK, or even get fancy and cutting-edge and talk about compounded topical morphine. Pretty gutsy, prescribing that, eh? (Hat tip to Alice Epitropoulos for finding this.) This is all real and makes a good argument against the use of topical anesthetics in this setting, but it misses the point.

The authors of the paper write about a setting and a process that are disconnected from reality.

Let us start with who is seeing the patients in the ER in question. A percentage (I could not find the number) was seen by “junior doctors.” While I am not entirely sure what this means, I take it that this is a euphemism for “resident.” Each of the 64 patients treated was seen in follow-up that appears to have occurred in the ER itself, presumably by “senior doctors.” It is unclear how many were referred to an ophthalmologist at this point, although clearly those with persistent staining or a “new” diagnosis got referred.

There is a massive disconnect between standard operating procedure in the ER in question and what is actually occurring in the majority of ERs in the United States now. The most charitable way to describe the authors’ awareness is that they are naive in the extreme as to how their study protocol differs from reality. As an ophthalmologist who has taken ER call for nearly 30 years at hospitals of various sizes and academic shapes, any corneal abrasion determined to be simple and straightforward in triage is shuttled off to a physician assistant or nurse practitioner. They are “streeted” with an antibiotic drop prescription and a next-day appointment with the covering eye doctor.

What pretty much guarantees the arrival of the patient in the eye doctor’s office is pain. Even with considerable pain, it is astonishing how many patients with a corneal abrasion simply blow off that appointment. The ones who were misdiagnosed (keratitis, iritis, laceration, etc) eventually make their way in, as do the ones with a retained foreign body. Again, it is pain that prompts them to follow up, and masking that pain with a topical anesthetic interferes with this natural course.

Polling my CEDARS/ASPENS colleagues yielded some version of best practices (bordering on standard of care): bandage contact lens, topical antibiotic drop and topical bromfenac. Neurontin (gabapentin) is used in some cases of intractable pain as is dilute topical anesthetic (as in PRK cases), including compounded topical morphine for the brave. As an aside, not a one of us prescribes systemic opiates. Patients are seen frequently, in many cases daily until the abrasion has healed.

Pain mitigation is an important part of caring for a patient with a corneal abrasion, and I certainly think Dr. Waldman and his colleagues have their hearts in the right place. As a community, ophthalmologists have done a good job of convincing ER docs not to prescribe topical steroids for a red eye in part because patients often fail to follow up and just keep taking the steroid. Alleviating but not eliminating discomfort increases the likelihood that abrasion patients will follow up with an ophthalmologist.

Perhaps we could channel our energies into encouraging the use of bromfenac, the most appropriate topical NSAID, to reduce pain and inflammation. This is a reasonable option for ER doctors (and physician assistants or nurse practitioners). They are doing something real to treat their patient’s pain, and they are much more comfortably in the arena of “best practices.” As a team, ER doctors and ophthalmologists will miss fewer opportunities to correct a missed diagnosis and patients will be at lower risk from their treatment. Even one case of injury from delayed care brought about from the use of topical anesthetics in this arena is one too many.

Imagine the guilt I would have if I had given my Dad that bottle of proparacaine and he did not follow up with his eye doctor on Monday.

Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

One topic that has been debated over the years is the use of topical anesthetics for patients with corneal abrasions. It has become more common among ER physicians to prescribe low-dose topical anesthetics for these patients and then schedule follow-up with an ophthalmologist. Most ophthalmologists have been trained that the use of these drops will actually delay healing and lead to further complications. This month, Darrell E. White, MD, discusses this growing practice among ER physicians and gives his stance on the controversy. We hope you enjoy this discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

My Mom was raised in a traditional Roman Catholic household, and therefore so were my siblings and I. Mom has always been a student of, and highly respectful of, the mores and family customs in the homes of her friends raised by traditional Jewish parents. My siblings and I like to tell our friends that what this got us as children was a double dose of maternal guilt. For example, my brother has been married for some 30 years, and I still have guilt that I did not palm the bottle of tetracaine sitting by the slit lamp when I took my Dad to the ER with a corneal abrasion on the day of my brother’s wedding.

Darrell E. White

So powerful is the lesson learned in training that even under the direct supervision of an ophthalmologist it was simply unthinkable to use a topical anesthetic in the care of a corneal abrasion.

On the interwebs, there has been an ongoing discussion between the ER doctor authors of a paper extolling the virtues of dispensing a topical anesthetic to corneal abrasion patients and several ophthalmologists who find themselves incredulous that this is even a topic. Writing in Academic Emergency Medicine, Waldman and colleagues concluded that it is safe, effective and desirable to give corneal abrasion patients enough topical tetracaine for 24 hours of treatment. They base this claim on 64 patients treated in whom there was no difference in corneal staining at 48 hours, and roughly twice the favorable rating by patients despite no difference in pain scores between treated and untreated groups.

The initial salvo of letters from ophthalmologists pointed out the numerous incorrect diagnoses made in the ER (misdiagnosed corneal ulcers, penetrating laceration, etc.) as the most obvious problem with the study. Frankly, it is hard not to just cite their objection and call it a day. Who among us has not seen the gamut of painful anterior segment problems sent to us 24 hours after a patient was diagnosed with a corneal abrasion in the ER? Indeed, those cases are the fortunate ones for the simple fact that they were seen in follow-up by an ophthalmologist.

PAGE BREAK

One hundred percent of these patients followed up because of persistent pain.

Every city that is home to an ophthalmology residency program has its own version of the corneal abrasion-topical anesthetic horror story. In the New York of the ‘80s, our story was particularly poignant because the patient was a physician. Legend had it that an academic endocrinologist suffered a scratch when her child swiped a finger across her cornea. We all know that there is no human being whose life is busier than a physician who is also a mother. With the power of the prescribing pen, she simply wrote a prescription for proparacaine and put a drop in every couple of hours. You know where this is going, of course; 5 days later she was diagnosed with a massive central corneal ulcer and eventually needed a transplant due to decreased central vision.

At this point it would be easy to fall back on our scientific training and talk about increased epithelial healing times associated with topical tetracaine, reference the use of dilute anesthetic in the perioperative period with PRK, or even get fancy and cutting-edge and talk about compounded topical morphine. Pretty gutsy, prescribing that, eh? (Hat tip to Alice Epitropoulos for finding this.) This is all real and makes a good argument against the use of topical anesthetics in this setting, but it misses the point.

The authors of the paper write about a setting and a process that are disconnected from reality.

Let us start with who is seeing the patients in the ER in question. A percentage (I could not find the number) was seen by “junior doctors.” While I am not entirely sure what this means, I take it that this is a euphemism for “resident.” Each of the 64 patients treated was seen in follow-up that appears to have occurred in the ER itself, presumably by “senior doctors.” It is unclear how many were referred to an ophthalmologist at this point, although clearly those with persistent staining or a “new” diagnosis got referred.

There is a massive disconnect between standard operating procedure in the ER in question and what is actually occurring in the majority of ERs in the United States now. The most charitable way to describe the authors’ awareness is that they are naive in the extreme as to how their study protocol differs from reality. As an ophthalmologist who has taken ER call for nearly 30 years at hospitals of various sizes and academic shapes, any corneal abrasion determined to be simple and straightforward in triage is shuttled off to a physician assistant or nurse practitioner. They are “streeted” with an antibiotic drop prescription and a next-day appointment with the covering eye doctor.

PAGE BREAK

What pretty much guarantees the arrival of the patient in the eye doctor’s office is pain. Even with considerable pain, it is astonishing how many patients with a corneal abrasion simply blow off that appointment. The ones who were misdiagnosed (keratitis, iritis, laceration, etc) eventually make their way in, as do the ones with a retained foreign body. Again, it is pain that prompts them to follow up, and masking that pain with a topical anesthetic interferes with this natural course.

Polling my CEDARS/ASPENS colleagues yielded some version of best practices (bordering on standard of care): bandage contact lens, topical antibiotic drop and topical bromfenac. Neurontin (gabapentin) is used in some cases of intractable pain as is dilute topical anesthetic (as in PRK cases), including compounded topical morphine for the brave. As an aside, not a one of us prescribes systemic opiates. Patients are seen frequently, in many cases daily until the abrasion has healed.

Pain mitigation is an important part of caring for a patient with a corneal abrasion, and I certainly think Dr. Waldman and his colleagues have their hearts in the right place. As a community, ophthalmologists have done a good job of convincing ER docs not to prescribe topical steroids for a red eye in part because patients often fail to follow up and just keep taking the steroid. Alleviating but not eliminating discomfort increases the likelihood that abrasion patients will follow up with an ophthalmologist.

Perhaps we could channel our energies into encouraging the use of bromfenac, the most appropriate topical NSAID, to reduce pain and inflammation. This is a reasonable option for ER doctors (and physician assistants or nurse practitioners). They are doing something real to treat their patient’s pain, and they are much more comfortably in the arena of “best practices.” As a team, ER doctors and ophthalmologists will miss fewer opportunities to correct a missed diagnosis and patients will be at lower risk from their treatment. Even one case of injury from delayed care brought about from the use of topical anesthetics in this arena is one too many.

Imagine the guilt I would have if I had given my Dad that bottle of proparacaine and he did not follow up with his eye doctor on Monday.

Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.