Corneal Abrasions and the Herpes Virus
Being a gardener has a variety of health hazards. About a year ago, while transplanting a dracaena, I scratched my cornea. Over the course of six hours it appeared to slowly have been improving, with less tearing and discomfort. Then, for whatever reason, it began to get worse. At 9:30 P.M. I decided that my eye should get some expert attention and accordingly attended a walk-in government medical clinic. The eye was “stained” and appropriately examined, and indeed, a scratch was demonstrated. I was given an antibiotic to instill in the eye, and a “patch” was prescribed for comfort. I was assured that these corneal scratches invariably heal quickly, often within twenty four hours. This certainly fit in with my teaching and experience, but did not explain why it had suddenly gotten worse after five to six hours.
The next morning (now twenty hours) my eye was no better. Since it was not following the usual pattern of healing, I phoned an ophthalmologist that I knew. After hearing my story he advised that I be seen by him immediately. On attending his busy office I was seen shortly, examined, and advised that the corneal lesion was not healing because it had been secondarily infected by a herpes virus. He explained that people who are inclined to have cold sores may secrete the active virus in their tears, and on occasion, will contaminate a corneal scratch with the virus and proceed on to an infected scratch. This infected scratch does not have the typical appearance of a corneal primary herpes infection (punctuate lesions with fluoracein staining), but rather presents by history, as mine did, and on examination, demonstrates an enlarging lesion with inflamed “loose” epithelial edges. Accordingly, this ophthalmologist froze my eye, scraped away the inflamed loosened edges, and gave me antiviral drops for my eye to be used every two hours, and a prescription for Valtrex to be started immediately. As is the medical axiom, he advised not to cover the eye in the presence of infection, and gave me anti-inflammatory drops to be used to assist with comfort (We were taught that covering the eye was done for reasons of comfort, but should never be covered in the presence of infection). Incredibly, my eye felt much improved by that evening, and the next morning felt normal.
Fast forward to May17/07, when someone near and dear to me, telephones, and relates that she had scratched her eye that morning (she thought, but wasn’t sure how she did it. She acknowledged and recalled rubbing her eye on awakening, but wasn’t certain if it felt abnormal before or after rubbing it). In any case it was becoming more painful as the day went on, so she attended a physician, who appropriately stained her eye, saw a corneal lesion, gave her fucidin antibiotic ointment (for infection, she said) and suggested she wear a patch to cover her eye. I remarked that it was unusual to cover an eye in the presents of infection, and it may be preferable, assuming the presents of infection as related by the patient, comfort permitting, to simply try to not blink by avoiding use of the eye (eg dark room, no T.V., reading, etc) and it should steadily improve. The lesson learned at this point should be: Unless you are prepared to take over complete care and responsibility of/for a situation, as a physician, one should not give even a modicum of advice.
At 9:30 P.M. that same evening things suddenly got much worse. The patient relates much more pain and swelling about the eye, and wishes to know if she should go to the emergency department. Knowing of the long line ups for our emergency departments and the unlikeliness of her being seen by an ophthalmologist, and, having already given advice on the matter (and feeling apprehensive about it since I did not do an examination), I thought I should actually do an assessment myself. Armed with Clavulin, Amoxil, Valrex, Viroptic, and ophthalmic Voltaren drops, I make the dreaded “house call”. To my surprise there is little actual swelling of the lids or orbital area, and the redness of the eye is definitely not in keeping with a bacterial infection. (Put away my samples of Amoxil and Clavulin for possible periorbital cellulites and the like!). On ordinary examination with a bright light it was evident that the cornea itself appeared clear, but it was also evident that there was “loose” appearing corneal epithelium in the infra-pupillary area were the corneal abrasion had been identified by staining earlier that day. I left the Viroptic eye drops and Valtrex (1000mgs to be taken stat and repeated in eight hours), with instructions to use the voltaren eye drops for comfort, not to patch because of the possibility of secondary herpetic infection, and see an ophthalmologist the next day (in case the lesion needed scraping and debridement).
Some twelve hours later I receive a call saying it was like a miracle, the eye felt much improved, but the physician she had seen originally wished to recheck her eye (kudos to him for being responsible and diligent). Then these events unfold:
The original physician stains her eye and is alarmed that the stained area is much larger. He refers her to an ophthalmologist (again kudos for referring when events are not clearly understood), who tells her she does not have a herpes infection of her eye and that she enlarged her original abrasion by blinking and not wearing the patch (although we were taught that the patch was for comfort only and you did not take off normal corneal epithelium with blinking.). She was told to stop the Valtex. Now the patient is in a quandary.
From the patients’ perspective, she is likely to be fine. If she had a secondary herpes infection, the two doses of 1000mgs of Valtrex twice in the first eight hours would likely take care of it since the trend is to treat herpes early, and very aggressively, for one to two days only (although I am puzzled by the ophthalmologist not continuing the Valtrex for another day or two since it has an extremely low side effect profile). From my perspective, the patient likely denuded some corneal epithelium in the morning (this is not uncommon if the patient has had a previous finger nail scratch to the cornea, and of interest is that this patient has had corneal laser corrective surgery. Do these patients experience a higher incidence of A.M. corneal epithelial lesions?) Whether she later denuded the epithelium by blinking (are post laser corrective surgery patients that susceptible and the epithelium that fragile months later, and why isn’t this emphasized more in the literature?), or whether she developed a herpetic secondary infection to explain the enlarged lesion cannot be proven, but wouldn’t it be wise to treat a potentially damaging condition preferentially? And what is to be done in the event of future morning lesions? It is clear to me that what a patient hears from a doctor is not always clear and meaningful to the patient. People who have episodes of A.M denudation (apparently there is some drying and subsequent sticking of the corneal epithelium to the lid during sleep, and on opening the eye in the morning some epithelium is torn off the cornea) need some approach to the problem. I used to suggest some Lacrilube in the eyes at night to prevent sticking and drying in these susceptible individuals. I wonder what advice this lady was given to help her deal with the possible recurrence of this event in the future. In any case, lesson learned. I certainly will have to do a better job of monitoring my involvement in the future. A patients’ perception of a situation is not always as the attending doctor related. In this case the initial attending physician may have said the fucidin ointment was to PREVENT an infection; not FOR an infection, and in that case, the patch was quite appropriate.
The next morning (now twenty hours) my eye was no better. Since it was not following the usual pattern of healing, I phoned an ophthalmologist that I knew. After hearing my story he advised that I be seen by him immediately. On attending his busy office I was seen shortly, examined, and advised that the corneal lesion was not healing because it had been secondarily infected by a herpes virus. He explained that people who are inclined to have cold sores may secrete the active virus in their tears, and on occasion, will contaminate a corneal scratch with the virus and proceed on to an infected scratch. This infected scratch does not have the typical appearance of a corneal primary herpes infection (punctuate lesions with fluoracein staining), but rather presents by history, as mine did, and on examination, demonstrates an enlarging lesion with inflamed “loose” epithelial edges. Accordingly, this ophthalmologist froze my eye, scraped away the inflamed loosened edges, and gave me antiviral drops for my eye to be used every two hours, and a prescription for Valtrex to be started immediately. As is the medical axiom, he advised not to cover the eye in the presence of infection, and gave me anti-inflammatory drops to be used to assist with comfort (We were taught that covering the eye was done for reasons of comfort, but should never be covered in the presence of infection). Incredibly, my eye felt much improved by that evening, and the next morning felt normal.
Fast forward to May17/07, when someone near and dear to me, telephones, and relates that she had scratched her eye that morning (she thought, but wasn’t sure how she did it. She acknowledged and recalled rubbing her eye on awakening, but wasn’t certain if it felt abnormal before or after rubbing it). In any case it was becoming more painful as the day went on, so she attended a physician, who appropriately stained her eye, saw a corneal lesion, gave her fucidin antibiotic ointment (for infection, she said) and suggested she wear a patch to cover her eye. I remarked that it was unusual to cover an eye in the presents of infection, and it may be preferable, assuming the presents of infection as related by the patient, comfort permitting, to simply try to not blink by avoiding use of the eye (eg dark room, no T.V., reading, etc) and it should steadily improve. The lesson learned at this point should be: Unless you are prepared to take over complete care and responsibility of/for a situation, as a physician, one should not give even a modicum of advice.
At 9:30 P.M. that same evening things suddenly got much worse. The patient relates much more pain and swelling about the eye, and wishes to know if she should go to the emergency department. Knowing of the long line ups for our emergency departments and the unlikeliness of her being seen by an ophthalmologist, and, having already given advice on the matter (and feeling apprehensive about it since I did not do an examination), I thought I should actually do an assessment myself. Armed with Clavulin, Amoxil, Valrex, Viroptic, and ophthalmic Voltaren drops, I make the dreaded “house call”. To my surprise there is little actual swelling of the lids or orbital area, and the redness of the eye is definitely not in keeping with a bacterial infection. (Put away my samples of Amoxil and Clavulin for possible periorbital cellulites and the like!). On ordinary examination with a bright light it was evident that the cornea itself appeared clear, but it was also evident that there was “loose” appearing corneal epithelium in the infra-pupillary area were the corneal abrasion had been identified by staining earlier that day. I left the Viroptic eye drops and Valtrex (1000mgs to be taken stat and repeated in eight hours), with instructions to use the voltaren eye drops for comfort, not to patch because of the possibility of secondary herpetic infection, and see an ophthalmologist the next day (in case the lesion needed scraping and debridement).
Some twelve hours later I receive a call saying it was like a miracle, the eye felt much improved, but the physician she had seen originally wished to recheck her eye (kudos to him for being responsible and diligent). Then these events unfold:
The original physician stains her eye and is alarmed that the stained area is much larger. He refers her to an ophthalmologist (again kudos for referring when events are not clearly understood), who tells her she does not have a herpes infection of her eye and that she enlarged her original abrasion by blinking and not wearing the patch (although we were taught that the patch was for comfort only and you did not take off normal corneal epithelium with blinking.). She was told to stop the Valtex. Now the patient is in a quandary.
From the patients’ perspective, she is likely to be fine. If she had a secondary herpes infection, the two doses of 1000mgs of Valtrex twice in the first eight hours would likely take care of it since the trend is to treat herpes early, and very aggressively, for one to two days only (although I am puzzled by the ophthalmologist not continuing the Valtrex for another day or two since it has an extremely low side effect profile). From my perspective, the patient likely denuded some corneal epithelium in the morning (this is not uncommon if the patient has had a previous finger nail scratch to the cornea, and of interest is that this patient has had corneal laser corrective surgery. Do these patients experience a higher incidence of A.M. corneal epithelial lesions?) Whether she later denuded the epithelium by blinking (are post laser corrective surgery patients that susceptible and the epithelium that fragile months later, and why isn’t this emphasized more in the literature?), or whether she developed a herpetic secondary infection to explain the enlarged lesion cannot be proven, but wouldn’t it be wise to treat a potentially damaging condition preferentially? And what is to be done in the event of future morning lesions? It is clear to me that what a patient hears from a doctor is not always clear and meaningful to the patient. People who have episodes of A.M denudation (apparently there is some drying and subsequent sticking of the corneal epithelium to the lid during sleep, and on opening the eye in the morning some epithelium is torn off the cornea) need some approach to the problem. I used to suggest some Lacrilube in the eyes at night to prevent sticking and drying in these susceptible individuals. I wonder what advice this lady was given to help her deal with the possible recurrence of this event in the future. In any case, lesson learned. I certainly will have to do a better job of monitoring my involvement in the future. A patients’ perception of a situation is not always as the attending doctor related. In this case the initial attending physician may have said the fucidin ointment was to PREVENT an infection; not FOR an infection, and in that case, the patch was quite appropriate.
posted by Al | 5:14 PM
|
17 comments
