Pain, pain, go away

Optometric Management, Apr 2000 by Garston, Matthew

Bandage contact lenses beat patching.

It's Friday afternoon and your assistant says that your next patient was struck in the eye while playing basketball. It's obvious from the way he holds his hand over his eye that he's very uncomfortable. Captain and leading scorer of his high school basketball team, he's desperate to get back on the court.

His examination is normal except for a large 4- to 5-mm central corneal abrasion. Should you patch his eye? Not necessarily. Here, I'll discuss a better approach to pain management.

Patch problems

We often use eyelid patches to manage pain from a corneal abrasion or recurrent corneal erosion syndrome. Because the upper lid moving over exposed nerve endings is what causes the pain, proper patching should solve the problem by immobilizing the eyelid. This also helps the corneal epithelial tissue regenerate by avoiding disruption of its surface. But patches aren't always applied properly. They have other drawbacks, too:

* They may not keep the lid closed and could make patients more uncomfortable.

* A large pad will cover the patient's eye, and he may not be able to get his glasses back on.

* The patch may block the patient's vision.

* The eyelids may move under the patch, increasing the discomfort.

* The tape holding the eye pad may irritate the patient's skin.

Bandage lens solutions

Bandage lenses decrease pain by covering the exposed nerve endings and protecting them from the trauma of upper eyelid movement. They have several advantages over patching:

* They don't require messy tape

* They don't block vision

* They don't make application of medication difficult

* They don't require upper eyelid immobility

* The patient may be able to visualize his eye in a mirror and judge whether it looks better.

I use this approach for treating large corneal abrasions (>2 mm), large areas of loose epithelium from a recurrent corneal erosion and after foreign body removal involving a large area of epithelial disruption. However, if there's indication of concurrent infection, I don't patch because doing so can promote bacterial growth. Also, I don't patch corneal ulcers because it will promote bacterial growth.

Fitting a bandage lens

When fitting a bandage contact lens, remove hanging or heaped-up epithelium from the center and edge of the defect with a wet sterile cotton swab. Wipe toward the center of the defect to ensure minimum expansion of the defect edges. Fit tight with

Once the lens has settled, check that it's not too tight. If it doesn't move, try to move it by pressing your thumb against the lower eyelid and pushing the lid against the edge of the lens. I try no more than three lenses to achieve a snug fit; then, I patch the eye in the traditional manner.

I also apply 1 to 2 fluoroquinolone drops before placing the contact lens and then daily, q.i.d., over it. I prefer fluoroquinolone drops to aminoglycoside drops because of better coverage and a much lower concentration of the preservative benzalkonium chloride (.005% to .01%). This preservative is toxic to corneal epithelial cells and its molecule is small enough to get into the soft lens.

If my patient is very uncomfortable, I will instill 1 or 2 drops of a mild cycloplegic agent such as homatropine 5 into the eye before applying the bandage lens because later, following significant corneal trauma, the patient will have a painful ciliary muscle spasm. If the cycloplegic agent is already working, this pain will be much less severe.

Continuing care

Because of the recent reports of corneal melts after cataract surgery, I usually don't use nonsteroidals, even though a cataract wound is different from a surface abrasion. Cycloplegia and a bandage lens should be adequate for pain management.

I check the patient daily, and I instruct him to use the fluoroquinolone antibiotic drops q.i.d. He can then wear the lens safely for at least 4 days or until the surface of the cornea has re-epithelialized.

After that, I remove the lens. I've found that pre-removal lubrication with unpreserved saline drops helps prevent the lens from sticking and facilitates removal.

I utilize the high water content lenses; they allow better oxygen transmission. (See table, page 26.)

Follow-up

Patients with significant abrasion have some risk of developing recurrent erosion syndrome, so I encourage daily use of artificial tears and nightly application of ophthalmic ointments before sleep for at least 3 to 4 weeks after total healing. Also, I've found that urging patients to avoid vigorous eye rubbing is vital in preventing recurrences.

Chosen therapy

Bandage soft lenses are my chosen therapy for pain relief from large corneal abrasions, recurrent erosion syndrome and significant surface trauma after foreign body removal. They helped me put my young basketball player back on the court in 3 days, just in time for the next game.

I insist on seeing bandage lens patients daily. They and their families appreciate anything that I can do to help them better understand the nature of the injury, minimize their pain and provide emotional support. Helping them is rewarding and a great practice builder too. Nothing is worse than pain - and no one is a better source of referrals than a patient whose pain has resolved thanks to your care.