CORNEAL ABRASIONSWHEN DO I GET MY TAPE ON?!

Laura Surike RN, BSN, SRNALeah Abbott RN, BSN, SRNA

OBJECTIVES

AT THE END OF THIS PRESENTATION, THE LEARNER WILL BE ABLE TO:

DEFINE WHAT IS A CORNEAL ABRASION

LIST COMMON CAUSES OF CORNEAL ABRASIONS

LIST TWO WAYS TO DECREASE THE CHANCE OF CORNEAL ABRASIONS

STATE THREE WAYS TO TREAT A CORNEAL ABRASION

“CORNEAL WHAT?.....I’M JUST TRYING TO GET MY INTUBATION AND ALL MY MONITORS ON BEFORE THE SURGEON YELLS AT ME FOR NOT HAVING THE DRAPES UP!” ---ANONYMOUS

Why are We Talking About Corneal Abrasions?

While rotating through various sites for clinical, every site taped the eyes differently

Some taped the eyes before ventilating the patient, others after intubation, and some throughout the induction process

Some sites used eye lubricant and others never used it

Some sites used silk tape or opsite while others used commercial eye cut outs

What we did find was there was NO consistency

Currently there is no standard of care as to when to tape the eyes or how to tape the eyes

What is known is that taping the eyes while undergoing GA helps to prevent corneal abrasions

CORNEAL ABRASION

THE MOST COMMON OCULAR COMPLICATION OF GENERAL ANESTHESIA

Cornea

The cornea is an avascular structure composed of 5 histologically distinct layers

Protected by a precorneal tear film composed of 3 layers: lipid, aqueous, and mucin

Lipid layer: Prevents evaporation of the aqueous layer and acts as a lubricant

Aqueous layer: oxygenates the corneal epithelium

Mucin layer: creates a hydrophilic surface on the corneal epithelium

The precorneal tear film is regenerated by blinking

Absence of blinking during general anesthesia renders the cornea vulnerable to injury

How do Corneal Abrasions Occur?

Cornea extremely sensitive to hypoxia

Partial pressure of oxygen in cornea can decrease greatly in as little as 30 seconds of hypoxia

Corneal hypoxia leads to edema →potential for loss of the epithelial layer →causing an abrasion

Physiologic factors that alter corneal blood flow can predispose pts to corneal injury

This includes conditions that ↓ arterial blood flow such as ↑ IOP, head malpositioning, or pressure from an incorrectly applied face mask

↓ venous return can also lead to corneal edema and subsequent abrasion

2 main mechanisms of perioperative corneal injury are mechanical abrasion or exposure-induced drying of the corneal surface

CAUSES Damage from anesthesia mask,

surgical drapes, and spillage of solution

During Intubation: End of plastic watch bands, jewelry, hospital ID cards, stethoscopes, laryngoscope handles

INTRAOP: GENERAL ANESTHESIA, LONGER CASE DURATION, POSITIONING, HEAD AND NECK PROCEDURES

DURING EMERGENCE: PT RUBBING EYES (PULSE OX PROBE), MAKE-UP(MASCARA), RIGID O2 MASK THAT RIDES UP IN THE EYES

OCULAR INJURY CAN OCCUR D/T:

LOSS OF PAIN SENSATION OBTUNDATION OF PROTECTIVE

CORNEAL REFLEXES ↓ TEAR PRODUCTION (BOTH BASAL

AND REFLEX TEAR PRODUCTION) SWELLING OF DEPENDENT EYES

WITH POSITIONING (PRONE, LATERAL)

HIGHER INCIDENCE WITH PRONE AND LATERAL POSITIONS

PATIENT VERBALIZES

FOREIGN BODY SENSATION PAIN TEARING PHOTOPHOBIA ↓ VISUAL ACUITY PAIN EXACERBATED BY BLINKING

AND OCULAR MOVEMENT

ABRASIONS USUALLY HEAL SPONTANEOUSLY WIHTIN 72 HRS WITHOUT SCARRING

BUT SEVERE EYE INJURY CAN CAUSE CATARACT FORMATION AND IMPAIR VISION

CORNEAL INJURIES

CORNEAL ABRASION

Complete destruction of corneal epithelium caused by trauma. (Did I check that lash reflex too hard?)

CORNEAL EXPOSURE

Damage to corneal epithelium caused by prolonged exposure or open eye

Corneal exposure can also occur in pts who have difficulty closing the eyes completely (lagophythalmos or exophthalmus)

ACUTE ANGLE-CLOSURE GLAUCOMA

Flow of aqueous humor (intra-ocular fluid) becomes blocked by an obstruction in the drainage system

Diagnosis

If a corneal abrasion is suspected, diagnosis is confirmed with a cobalt-blue filtered light and the application of fluorescein

Indications for Specialist Referral:

Hx of significant trauma Worsening of symptoms despite tx Erosion or infiltrate around the edges

of the abrasion (possible infection) Rare instances of healed epithelium

poorly adhered to underlying layers that leads to recurrent corneal erosions

TREATMENT

No standard tx Symptomatic tx can include artificial tears Prophylactic application of antibiotic

ointment (controversial but may help decrease ulcer formation)

Eye patching used in the past --- recently studies are showing that patching not helpful and may delay healing

Small abrasions often need no tx usually heal within 24-72 hrs

Topical NSAIDS such as diclofenac or toradol can help reduce pain

No topical anesthetics because they can hinder healing, mask worsening symptoms, and lead to keratitis and damage corneal epithelium

Symptoms usually resolve in 2 months without complication

No improvement in 24 hrs, consult ophthalmology

Benchmark Study

The Benchmark study that examined taping the eyes in relation to corneal abrasions was performed in 1977 by Batra & Bali

Study 0f 200 patients divided into 2 groups

Group 1 eyes were left uncovered Group 2 eyes were deliberately

closed with tape or vaseline gauze

Benchmark Study

In group 1, 59/100 participants had eyes that remained partially open. The other 41 had natural approximation of the eyes

Batra and Bali found that 26/59 (44%) whose eyes remained partially opened had corneal abrasions after fluorescein eye staining was performed postoperatively

Those with natural approximation of the eyelids and all those in group 2 were not found to have a corneal abrasion

Benchmark Study Eyes were checked for corneal abrasions

via fluorescein eye stain testing Positive staining (which indicated a corneal

abrasion) was present only in the inferior third of the cornea of those who developed corneal abrasions. This was the only area of the eye left exposed while under GA

This was the 1st study examining corneal abrasions and proved without a doubt that eyes should be taped or closed when the patient is undergoing GA

Ranked 6th in Importance to Avoid

Corneal abrasions are the most common ocular complication while undergoing GA, however; corneal abrasions are not one of the most common complications of undergoing GA

A study conducted by Macario, Weinger, Truong and Lee (1999) examined anesthesia outcomes that were common and important to avoid

Based on the ranking of 56 anesthesiologists, corneal abrasions were ranked 29th out of 33 outcomes in frequency of occurrence while undergoing routine outpatient surgery

However, when asked about what outcomes are important to avoid, corneal abrasions were ranked 6th out of 33 outcomes

Although not frequently occurring, corneal abrasions are certainly important to avoid

Costly Another reason that corneal abrasions and

eye injuries are important to avoid are the costly monetary rewards that can be received after eye injuries are sustained

In a closed claim analysis project performed by American Society of Anesthesiologists in 1992, 3% of all claims were related to eye injury (71/ 2,046)

Of those eye injuries, 25/71 (35%) were due to corneal abrasions and 83% occurred while under GA (Gild, Posner, Caplan & Cheney)

Costly

Of the 71 patients that sustained eye injuries, the patient received compensation in the form of payment in 70% of the cases

Patient rewards after sustaining eye injury from anesthesia ranged from $25.00- $1,000,000.000 (Gild, Posner, Caplan, Cheney, 1992)

Average cost of treating a corneal abrasion was $3,000.00 and permanent injury persisted in 12% of the cases

Costly

Standard of care for eye protection was ONLY found in 41% of the cases!

Reasons they found in their study for corneal abrasions were the following: Patient movement Spillage of chemicals or prep solution Direct trauma to the eye from OR

padding, needle from retrobulbar block, face mask and laryngoscope falling into the eye

Most Common Eye Injury in Multiple Studies

In multiple studies examining eye injuries in non- ocular surgery, corneal abrasions were the number one eye complication

A retrospective study by Roth et al. (1996) found that the most common eye injury was also corneal abrasions

Most Common Eye Injury in Multiple Studies

They found that 21 out of 34 (62%) patients who sustained eye injuries from a group of 60,965 patients had corneal abrasions

In Roth et al. study they found a cause of corneal abrasions in only 21% of the cases. The causes they could determine were loosening of tape covering the eyes, iodine prep dripping into the eye and trauma from a intravenous pole falling into the eye

Most Common Eye Injury in Multiple Studies

In another retrospective study, Yu et al. (2010) found that 10 of 24 (42%) patients, who sustained eye injuries post- operatively from a study of 75,120 operative cases, had corneal abrasions

Yu et al. in their study found corneal injury to be from incomplete closure of the eye lid, talcum powder falling in the patients’ eye from gloves and surgeons request that the eyes be left uncovered

Multiple Factors Can Lead to Development of Corneal Abrasions

Physiological changes Mechanical trauma Chemical trauma Positioning Duration of Surgery Location of surgery

Some of these factors are preventable while other are out of our control.

As CRNA’s and SRNA’s we have a responsibility to protecting the patient and on a daily basis we perform actions that help to prevent corneal abrasions

Physiological Changes of the Eye Under General Anesthesia

Abolishment of normal protective eyelid reflexes

Failure of the eyelids to close (lagophthalmos)

Abolishment of blink reflex Masking of normal perception of pain Decreased tear production Abolishment of the ability of the

globe to turn upwards (Bells Phenomenon abolished)

Physiological Changes

Loss of eye lid reflex This reflex closes the eyelid and

helps to protect the eye from injury When this is lost the eye is then at

risk for incomplete closure of the eyelids (lagophthalmos) and exposure of the cornea to the dry operating room air

Physiological Changes

Failure of the eyelids to close is called lagophthalmos

Due to loss of blink and eye lid reflex The study by Batra and Bali (1977)

found that in their study, 59% of the patients had incomplete eyelid closure while under GA

This exposes the eye to air and drying of the cornea

Physiological Changes

Loss of Blink Reflex Normally a pre-corneal tear film is

present protecting the cornea. The blink reflex replenishes the pre-corneal tear film

When this reflex is obtunded, the eye is predisposed to drying

If the eye is left open, this can rupture the pre-corneal tear film and dry patches can form on the cornea

Physiological Changes

Pain perception is lost under GA A insult to the eye may occur but the

patient may be unable to feel it and react while being under the effects of general anesthesia

Physiological Changes

Decreased basal tear production A study by Krupin, Cross & Becker (1977) found

that tear production was greatly reduced by GA In their study they measured tear production at

various time intervals in 20 patients undergoing GA. Ten minutes after GA was in progress, there was a significant change in tear production (P<.001). At the 30 minute interval, tear production was further reduced (P<.001) as well as at the 60 minute interval (P<.001)

Physiological Changes

Even when surgery is over, decreased basal tear production can persist found Grover, Kumar, Sharma, Sethi and Grewal (1998) in their study of 150 patients under GA

They divided the patients into 3 groups all which had an overall reduction in basal tear production when preoperative and postoperative basal tear production values were compared

With a reduction in basal tear production, the cornea is predisposed to drying perioperatively

Physiological Changes

Bells Phenomenon is abolished This is when the globe turns upwards

placing the cornea under protection of the upper eyelid during sleep

42% of the population has this and when a patient undergoes GA this phenomenon is abolished

Cornea is then left unprotected if the eye is left open

Bells Phenomenon

Risk Factors and Co-Morbidities that Increase Risk of Corneal Abrasion

Age > 41 years old in women and post-menopausal

Graves Disease Anemia

Risk Factors

Study by Craig and Tomlinson (1995) found that women >41 years old were at increased risk for corneal abrasions

As women age there is a decrease in prolactin and estradiol

In their study they found in women <41 years old, there was increased tear flow and lower tear osmolality compared to those > 41 years old

Risk Factors

Another study by Mathers, Stovall, Lane, Zimmerman and Johnson (1998) found that in women undergoing menopause, when prolactin and sex hormone levels are decreased, there is reduced tear production

Those > 41 years of age and going through menopause or post-menopausal are at increased risk for corneal abrasions

Risk Factors

Graves Disease Patients with this disease can have

exophthalmos which can result in difficulty closing the eye

A study by Martin, Weingarten, Gunn, Lee, Mahr, Schroeder and Sprung (2009) found graves disease to be associated with corneal injury after univariate analysis

Risk Factors

Anemia Its mechanism related to corneal

abrasions is currently not understood Also there is no method to treat

preoperative anemia that is superior to another to reduce corneal abrasions

Only one retrospective study by Yu et al. (2010) has identified anemia as a significant risk factor but worth mentioning

Mechanical Trauma

Pressure on the Eye Direct trauma due to various reasons

Mechanical Trauma

Pressure on the eye can be from many things but commonly from facemasks

Pressure applied to the globe can reduce choroidal blood flow which decreases blood flow to the peripheral cornea

This is can also be a mechanism that predisposes a patient to developing a corneal abrasion in the lateral and prone position

Extremely important to check eyes frequently

Mechanical Trauma

Mechanical Trauma

Watchbands, wrist jewelry Laryngoscope Dangling name badge, necklace or

stethoscope Surgical drapes Checking the eyelid reflex Incomplete closure of the eye when mask

ventilating Patient rubbing their eyes post-operatively

Chemical Trauma

Chemical solutions for various surgeries may be used to clean the face

These solutions can drip into patients eyes if not properly protected/ covered/ closed

In the study by Gild et al (1992), out of 71 patients with injuries, the mechanism of injury was spillage of preparation solution in 9 cases

Duration of Surgery

Longer duration of surgery was found to be a risk factor for developing a corneal abrasion

Batra and Bali (1977) found that the maximal incidence of corneal abrasion was seen in patients undergoing GA between 90- 150 minutes

No corneal abrasions were found in patients undergoing GA < 60 minutes in their study

Duration of Surgery

In a retrospective study by Roth et al. (1996) an independent risk factor for developing a corneal abrasion was length anesthesia time (>4 hours). They found that as the hours of anesthesia given increased, the risk for developing a corneal abrasion increased

A more recent retrospective study by Martin et al. (2009) also found this to be true in their findings

Positioning Prone and Lateral positions In these positions there is increased risk

of pressure on the eye, mechanical trauma during positioning and increased ICP from decreased venous return

Yu et al. (2010) in their retrospective study found the lateral and prone positions statistically significant

Roth et al. (1996) also found this in their study

Location of Surgery

Head and Neck Surgery Procedures involving the head and neck

increase the rick of developing a corneal abrasion since the surgical field is closer the eyes

There may be direct trauma to the eye from the surgeon or instruments used

These procedures may not allow the surgeon to tape the eyes because it could be in their surgical field

Research

There were 2 studies that retrospectively looked at the incidence and risk factors for corneal abrasions

Some risk factors were the same while others were different

Research

Roth, Thisted, Erickson, Black and Schreider (1996) found the following as statistically significant risk factors: Duration of surgery Inpatients undergoing surgery Patients having surgery on a Monday Use of general anesthesia Head and neck surgery Lateral position

Research

Yu, Chou, Yang and Chang (2010) in their study found the following as statistically significant risk factors: Anemia Head and neck surgery Lateral and prone positioning Fiberoptic intubation Deliberate hypotension Duration of anesthesia

Research Martin, Weingarten, Gunn, Lee and

Schroeder (2009) performed a prospective study in which they initiated a performance improvement initiative and then a time period was examined looking at corneal abrasions. Risk factors they found statistically significant were the following: Duration of anesthesia Head and neck surgery Graves disease ASA status of I or II Anesthesia provider (SRNA’s!!!!!)

Strategies for Eye Protection

Now that we know different mechanisms and risk factors for corneal abrasions, how do we protect against them?

Very limited research assessing different methods to protect the eyes during the course of general anesthesia

PREVENTION

According to Barash, “…tape the eyelids closed immediately after induction, and during mask ventilation and laryngoscopy.”

Tape eyes after induction immediately after the loss of lid reflex (before mask ventilation or endotracheal intubation)

Be very careful with checking eyelid reflex Take care when taping eyes to fully shut and closing

eyelids Care regarding dangling objects when leaning

over pts Close observation as pts awaken (pts often try to rub their eyes or

nose as they recover from the effects of anesthesia)

Various Prevention Methods

Taping the eyes Lid taping only Eye drops Hydro- gel Ointments Lid taping plus ointment Goggles

Prevention

Taping/ Opsite/ Eye Cutouts Without a doubt taping the eye is necessary

during GA and the best method to help protect the eye

Ensure that the edges of the eyelid are approximated and the tape is secure

Check eye tape periodically → esp. after repositioning

Tape may lose adherence with exposure to tears or moisture → retape when indicated by visual inspection

Prevention

Lid taping only Good for cases less than 90 minutes Supine patient position No high risk surgery (head/neck) No exophthalmos or lagophthalmos Great if tape won’t come off and lids

remain shut Avoids post-op blurring of vision that is

associated with ointment

Prevention Methylcellulose Eye Drops Good lubricant Easy to Instill and Cheap When compared to petroleum based

ointment, methylcellulose eye drops offered better protection of the eye in a study by Boggild-Madson, Bundgarrd- Nielsen, Hammer and Jakobson (1981). They found lower rates of edema, pink eye and blurred vision in the methylcellulose group

Prevention Hydro-gel Never seen it used before but an option A study conducted by Smolle, Keller,

Pinggera, Deibl, Rieder and Lirk (2004) compared clear hydro- gel to eye ointment in providing eye comfort after surgery

The use of hydro- gel when compared to eye ointment was found to have reduced eye inflammation, reduced eye itching upon emergence, better patient comfort, less blurred vision and less adherent eye lashes

Prevention

Ointments Mixed research results Advantages

Good for longer case to help keep eye lubricated Disadvantages of ointments:

Occasional allergic reaction Flammability → makes use undesirable during surgery

around face and contraindicated during laser surgery Blurred vision in early post-op period The blurring and foreign body sensation associated

with ointments may ↑ incidence of post-op corneal abrasions if it triggers excessive rubbing of the eyes

Prevention

Petroleum ointment was found to cause edema, pink eye, and blurred vision more than the use of methylcellulose solution in a study by Boggild-Madson, Bundgarrd- Nielsen, Hammer and Jakobson (1981)

Prevention

Another study conducted by Siffring and Poulton (1987) assessed the prevention of ocular complications during general anesthesia

This study use 4 groups to evaluate different methods of eye protection: Group A used Lacri- lube petroleum ointment

and tape Group B used Duratears ointment and tape Group C used methylcellulose drops and tape Group D used only hypoallergenic tape

Prevention

Both groups A and B found blurred vision present post operatively

Both Group C and D did not use petroleum based ointments to protect the eyes and only one or less subjects complained of blurred vision

Prevention

Lid taping plus ointment: Good for cases lasting >90 min Good for high risk procedures and

position Gives additional protection if there is

concern about tape coming off Check proper eye closure and reapply

ointment every 60-90 minutes in high-risk patients

Prevention

Goggles May help with prone cases but offer

little advantage to reduced eye dryness

Prevention

Apply pulse oximeter to non-dominant hand

Do not place pulse oximeter on index or middle finger

Prevention

Prevention

Recent Study

Recent prospective study by Martin, Weingarten, Gunn, Lee and Schroeder (2009) in which they initiated a performance improvement initiative within their anesthesia department whose aim was to reduce perioperative corneal abrasions

Initiative consisted of 2 parts: 1st phase increased awareness of the provider by

sending an email when a patient of theirs experienced a corneal abrasion

2nd phase consisted of formal teaching of personnel regarding factors that lead to corneal injury

Recent Study

Researchers evaluated the rate of corneal injuries during the 1st initiative period in which there was a decrease in corneal abrasions (1.51 corneal abrasions per 1,000 surgeries at the start of the study vs. 1.37 corneal abrasions per 1,000 at the end of 1st initiative period )

During the 2nd initiative period, the rate of corneal injury decreased even further (0.79 corneal abrasions per 1,000 surgeries)

Recent Study

In this study procedure they instructed the anesthesia provider to tape the eyes shut during induction as soon as the eyelid reflex disappeared and before any airway management.

Emphasis was made to assure the eyelid was fully closed

This is the ONLY study that has mentioned when to tape the eyes! Huge gap in knowledge exists still!

Gaps in Literature

When to get your tape on!!! Ultimately, it is up to the anesthesia

provider to decide when to tape the eyes

We challenge you to try and tape the eyes during induction, after the lid reflex is lost and prior to mask ventilating the patient

Conclusion

Corneal Abrasions should be try to be prevented with every anesthetic given

Many methods of eye protection exist but limited research as to which one is superior

Literature suggests to tape eyes after the lash reflex is gone and prior to intubation

Continue to strive to give the best care to patients with every anesthetic given

References

Barash, P., Cullen, B., Stoelting, M., Cahalan, M., Stock, M. (2009). Clinical Anesthesia, 6th Ed. 2009. Lippincott: Philadelphia, PA.

Batra, Y.K., & Bali, I.M. (1977). Corneal abrasions during general anesthesia. Anesthesia and Analgesia…Current Researches, 56(3), 363-365.

Cross, D.A., & Becker, B. (1977). Decreased basal tear production associated with general anesthesia. Archives of Ophthalmology, 9, 107-108.

Gild, W.M., Posner, K.L., Caplan, R.A., & Cheney, F.W. (1992). Eye injuries associated with anesthesia. Anesthesiology, 76, 204- 208.

Macario, A., Weinger, M., Truong, P., & Lee, M. (1999). Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panal of expert anesthesiologists. Anesthesia and Analgesia, 88, 1085- 1091.

References

Martin, D.P., Weingarten, T.N., Gunn, P.W., Lee, K., Mahr, M.A., Schroeder, D.R., & Sprung, J. (2009). Performance improvement system and postoperative corneal injuries: incidence and risk factors. Anesthesiology, 111(2), 320-326.

Mathers, W.D., Stovall, D., Lane, J.A., Zimmerman, M.B., & Johnson, S. (1998). Menopause and tear function: the influence of prolactin and sex hormones on human tear production. Cornea, 17(4), 353-358.

Roth, S., Thisted, R.A., Erickson, J.P., Black, S., & Schreider, B.D. (1996). Eye injuries after nonocular surgery: a study of 60,965 anesthetics from 1988 to 1992. Anesthesiology,85(5), 1020-1027.

Smolle, M., Keller, C., Pinggera, G., Deibl, M., Rieder, J., & Lirk, P. (2004). Clear hydro-gel, compared to ointment, provides improved eye comfort after brief surgery. Canadian Journal of Anesthesia, 51(2), 126-129.

Yu, H.D., Chou, A.H., Yang, M.W., & Chang, C.J. (2010). An analysis of perioperative eye injuries after noncoular surgery. Acta Anaesthesiology of Taiwan, 48(3). 122-129.