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Symptoms noted on presentation at Sibley Memorial

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Title: Symptoms noted on presentation at Sibley Memorial


1
Symptoms noted on presentation at Sibley Memorial
Emergency Department on August 26, 201 included
2
This is the cover of a brochure published in the
summer of 2011 by Sibley Hospital. Featured on
the cover is Dr. Copes photograph along with an
introductory heading to a new fast track
initiative to move patients in and out of the ER
at an accelerated pace. I was at the ER for a
total of 35 minutes and one wonders how much of
that had to do with this financially motivated
imitative.
3
This presentation includes salient points about
the injury, infection and subsequent Pain and
suffering that I sustained as a result of
misdiagnosis and mistreatment that Exacerbated
or caused a melting corneal ulcer. The
mismanagement of my Heathcare on August 25th
occurred at Sibley Memorial Hospital by attending
physian Gregory Cope, MD. Corneal abrasions(From
HCP LIVE published in 2007) The management of
corneal abrasions involves pain relief and
prevention of secondary infection. The decision
to patch an eye after a corneal abrasion is very
controversial.13 Patching the eye closed will
alleviate some pain, but it does not accelerate
corneal healing.14 Eye patching should be
avoided if the corneal abrasion was caused by
organic trauma or contact lenses because the
patching can allow microbial contaminants to
proliferate overnight Soft contact lens use It is
also important to ask about the use of soft
contact lenses. A soft contact lens wearer with
a red eye should be presumed to have an
infectious corneal ulcer (bacterial keratitis)
until proven otherwise. There is a high
incidence of gram-negative corneal ulcers
(ie, Pseudomonas aeruginosa infection) in
patients who sleep while wearing their contact
lenses.6 Any corneal epithelial defect with an
underlying "white" corneal opacity noted on
examination should be assumed to be a corneal
ulcer (Figure 3). Such a patient should urgently
be referred to an ophthalmologist. If not
properly diagnosed and treated, the risk of
developing a visually debilitating scar or a
corneal perforation is high because the microbial
enzymes can rapidly melt the cornea.7 Treatment
consists of topical fortified broad-spectrum
antibiotics applied to the eye at hourly
intervals. Topical corticosteroids are
contraindicated in the presence of infectious
corneal ulcers because they may accelerate
further melting of the cornea.
4
Where does information for the emergency
physician come from?
Challenge unique to the emergency physician
Relevant information can come from literature in
any specialty
Original studies, review articles,
editorials Literature interpretation
clearinghouses/systematic reviews Cochrane,
BestBETs, I nfo POEMs, Clinical
Evidence Opinion clearinghouses EMA, ACP
Journal Club, EM Reports Paper textbooks
(Rosen's Emergency Medicine, Yanoff's
Ophthalmology) Online textbooks (UpToDate,
eMedicine, Jeff Mann's EM Guidemaps, review Of
Optometry.com) Guidelines - local,
national Local practice Personal
experience
5
Note when This was published
Management
Schein, O.D., et al, Am J Emerg Med 11(6)606,
November 1993. Contact Lens Abrasions and the
Nonophthalmologist
About 25 million persons in the U.S. wear contact
lenses. Users of contact lenses who sustain
corneal abrasions often initially present to
primary care physicians. The authors, from the
Johns Hopkins University in Baltimore, discuss
the management of corneal abrasions in these
individuals. Contact lens-associated ulcerative
keratitis, a break in the corneal epithelium with
underlying suppuration of the corneal stroma, is
usually due to bacterial infection and is most
commonly caused by Pseudomonas species. The risk
of contact lens-associated ulcerative keratitis
is increased 10- to 15-fold with overnight use
of extended-wear soft lenses as compared with
daily wear soft lenses. Appropriate management
differs from that of the patient presenting with
a corneal abrasion not associated with contact
lens use. Erythromycin and sulfas that are
frequently employed in patients with other types
of mechanical corneal abrasion are inadequate in
these cases. Aminoglycoside ointments (e.g.,
tobramycin or gentamicin) or combination products
such as Polymyxin B and Bacitracin, which are
effective against Pseudomonas, should be
utilized. Routine patching is discouraged, as
this intervention limits tearing and increases
the temperature and humidity of the ocular
surface, favoring bacterial replication. Topical
steroids also promote bacterial replication.
Since the patient will not experience the pain
relief produced by patching, adequate oral
analgesics should be employed. Early follow-up
should be scheduled (typically within 24 hours),
when reexamination with a slit- lamp
biomicroscope should be performed. Three cases
are discussed in which initial mismanagement
resulted in significant sequelae (and litigation
in two cases).
6
Management
Undebated Approaches
Do not prescribe topical anesthetics for any
reason
Do not patch high risk corneal abrasions, meaning
Emergency protocol should be implemented if there
is no Improvement in symptoms four hours after
removal of the contact lens. The assumption of
microbial keratitis is standard and an Emergency
consult with an ophthalmologist is necessary for
Immediate evaluation and treatment.
7
Management
Schein, O.D., et al, Am J Emerg Med 11(6)606,
November 1993. Contact Lens Abrasions and the
Nonophthalmologist
About 25 million persons in the U.S. wear contact
lenses. Users of contact lenses who sustain
corneal abrasions often initially present to
primary care physicians. The authors, from the
Johns Hopkins University in Baltimore, discuss
the management of corneal abrasions in these
individuals. Contact lens-associated ulcerative
keratitis, a break in the corneal epithelium with
underlying suppuration of the corneal stroma, is
usually due to bacterial infection and is most
commonly caused by Pseudomonas species. The risk
of contact lens-associated ulcerative keratitis
is increased 10- to 15-fold with overnight use
of extended-wear soft lenses as compared with
daily wear soft lenses. Appropriate management
differs from that of the patient presenting with
a corneal abrasion not associated with contact
lens use. Erythromycin and sulfas that are
frequently employed in patients with other types
of mechanical corneal abrasion are inadequate in
these cases. Aminoglycoside ointments (e.g.,
tobramycin or gentamicin) or combination products
such as Polymyxin B and Bacitracin, which are
effective against Pseudomonas, should be
utilized. Routine patching is discouraged, as
this intervention limits tearing and increases
the temperature and humidity of the ocular
surface, favoring bacterial replication. Topical
steroids also promote bacterial replication.
Since the patient will not experience the pain
relief produced by patching, adequate oral
analgesics should be employed. Early follow-up
should be scheduled (typically within 24 hours),
when reexamination with a slit- lamp
biomicroscope should be performed. Three cases
are discussed in which initial mismanagement
resulted in significant sequelae (and litigation
in two cases).
8
Management
Schein, O.D., et al, Am J Emerg Med 11(6)606,
November 1993. Contact Lens Abrasions and the
Nonophthalmologist
About 25 million persons in the U.S. wear contact
lenses. Users of contact lenses who sustain
corneal abrasions often initially present to
primary care physicians. The authors, from the
Johns Hopkins University in Baltimore, discuss
the management of corneal abrasions in these
individuals. Contact lens-associated ulcerative
keratitis, a break in the corneal epithelium with
underlying suppuration of the corneal stroma, is
usually due to bacterial infection and is most
commonly caused by Pseudomonas species. The risk
of contact lens-associated ulcerative keratitis
is increased 10- to 15-fold with overnight use
of extended-wear soft lenses as compared with
daily wear soft lenses. Appropriate management
differs from that of the patient presenting with
a corneal abrasion not associated with contact
lens use. Erythromycin and sulfas that are
frequently employed in patients with other types
of mechanical corneal abrasion are inadequate in
these cases. Aminoglycoside ointments (e.g.,
tobramycin or gentamicin) or combination products
such as Polymyxin B and Bacitracin, which are
effective against Pseudomonas, should be
utilized. Routine patching is discouraged, as
this intervention limits tearing and increases
the temperature and humidity of the ocular
surface, favoring bacterial replication. Topical
steroids also promote bacterial replication.
Since the patient will not experience the pain
relief produced by patching, adequate oral
analgesics should be employed. Early follow-up
should be scheduled (typically within 24 hours),
when reexamination with a slit- lamp
biomicroscope should be performed. Three cases
are discussed in which initial mismanagement
resulted in significant sequelae (and litigation
in two cases).
9
The Search
Cochrane BestBets EMA
Database infoPOEMs - several articles
I already knew about ACP Journal Club,
Clinical Evidence no relevant info National
Guideline Clearinghouse, Ontario Guidelines
Advisory Committee, ACEP Clinical Policies
Policy Statements, CAEP Policies Guidelines,
GuideEM, Primary Care CPG's. no relevant
info EM Reports - Eye emergencies and Eye
trauma reviews Journal Watch EM - two
articles I already knew about PubMed
10
Applying the Patch
Had I not been a contact lens wearer and not
removed my lens the night before (and seen
improvement in the hours since removal) and if
the abrasion was considered large 10 mm in
diameter then a minority of physicians may have
patched the eye. The key is that they would have
patched the eye, not given me the materials and
written and verbal instructions to do so myself
when I got home. This was presumably because I
was driving however, I should have been advised
not to drive. Note, the time spent in the ER was
35 minutes exactly and discharge was at 700 pm.
In the interim it had grown to dusk outdoors. My
visual acuity without correction in the left eye
was legally blind. All facts known and noted by
Dr. Cope. Below is a description of how patching
was formerly done in non contact lens wearers
Two gauze eye pads and three strips of tape are
required for patching. Antibiotic ointment is
applied to the eye by instilling a small amount
(1/2" to 1" ribbon) in the inferior cul-de-sac.
One pad is folded in half. The patient is asked
to close both eyes gently. There should be no
squeezing of the orbicularis muscles. The folded
patch is used to occupy the space over the globe
in the orbit and apply pressure to the globe. The
second pad is then placed over the folded pad.
The patient or an assistant is asked to apply
firm pressure to the second pad, while it is
being taped firmly with the three strips of tape.
These strips are most effective if place
obliquely from the midline over the nose toward
the cheekbone. The patient is then asked to open
the eyes and report if the lid under the patch
can be raised. If it can then the patch has not
been applied successfully and must be redone. The
patch is left in place overnight, and no more
than 24 hours. A patch that is worn too long may
interfere with the diagnosis of infection because
the patient cannot monitor vision and discharge.
11
Pseudomonas Ulcers Following Patching of Corneal
Abrasions Associated with Contact Lens Wear
  • Clemons, Carol S. MD Cohen, Elisabeth J. MD
    Arentsen, Juan J. MD Donnenfeld, Eric D. MD
    Laibson, Peter R. MD
  • We report our experience with six patients-each
    with a history of contact lens use-who were
    diagnosed as having Pseudomonas corneal ulcers
    after having been pressure patched in treatment
    for apparent corneal abrasions. Four of these six
    patients (67) required penetrating keratoplasty
    due to marked central corneal scarring following
    healing of their corneal ulcers. By comparison,
    among the 44 patients with a history of contact
    lens use hospitalized at Wills Eye Hospital
    between January 1978 and June 1986 with
    Pseudomonas corneal ulcers, only 11 (25)
    required corneal transplantation. It is important
    to be aware that serious ulcers associated with
    the use of contact lenses can present initially
    as sterile-appearing erosions. Pressure patching
    should be avoided in patients with corneal
    abrasions and a history of contact lens use.
    Note Even unweighted, this represents an
    increase by 42 percent in the percentage of
    patients who developed P. Aeruginosa infections
    soley because they were pressure patched, with no
    other variations in treatment, presentation or
    etiology. In reality the percentage is much
    greater because of the number of cases involved
    in the unpatched group.
  • (C) 1987 The Contact Lens Association of
    Ophthalmologists, Inc.

12
Vance Wilson was planning to leave on a vacation
to the Black Hills of South Dakota on Friday,
August 26th, 2011 (labor day weekend. He had
just purchased a Canon p95 camera and was testing
it on the evening of August 24th, 2011. This
photo was taken with the self timer function at
about 10 pm. A few hours earlier, Mr. Wilson had
removed his left contact lens due to a scratching
or irritated feeling as this photo shows, his
left eye appears fairly clear at that time.
Twenty hours later, he presented at the Sibley
Memorial Hospital Emergency department because of
increased redness, photophobia, tearing, pain,
and spasm. He had not put the contact lens in
since its removal before this photo was taken.
Mr. Wilson followed The instructions and Used the
materials given to him by Dr. Gregory Cope
patching his left eye after applying a ribbon of
the erythromycin ointment from the sample tube
obtained from the physician at bed time which
that evening was at 1230 am. Nine or ten hours
later he awoke to blindness, copious blue-green
discharge, eyes crusted shut and in debilitating
pain. Shocked, he called Washington Eye
Physicians and Surgeons and scheduled an Exam for
that afternoon. This photo was taken by Dr. Neil
Martin at Washington Eye on September 1, 2011 at
approximately 300 PM, following a week of
harrowing treatment At Johns Hopkins University
in Baltimore, MD. Prior to this the eye was
completely obscured By a white mucous substance.
Mr. Wilsons vision at this stage was hand
movement at 4 feet.
13
Wilson, Vance left eye on September 1, 2011
(photographed by Dr. Neil Martin Washington Eye
Physcians and Surgeons.
14
Vance Wilson on May 25th, 2012 following corneal
transplant surgery note this surgery was needed
to correct the scarring that resulted from
Sibleys mistreatment and performed almost
exactly nine months after the injury and
infection inflicted at Sibley Memorial Hospital.
The following are issues resulting from the
August, 26th, 2011 incident noted in Mr. Wilsons
left eye as of October 15, 2012 Posterior
Synechiae (scarring of the posterior chamber
Unevenly shaped Iris due to melding of pupil and
iris tissue during infection. 2 Cataract formed
during infection Neovascularization formed
during infection. Exaggerated astigmatism uneven
topography. Each of these conditions has a
cumulative negative impact in increasing the
risk for future rejection of the transplant
and additional complications, some eye
threatening. (evisceration of the eye.) The
surgeon who perfomred the transplant has stated
that the prognosis is unknown due to the deeply
scarred eye tissue current vision in left eye is
2070 to 20100 (fluctuating). Mr. Wilson is
still using steriod drops every four hours in his
left eye. There are eleven stitches' still in
the eye (originally there were 18.)
15
Comparison photo showing scar taken on April
30th, 2012 left eye Is at right in photograph.
The Corneal transplant was performed on May 23rd,
2012.
16
Pseudomonas Ulcers Following Patching of Corneal
Abrasions Associated with Contact Lens Wear
  • Clemons, Carol S. MD Cohen, Elisabeth J. MD
    Arentsen, Juan J. MD Donnenfeld, Eric D. MD
    Laibson, Peter R. MD
  • We report our experience with six patients-each
    with a history of contact lens use-who were
    diagnosed as having Pseudomonas corneal ulcers
    after having been pressure patched in treatment
    for apparent corneal abrasions. Four of these six
    patients (67) required penetrating keratoplasty
    due to marked central corneal scarring following
    healing of their corneal ulcers. By comparison,
    among the 44 patients with a history of contact
    lens use hospitalized at Wills Eye Hospital
    between January 1978 and June 1986 with
    Pseudomonas corneal ulcers, only 11 (25)
    required corneal transplantation. It is important
    to be aware that serious ulcers associated with
    the use of contact lenses can present initially
    as sterile-appearing erosions. Pressure patching
    should be avoided in patients with corneal
    abrasions and a history of contact lens use.
    Note This represents an increase by 42 percent
    in the percentage of patients who developed P.
    Aeruginosa infections soley because they were
    pressure patched, with no other variations in
    treatment, presentation or etiology.
  • (C) 1987 The Contact Lens Association of
    Ophthalmologists, Inc.

17
Symptoms noted photophobia, pain FBS, clear
discharge, loss of vision Was not noted but that
is inexplicable because a) I was not wearing
glasses and my vision was very poor and b) an
epithelial defect was noted Centrally on my left
cornea. I do not recall And there is not mention
of a visual Acuity exam.
Dr. Cope noted a centrally located defect on my
left cornea. He also noted that I had removed my
left contact lens the evening before and seen in
the hours since then (about sixteen hours)
worsening or progressing symptoms, warranting an
emergency ophthalmological consult (standard of
practice, nationally)

I think this alone says it all.
algorithm
Abrasion was not large the ulcer Was measured at
4.5 cm D the next Day at Washington Eye. I
verbally rated Pain as a 7 on a 1-10 scale
noted in chart.
18
Corneal Abrasions Corneal abrasions are defects
of the normal corneal epithelium caused by trauma
from small objects (often a fingernail, twig,
hairbrush, or comb). They also occur after
removal of a foreign body. Corneal abrasions from
contact lenses represent a separate category with
a unique set of clinical problems. In a one-year
survey of admissions to a British emergency eye
clinic, corneal abrasions accounted for 10 of
the visits.54 Corneal abrasions are quite
painful, and most people do not return to full
functioning until the abrasion is healed.
Patients describe immediate, sharp pain followed
rapidly by tearing, photophobia, a decrease in
visual acuity, and a persistent foreign body
sensation. The eye will appear injected. Topical
anesthetic drops will often significantly improve
the pain, reduce blepharospasm, and allow a full
examination. Fluorescein staining reveals the
corneal defect. The magnification provided by a
slit lamp allows a detailed quantification of the
size as well as the depth of the lesion. The
natural history of most abrasions is full healing
in 2-3 days. Except in the cases of abrasions
associated with contact lens use, infection
occurs in fewer than 1 of cases. Until the
mid-1990s, accepted therapy involved occlusive
eye patches, antibiotic ointments (felt to be
more soothing than drops), oral analgesics, and
optional cycloplegics. The theory behind the
occlusive patches was to provide a stable corneal
environment to promote rapid reepithelialization.
Patches were also thought to reduce pain. A
meta-analysis by Flynn et al in 1998 that
combined five randomized clinical trials showed
no statistical difference in healing between
patched and un-patched eyes, and no reduction in
pain in patients whose eyes were patched.55 These
trials, however, enrolled only patients with
small- to moderatesized abrasions (lt 10 mm2).
Large abrasions seem to enjoy improved healing if
patched.56 Unlike eye patching, topical NSAID
drops may improve patient comfort. In one
randomized, double-blind, placebo-controlled
trial of 100 patients with corneal abrasions,
topical ketorolac 0.5 (Acular) was shown to
reduce pain and photophobia significantly at the
one-day mark. The ketorolac group was also able
to return to function one day sooner, on average,
than the placebo group. There was no difference
in rates of healing or complications.56 A smaller
study using diclofenac 0.3 (Voltaren)
19
showed a small but statistically significant
improvement in pain scale at two hours.57 The
exact mechanism of action of these topical NSAIDs
has not yet been delineated. It is probably some
combination of reduction in pain sensation and
antiinflammatory effect.56 For traumatic,
non-contact lens abrasions with significant pain,
Kaiser et al recommendketorolac 0.3 QID for
three days or until the patient is comfortable, a
broad-spectrum antibiotic ointment TID for three
days or until the abrasion is healed, an optional
shortacting cycloplegic such as cyclopentolate,
and no patch (unless the abrasion is gt 10
mm2).56 Many emergency physicians prescribe
narcotic pain medicines for patients with corneal
abrasions these drugs are especially appreciated
when the patient tries to go to sleep. Corneal
abrasions in contact lens users represent a
distinct problem. There are approximately 25
million contact lens wearers in the U.S. They are
all at increased risk of developing infected
abrasionsreferred to as ulcerative keratitis.
Overnight, extended-wear soft lenses carry a 10-
to 15-fold risk of infection. The causative
organism is most often Pseudomonas species. The
course can be fulminant, leading to permanent
vision loss from corneal scarring. Do not patch
corneal abrasions secondary to contact lens use.
In 1987, Clemons et al reported six cases of
Pseudomonas keratitis following pressure patching
for contact-lensassociated corneal
abrasions.58 The occlusive patch favors bacterial
replication by raising corneal temperature and
interfering in the normal protective effects of
routine eye blinking, tear exchange, and tear
movement. The treatment of contact-lens-associated
abrasions should begin with an antibiotic
ointment that covers Pseudomonas (such as
gentamicin Genoptic or combination
polymixin/bacitracin). Steroid combinations
should be avoided, as they may favor bacterial
replication. Follow-up within 24 hours should be
arranged, because suppuration of the abrasions
can occur rapidly. Contact lens use should not
resume until the abrasion is fully healed.59 The
offending lenses should be replaced or inspected
carefully for evidence of damage. Note the
pressure patching accelerated suppuration sot
that it had occurred within 15 hours and probably
much sooner.
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