therapeutic case

Treating a Pediatric "Scratch"

This case discusses how to manage a child's painful corneal abrasion.

J. MAX KOSTECKI, O.D., F.A.A.O.

Presentation

A six-year-old female presented to our office with pain OD. The patient was referred by her pediatrician, who was unable to see the eye accurately without a slit-lamp biomicroscope.

A scratch from a friend

The young patient said she had trouble opening her eyes, because she was in "so much pain." The patient had difficulty seeing the 20/400 big "E" on the Snellen chart. Vision OS was 20/20.

The patient's mother said she was reasonably sure that the girl's friend had "accidentally scratched her eye with the end of her fingernail." Past ocular history revealed no previous injury to the eye or prior visit with an eyecare practitioner. The patient did mention, however, that she recently "passed" a vision screening at her elementary school.

Her past medical history was unremarkable, revealing no known allergies or medication use.

Under the lamp

For the examination, I instilled one drop of 0.5% proparacaine HCl ophthalmic solution, and then applied one strip of fluorescein sodium to perform a slit lamp exam using the cobalt blue filter. Under the microscope, I could see she had a central 4 mm × 1 mm corneal abrasion. The epithelium had all been scraped to one side of the abrasion, like a fresh snow pile at the end of a shoveled driveway. The conjunctiva also appeared very red, and had moderate chemosis and injection.

Diagnosis

I assessed the patient as having a superficial corneal abrasion on her right eye (OD), and secondary inflammatory conjunctivitis on her right eye (OD).

Initial treatment

To treat the corneal abrasion and secondary inflammatory conjunctivitis:

1. I flushed the cornea and conjunctiva with 2 oz. (59 mL) of sterile isotonic buffered solution (98% Purified Water) (Eye Wash), which I hand squeezed from the bottle. This cleaned the wound and flushed the loosely debrided corneal epithelial membrane.

2. I re-examined the eye under the slit-lamp biomicroscope to ensure that we had removed all of the loose epithelium. I then rinsed the abrasion thoroughly.

3. I instilled one drop of cyclopentolate 1.0% ophthalmic solution in the eye to prevent a painful secondary uveitis, and to aid in resolving the pain response.

4. I instructed the patient to take over-the-counter children's acetaminophen, or children's ibuprofen, as needed for pain, (and not to exceed the maximum dosing according to the package insert given on the bottle.)

5. Finally, I instilled one drop of azithromycin ophthalmic solution 1% (AzaSite, Inspire Pharmaceuticals) in the office. I instructed the patient's mother to instill another drop at home, and then see me in the morning.

Follow-up management

At the next visit, 15 hours later (the next morning), the patient said she was experiencing "no pain." She could almost see the 20/25 (OD) on the Snellen chart and her cornea had almost completely reepithelialized.

Her conjunctiva had also improved — it looked clear and quiet. I told the patient's mother to instill the azithromycin ophthalmic solution b.i.d. the second day, then q.d. for the next five days, which is the standard prescribing protocol.

I re-examined the patient on the third day. She was 100% improved subjectively and objectively. Her vision was now 20/20 OU. We subsequently scheduled a follow-up re-check and a comprehensive eye exam, all of which were unremarkable — which in my thoughts were quite remarkable considering how much pain this child endured from a corneal abrasion just one week prior.

Discussion of therapy

In selecting an antibiotic, I looked for the following characteristics:

► a potent broad-spectrum antibiotic. Azithromycin ophthalmic solution offers coverage against the most common gram-positive and gram-negative bacteria, as well as atypical bacteria.

► tolerability. During my discussions with the child's parents, I discovered that the patient had already used oral azithromycin (Zithromax) in the past with success. This gave me an indication that the patient may also respond well to the topical ophthalmic version. The package insert lists the medication as clinically safe and well tolerated in children one year of age and older.

► simple dosing. Azithromycin ophthalmic solution is labeled as one drop b.i.d. × 2 days, followed by one drop q.d. × 5 days, or a total of nine drops over the course of one week. This easy regimen may result in better compliance by the patient.

► duration. In combination with its vehicle, DuraSite, azithromycin ophthalmic solution was capable maintaining therapeutic levels of the drug in the ocular environment for at least 24 hours, according to DuraSite's developer, InSite.

In addition to these properties, literature also documents the anti-inflammatory properties of azithromycin. This leads me to believe that the drop would also make a good choice when inflammation is an issue — in cases where using an antibiotic/steroid combination eye drop would be contraindicated. OM