Tetracaine - The Controversy

Corneal abrasions are a commonly encountered eye-related presentation in the emergency department (ED) [1]. Patients will often have a significant amount of pain from even minor abrasions. Topical anesthetics such as tetracaine have been found to be effective in treating the pain and are now routinely used in the ED [2]. However, the use of topical anesthetics for corneal abrasions in the outpatient setting is controversial due to concerns over safety and delayed healing.

  Corneal Abrasions and Short-Term Topical Tetracaine

Clinical Take Home Point: 24 hours of topical 0.5% tetracaine for uncomplicated corneal abrasions reduced pain scores at 24 to 48 hours and was opioid sparing for breakthrough pain compared to placebo. Larger trials would be needed to rule out rare adverse events but adding this study to previous data it seems that 24 to 48 hours of topical anesthetic use for uncomplicated corneal abrasions is safe. It is important to emphasize the need for follow-up, short-term use, and return precautions in these patients to avoid long-term use of these medications.

 Cornea Specialists Do Not Recommend Routine Usage of Topical Anesthetics for Corneal Abrasions

As corneal specialists, we have noted an increasing number of patients with corneal abrasions who are being discharged from emergency departments (EDs) with topical anesthetics. This trend is concerning. In conclusion, the recent practice pattern for emergency medicine practitioners to discharge patients with full bottles of topical anesthetic drops is perplexing to us. To our knowledge, there are no studies that support the use of topical anesthetic drops for corneal abrasions because there is no demonstrated benefit, with potential for visual impairment. As we demonstrate here, the majority of cornea-trained ophthalmologists would not dispense topical anesthetics for a traumatic corneal abrasion themselves and strongly disagree that this should or could be a practice pattern in either the ED or clinical setting

 Short Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double Blind Randomised Clinical Trial

The Bottom Line... This study indicates tetracaine is more effective in providing analgesia compared to commonly used alternative- artificial tears with a significant difference in NRS scores at 24-48hours. This specific study has not been powered for safety and should not be used for this. Other studies have however shown safety for short term use As a result of this combined information I will selectively start prescribing topical tetracaine for patients with simple uncomplicated corneal abrasions that I am confident will follow advice on use being short term only

 Topical Anaesthetics for Corneal Abrasions

Corneal abrasions are extremely painful. Patients deserve a good analgesic strategy. Topical anesthetics may cause occasional problems in patients who abuse them, but there is no evidence that they are harmful if used for a short period of time (typically corneal abrasions heal within 24-48 hours). At this point there is not enough evidence to definitively prove that they are safe, however, I don’t think there is any convincing evidence that a short course could be harmful. I think these medications are reasonable to use for reasonable patients.

 Topical Anesthetics for Corneal Abrasions

Traditional teaching warns against the use of these agents due to a reported risk of worsening corneal injury, but there is scant evidence to support this. We will look at four fairly recent articles that compared treatment with and without topical anesthetics to try to come to a more evidence-based conclusion.

Go Deep on Corneal Abrasions

Understanding the physiology of rupture and repair will improve your management decisions.

An audit of corneal abrasion management following the introduction of local guidelines in an accident and emergency department

A&E staff members are capable of managing corneal abrasions if they are given guidance and some training. This audit identified shortcomings in current management and showed that guidelines can significantly improve clinical practice.

Corneal Emergencies

The article covered in this podcast is Waldman et al, is a study of tetracaine in corneal abrasions.

Corneal Eye Scratch

Many people think that a patch over the eye will help the cornea heal, but this belief is incorrect. If you patch your eye, you may actually delay the healing process and increase your risk for infection. It’s much better to go without a patch, as the cornea replaces itself every five days.

Mapping the body: the cornea

Medical training is not even in its distribution. While three months were devoted to teaching us obstetrics and gynaecology, the study of soft tissue disorders was renamed rheuma-holiday, and my tutelage in ophthalmology was practically non-existent. No wonder then that my grasp of the human eye remains shaky – and that a good part of what I know about the cornea has come from personal rather than educational experience.

Traumatic Corneal Abrasion

Eye-related problems are a common presentation in the emergency department (ED), accounting for approximately 8% of cases, with corneal abrasions representing almost half of the diagnoses. As such, being able to diagnose and manage a corneal abrasion acutely and knowing when to refer is imperative.