11021470520620120002 2012 eMED Ltd Frozen corneas in the desert a case report Imran Ansari and Chris Canning Moorfields Eye Hospital Dubai PO Box 505054 Dubai UAE Corresponding address Dr Imran Ansari Moorfields Eye Hospital Dubai PO Box 505054 Dubai ID: 71615
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GrandRoundsVol12pages69Specialities:EmergencyMedicineandSurgery;OccupationalHealth;OphthalmologyArticleType:CaseReportDOI:10.1102/1470-5206.2012.00022012e-MEDLtd Frozencorneasinthedesert:acasereportImranAnsariandChrisCanningMoorfieldsEyeHospitalDubai,POBox505054,Dubai,UAECorrespondingaddress:DrImranAnsari,MoorfieldsEyeHospitalDubai,POBox505054,Dubai,UAE.Dateacceptedforpublication12December2011Thisisararecaseoffreezingofthecorneasinextremelycoldconditions.Alargeproportionoftheworldspopulationinhabitsareaswherefrequentexposuretosubzerotemperaturesiscommon.Earlyrecognition,appropriatereferralandtreatmentoffrozencorneasmayhelptominimizeanypotentialcomplicationsthatcandeveloplateron,aswellasreducepainandsufferingforthepatient.A39-year-oldwhitemanpresentedwitha48-hhistoryofseverebilateralocularpain,rednessandphotophobia.Hedeniedanyrecollectionofinfection,traumaorforeignbodyenteringtheeyes,andhissymptomsstartedafterboardingalong-haulflightfromCanadatotheUnitedArabEmirates.DuringhisstayinCanadathepatienthadfrequentlyparticipatedinwintersports,andrightupuntildeparture,hadbeenexposedtoanextremelycoldoutdoorenvironment.Onexaminationhewasfoundtohavebilateraldiffusestainingofthecornealepithelium.Noothercauseofsuchcornealinjurycouldbefoundfromthehistoryorclinicalexamination,andhisfeatureswerethoughttobeduetocornealfreezingwithsubsequentthawingoftissue.Hewasstartedonintensiveocularlubricants,topicalantibiotics,togetherwithamydriaticagentandtopicalnon-steroidalanti-inflammatories.Subsequentlyhissymptomsandvisualacuityrapidlyimproved.After1weekhisunaidedvisualacuitywasbackto6/6andhewassubsequentlydischarged.Freezingofthecorneasisuncommonandoccursinindividualswhohavekepttheireyesopeninhigh-wind-chillandfreezingtemperatureswithoutprotectivegoggles.Soldiers,pilots,skiers,bicyclists,iceskaters,andsnowmobilersandmountaineersareatparticularrisk.Treatmentfocusesoncontrollinginflammationandpreventingsecondaryinfection,andincludescycloplegia,eyelidclosurewithadressing,topicallubricants,antibioticsandsteroids.TheprognosisisfavourableprovidedtherehasbeennodamagedeeptoBowmanslayer.Severekeratitismayrequirelamellarandpenetratingkeratoplasty.Cornealfreezinginjuriesshouldbekeptinmindinemergencyroomsparticularlyinareaswhereoutsidetemperaturesareextremelycold,andwheremembersofthepublicareroutinelyexposedtohighwindchillsuchasparticipantsinwintersportsandalsomilitarypersonnel.Educatingthesegroupsofpeopleaboutpotentialinjuriestocoldisimportantforpreventionoflastingpermanentdamagetotheocularstructuresandothertissuesinthebody.Cornea;injury;freezing. Thispaperisavailableonlineathttp://www.grandrounds-e-med.com.IntheeventofachangeintheURLaddress,pleaseusetheDOIprovidedtolocatethepaper. Cold-relatedinjuriesexistonaspectrumofseverityrangingfromminortissueinjurytodevastatinginjuriescausingpermanentdamagetodeepstructures.Minorinjuryisoftensustainedasaresultofprolongedexposuretocoldconditionsatnon-freezingtemperatures;itincludesfrostnip,chilblainandtrenchfoot.Frostbiteiscausedbyexposuretofreezingconditionsandimpliesseveredamagetoinvolvedtissuetissue.Althoughtemperatureplaysakeyroleintheseverityofcold-relatedinjuries,itisthedurationofexposuretocoldconditionsthatdeterminestheextentofinjury.Inadditiontotemperature,otherenvironmentalfactorscontributingtocold-relatedinjuryincludecontacttime,humidity,wind-chillfactor,windvelocity,andwetskin.Hostfactors,suchaslackofproperclothing,alcoholordrugintoxication,andmalnutrition,alsoplayamajorrolerole.Inadditiontotissueinjuryoftheextremities,otherinjuriesassociatedwithprolongedexposuretocoldconditionsneedtobeconsidered.Ophthalmologicinjurysuchascornealfreezingandabrasionsmayoccurinconditionsofhighwindchillandwindvelocity.Theseinjuriesaremorelikelytooccurinrecreationalsportssuchassnowmobilingandand.DiagnosisrequiresadequateophthalmologicevaluationwithaslitlampandfluoresceinWehighlightacaseseeninDubai,UnitedArabEmirates,whereapatientsufferedfromseverebilateralcornealinjuryafterprolongedexposuretoextremecold.CasepresentationA39-year-oldwhitemanpresentedtoourclinicwitha48-hhistoryofseverebilateralpain,rednessandphotophobia.Hedeniedanyrecollectionofinfection,traumaorforeignbodyenteringtheeye,andhissymptomsstartedsoonafterboardingalong-haulflighttoDubaiwhereheresides.Therewasaprevioushistoryoflaserrefractivesurgery(LASIK)7yearsago,butnoothersignificantocularhistory.FollowingLASIKheenjoyedexcellentunaidedvisualacuityupuntilthisepisode.Hedeniedtheuseofcontactlenses.Hewasmedicallyfitandwell.HewasreturningfromabusinesstripinCanadaattheendofwhichhespent4daysonawintersportsholiday.TemperatureswereextremelycoldreachingC,withverywindyconditions.Hisactivitiesincludingsnow-mobilingandskiing,howeverheonlyusedgogglesoccasionallywhenoutdoors.Beforeboardinghislong-haulflighttoDubai,hehadspentthemorningsnowboarding,againwithouttheuseofgoggles.Hemadehiswaystraighttotheairportandhissymptomsstartedsoonafterboarding.Afteraveryuncomfortableflighthecamestraighttoourclinicfromtheairportduetotheseverityofhissymptoms.Onexaminationhewasobviouslyuncomfortableandindistress.Therewasconjunctivalinjectionandbilateraldiffusestainingofthecornealepithelium,withintheboundariesoftheLASIKflaps(Figs.1and2).TheLASIKflapswerewellalignedandcentredandtheinterfaceswere Fig.1.Epithelialdefectinthelefteye.Frozencorneasinthedesert clear.Therewasnoanteriorchamberactivityandtheposteriorsegmentswereunremarkable.Theupperlidswereevertedandnoforeignbodywasvisible.Noothercauseofsuchcornealinjurycouldbefoundfromthehistoryorclinicalexamination,anditwasthoughttobeduetocornealfreezingwithsubsequentthawingoftissueleadingtocornealepitheliopathy.Hewasstartedonintensiveocularlubricantsandtopicalantibiotics,togetherwithamydriaticagentandtopicalnon-steroidalanti-inflammatories(NSAIDS).Hewasreviewedonadailybasis,andhissymptomsandvisualacuityrapidlyimproved.After1weekhisunaidedvisualacuitywasbackto6/6withnoresidualsignsofcornealinjury,andhewassubsequentlydischarged.Freezingofthecorneasisanuncommoninjuryreportedtooccurinindividualswhohavekepttheireyesopeninhigh-wind-chillsituationsandfreezingtemperatureswithoutprotectivegoggles.Bythetimemostcold-damagedcorneasareexaminedbyanophthalmologistthecorneas,arenolongerinafrozenstate,andinitialcornealflareandpainduringrewarmingaresignsofthisinjury.SoldiersSoldiers,pilots,skiers,bicyclists,iceskaters,andsnowmobilershaveallbeenobservedwiththiscondition.Otheractivitiesthatarelinkedtothisinjuryincludemountaineeringandsnowboarding.Inadditiontoextremeenvironmentalconditions,animpairedblinkingreflexandincompleteclosureoftheeyelidsduringblinkingduetoaloweringofthesurfacetemperatureofthecorneaarefactorsthatareinvolvedincornealdamage.Treatmentfocusesoncontrollinginflammationandpreventingsecondarybacterialinfection,andincludesinducedcycloplegia,eyelidclosurewithadressing,topicallubricants,antibioticsandsteroids/NSAIDS.Theoverallprognosisisfavourableasgenerallytheinjuryisasuperficialepithelialone,andaslongastherehasbeennodamagedeeptoBowmanslayer,italmostuniversallyhealswithnoscarwithinaweek.Severekeratitisandcornealopacificationhowevermayrequirelamellarandpenetratingkeratoplastydependingontheamountoftissuedestroyed.ItisnotconfirmedwhetherpreviouslaserrefractivesurgerypredisposestothisconditionbutotherreviewshavefoundcornealnervesareseveredduringtheLASIKprocedureproducinganabnormalblinkreflex.Thismayaggravateapre-existingdryeyecondition.Itmaythereforebeprudenttowarnpatientsundergoingrefractivesurgery,whoresidein,orareregularlyexposedtoextremecoldandwindyconditionstouseadequateprotectivemeasures,suchasgogglesandsuitableheadgearwhenoutside.Similarly,implicationsalsoariseformilitarypersonnelwhooperateinsubzeroconditions.TeachingpointsCornealfreezinginjuriesshouldbekeptinmindinemergencyrooms,particularlyinareaswithanextremelycoldclimate,andwheremembersofthepublicorpersonnelareexposedtohigh Fig.2.Epithelialdefectintherighteye.I.AnsariandC.Canning windchill.Educatingpeoplewhoareexposedtoextremecoldaboutpotentialinjuriesisimportantforpreventionoflastingpermanentdamagetotheeyesandothertissuesinthebody.Writteninformedconsentwasobtainedfromthepatientforpublicationofthiscasereportandaccompanyingimages.AcopyofthewrittenconsentisavailableforreviewbytheEditor-in-Chiefofthisjournal.CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.1.CruzTM,KnappB.Theemergentpatient:cold-relatedinjuries.EmergMed2006;38:1013.2.KolstadA,OpsahlJr,R.Coldinjurytocornealepitheliumacauseofblurredvisionincross-countryskiers.ActaOphthalmol1969;47:6569.3.GruppoL,MaderTH,WedmoreI.Ocularproblemsinmilitaryfreefallparachutists.MilMed2002;167:797800.Frozencorneasinthedesert