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ORIGINAL ARTICLE
Year : 2021 | Volume
: 28
| Issue : 3 | Page : 151-158
Diagnosis and management of corneal abrasion perception of (primary health care physicians and emergency physicians) and its determinants in Saudi Arabia – A survey
Waseem Aalam1, Maan Barry2, Majed Alharbi2, Shadi Tamur3, Ahmad Wazzan4, Deepak P Edward5
1 Department of Ophthalmology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
2 Department of Ophthalmology, Faculty of Medicine, Taibah University, Medina, Saudi Arabia
3 Department of Paediatric Emergency, Faculty of Medicine, Taif University, Ta'if, Saudi Arabia
4 Emergency Medicine, King Abdul Aziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
5 Department of Ophthalmology and Visual Sciences, University of Illinois College of Medicine, Chicago, Chicago, IL, USA
Correspondence Address:
Dr. Waseem Aalam
Department of Ophthalmology, Faculty of Medicine, University of Jeddah, POB 6633, Jeddah 21423
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/meajo.meajo_96_21
Abstract
PURPOSE: The purpose of the study was to determine knowledge, practice, and resources available to primary care physicians to diagnose and manage corneal abrasion in Saudi Arabia.
METHODS: This cross-sectional survey was held in 2017. Family physicians and emergency physicians attending an international conference were surveyed. The questions related to demography, invagination, and tools available in their institute were collected. The questionnaire on how to diagnose and how they manage case of corneal abrasion was also collected using tablet-based software.
RESULTS: Two hundred and twenty-five participants participated in the survey. Exposure to eye patients in two-third of participants was too low (93; 39.6%). Resources for diagnosing corneal abrasion were available in limited centers (51; 21.7%). The rate of good practice to manage corneal abrasion was 21.2% (95% confidence interval 16.0; 26.5). Certified emergency physicians (P < 0.001) and western and central regions (P < 0.001) were positively associated with good practice. Availability of slit lamp (P = 0.2) was not significantly associated with the level of practice to manage corneal abrasion. Fluorescein staining and use of cobalt blue light are essential for diagnosing corneal abrasion as per 40% of participants. About 44.7% of participants replied that antibiotics and lubricants should be used to treat. Nearly one-fourth of participants suggested urgent reference to the ophthalmologist. Use of specific antibiotic varied widely; however, ofloxacin was the main choice of antibiotic in treating corneal abrasion.
CONCLUSION: The knowledge and practice among physicians about corneal abrasion were low. Integrating primary eye care into emergency services through provision of required resources and training physicians is recommended.
Keywords: Cornea, corneal abrasion, ocular emergency, ocular trauma, primary eye care
Introduction 
One excruciatingly painful and frequently occurring eye injury is corneal abrasion. If it is minor, healthy corneal cells quickly fill the defect and avoid complications such as infection and secondary vision damage. However, if it affects the deeper corneal tissue, the patient may need active intervention and healing may take 1 or 2 days.[1] More than one-fourth of ocular emergencies in a tertiary eye hospital were reported to have a diagnosis of corneal abrasion.[2] In general, hospitals of developing countries, one in eight ocular emergencies, were related to corneal abrasion.[3] In western Saudi Arabia also, one general hospital recorded 9.3% of all cases in the emergency room setting were with corneal abrasion.[4] Thus, physicians in an emergency department need to be aware of the diagnosis and management of corneal abrasion. This association of American family physicians recommended this protocol, and special focus is put while training family physicians in the USA to diagnose and manage corneal abrasion.[5] Unfortunately, there is no consensus in the management of corneal abrasions by emergency physicians. Protocols were proposed for British and Canadian physicians, but it is unclear if these protocols are being followed.[6],[7] Even among practicing ophthalmologists of Saudi Arabia, there was lack of institutional guidelines to manage traumatic corneal abrasion.[8]
In 2017, it was reported that in Saudi Arabia, 8000 family physicians provided emergency care at the primary care level.[9] To the best of our knowledge, primary eye care services are not yet integrated to the primary health-care system in Saudi Arabia resulting in excessive referrals to secondary care systems or eye specialists (reference) based on this possible gap in services, we felt that a study to determine the available resources and the primary health-care physician's perception about diagnosis and management of corneal abrasion would provide important baseline information on the approach to the management of this common disorder.
We present outcomes of a survey of emergency physicians and family physicians' working at health institutions of Saudi Arabia except in eye units focusing on the resources, knowledge, and practice for the diagnosis and management of corneal abrasion.
Methods This cross-sectional survey was approved by the ethical committee of our institute. Since the identity of the participants was not disclosed, written informed consent was waived. The study was undertaken in 2016–17 during the Saudi Society of Emergency Medicine Conference held in Jeddah, Saudi Arabia. We also sent the survey electronically to all family medicine society members, and emergency medicine society members in Saudi Arabia as well as multiple visits to primary care centers and emergency departments. Three investigators were involved in the field part of the study. The survey form was pretested before the participants were invited. The form was amended based on the clarity of questions and options to tick according to the pilot participant's feedback.
Through the survey, we targeted 500 emergency physicians and 500 family physicians working at institutions of Saudi Arabia. We assumed that 20% of participants will have correct knowledge about diagnosis and standard practice for corneal abrasion.[9] To achieve a 95% confidence interval (CI) and 5% acceptable error margin and clustering effect of 1.2, we need to interview at least 237 participants. To calculate the sample size, we used the Stat calculator of OpenEPI software.[10]
At the registration counter of the conference, three I-pads were kept for the participants to complete the web-based survey. The participants were requested to participate in this anonymous survey. The form to collect information is given in Appendix 1.
We contacted booth societies of family medicine and emergency medicine and they agreed to send the survey to all family medicine society members and emergency medicine society members in Saudi Arabia. We also visited their workplace frequently to remind them to complete the survey.
The demographic information included nationality, region of Saudi Arabia where the physician was working, type of job responsibility, workload of eye patients, and general patients to whom they provide care. The resources available for diagnosis in their workplace included slit-lamp biomicroscope and their practice of using this tool for the diagnosis of corneal abrasion. There were two questions regarding diagnosis, five questions regarding treatment, and two questions about follow-up regimens to manage cases of corneal abrasion that they follow. The participant was to select one of the multiple options for each question.
The survey completed by the participant was transferred into a spreadsheet through the platform Surveymonkey®.[11] The responses of the participant were compared with correct answers of three experts that were predetermined (one cornea surgeon, one emergency physician, and one primary health-care physician). For each correct answer, +1 score was given and for each wrong answer, −1 score was given. The score of each participant for diagnosis, management, and follow-up protocol was summed up and the overall score for all participants was estimated. If the score was more than 75%, the level of physicians was considered excellent. If it was 51% to 75%, we defined it as good. For scores 26% to 50%, we considered as poor and score of 25% or less was defined as very poor practice to manage corneal abrasion.
The data were transferred into a spreadsheet of Statistical Package for Social Studies (SPSS 25) (IBM, Chicago, Illinois, USA). For qualitative variables, we presented them as frequencies and percentage proportions. For comparing the survey outcomes in subgroups, we calculated relative risk, its 95% CI, and two-sided P value. P < 0.05 was considered statistically significant.
Results We surveyed 235 participants who responded to the survey. Their mode of participation was through Jeddah meeting 125, E-mail 43, and by “visits to primary care centers and emergency departments” 67. The participants' profile is given in [Table 1]. The proportion of Saudi physicians among participants was equal to non-Saudi physicians. The proportion of physicians from western Saudi Arabia was large in our study. The proportion of participants by type of work in the study was adequate to undertake international comparison.
The work pattern of physicians participating in the study and the resources available to diagnose and manage corneal abrasion are given in [Table 2]. One-fourth of attending physicians were overburdened by general patients. Exposure to eye patients in two-third of participants was too low (93; 39.6%). Resources for diagnosing corneal abrasion were available in limited centers (51; 21.7%).
Level of practice of emergency physicians to manage corneal abrasion was compared to cornea surgeons recommended standard [Figure 1]. Excellent + good grade of practice to manage corneal abrasion was reported in 50/235 = 21.2% (95% CI 16.0; 26.5).
Figure 1: Grades of practice to manage corneal abrasion among participating physicians compared to expert panel. X-axis denotes grades of practice. Excellent = >75% correct responses, good = 51 to 75% correct responses, poor = 26% to 50% correct responses, and very poor = 25% or less correct responses. Y-axis denotes the percentage of physicians. The upper and lower ends of high low line show 75% and 25% confidence interval. Central value is the mean response scoreThe factors associated with an acceptable level of management practice for corneal abrasion among physicians are given in [Table 3]. Variation in practice to manage corneal abrasion by type of physician (P < 0.001) and region of the Kingdom they work was significant (P < 0.001). Certified emergency physicians had better practice to manage corneal abrasion compared to others. However, certified family physicians were not. The practice to manage corneal abrasion was significantly different in five zones of Saudi Arabia, western and capital being best compared to other. However, nationality (P = 0.7) and availability of slit lamp (P = 0.2) were not significantly associated with the level of practice to manage corneal abrasion.
Table 3: Grade of practice to manage corneal abrasion among participating physicians and their determinantsThe response to different questions related to diagnosis and management of corneal abrasion by the participant is given in [Table 4]. Four out of ten participants considered that fluorescein staining and use of cobalt blue light are essential for diagnosing corneal abrasion. Less than half of the participants were of opinion that antibiotics and lubricants should be used to treat corneal abrasion. About 27.2% of participants suggested urgent reference to the ophthalmologist. Use of specific antibiotics varied widely; however, ofloxacin was the main choice. Nearly one-fourth of participants were not sure about the protocol for reference and follow-up of a case of corneal abrasion.
Table 4: Diagnosis and treatment practice for corneal abrasion by Saudi primary care physicians Discussion In this study, we noted poor level of awareness and resources for managing corneal abrasion among physicians working at primary eye care level; be it primary health centers or emergency units of hospitals. Certified emergency physicians and physicians working in central and western Saudi Arabia had better knowledge about corneal abrasion management. Standard operating procedures and resources to diagnose and manage corneal abrasion were not uniform in all parts of KSA.
The survey was carried out targeting emergency handling physicians of Saudi Arabia. Use of Google-based data collection on tab enabled for the fast and reliable information from physicians in large number. Anonymity of personal identity in this survey enabled the participants to provide frank opinions without fear of punishment for poor performance or reward for favorable replies. The data would not only enable the decision-makers to improve eye care of patients with corneal abrasion brought at primary level as emergency but also guide medical educationists to focus on weak areas in emergency medical care in the Kingdom.
To diagnose corneal abrasion, magnification, fluorescein staining of corneal epithelium, and viewing the defect using blue light are preferred.[12] The source of blue light could be after the use of cobalt blue filter or wood lamp. Poor knowledge about the method of diagnosis in our study could be attributed to both lack of resources and omission of training physicians in standard eye care.
The standard protocol for treating corneal abrasion varied depending on the cause, depth of the injury, presence of foreign body in cornea, and available resources, especially topical antibiotic medication available at primary eye care level.[5] Even in industrialized countries, there is a lack of consensus for managing corneal abrasion in emergency.[13] The management also varied but all three methods such as use of bandage contact lens, application of antibiotic ointment, or pressure patch application were found to be equally effective in epithelialization of abrasion.[14]
In our study, one-fourth of participants were certified emergency physicians. In contrast, a study in Canada had three-fourth of participants that were certified emergency physicians.[13] In our study, 27% of physicians favored seeking ophthalmologist's assistance in the management of corneal abrasion. In contrast, Canadian emergency physicians preferred first aid and then 88% of cases to ophthalmologists for follow-up. This implies that as and when certified emergency physician increases in the Kingdom, the care of corneal trauma will improve. Those in central and western parts of the Kingdom had better knowledge about the management of corneal abrasion. This could be better exposure of these physicians to ophthalmic practice under supervision of eye care professionals.
Standard operating procedures to manage corneal abrasion in emergency unit of a hospital were recommended in Australia.[15] Cornea subspecialists could play an important role in training primary eye care physicians and thus strengthening eye care at primary level and evaluate the impact of such policy change in coming years.
The survey may not be representative of all physicians managing corneal abrasions in KSA. Therefore, extrapolation of study outcomes should be done with caution. Objective assessment of practice to manage corneal abrasion or an audit of corneal abrasion cases referred to ophthalmic services could be a better benchmark to study the level of knowledge and practice of physicians. However, in a country where primary eye care is not integrated within primary health services or emergency services, such a survey also could provide evidence to the stress of such World Health Organization-recommended strategy to improve eye health care.
Conclusion This survey highlighted the lower level of knowledge and practice among physicians to manage corneal abrasion and perhaps other ocular emergencies in the Kingdom. There is an urgent need for integrating primary eye care into emergency services through the provision of required resources and training physicians in standard operating procedures for ocular emergencies. This will not only reduce the workload on ophthalmic services, but patients will receive urgent and adequate care in hospitals without ophthalmology services.
Acknowledgments
We thank staff of PHC and Jeddah conference organizers to assist us in the survey.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Appendix 1: Study's survey questions Case: 40-year-old male presented with right eye pain, redness, tearing and difficulty on opening his eye after his eye poked by his son finger. On Exam: patient has minimal decrease in visual acuity, no foreign body seen in the eye, no hyphema and no sign of rupture globe. You suspected a diagnosis of corneal abrasion
Please answer the following questions:
Do you have slit-lamp Microscope in E.R/Primary health care center?a- Yes
b- No
If the answer is yes do you use slit lamp to examine Eye cases?
a- Yes
b- No
To diagnose a corneal abrasion in the (Emergency Department/ Primary Health Care Centre): (one answer only)a- I inspect the eye only for visible abrasion
b- I Apply fluorescein dye on the affected eye and examine it with no light
c- I Apply fluorescein dye and examine it with regular light
d- I Apply fluorescein dye and examine it with blue light
e- I don't feel comfortable making this diagnosis, I will call Ophthalmology
f- I do not have fluorescein dye available at my facility
if the diagnosis of corneal abrasion has been confirmed, how would you treat this case. (one answer only)a- No treatment is indicated and I will reassure the patient
b- Prescribe topical antibiotic drops or ointment and lubricating eye drops (artificial tears)
c- Prescribe topical antibiotics only
d- Prescribe lubricating eye drops (artificial tears) only
g- Urgent ophthalmology consult, I don't feel comfortable treating this problem.
If you are going to use antibiotics to treat the corneal abrasion, what is your drug of choice (one answer only )a- Oflaxacin
b- Moxifloxacin
c- Gentamicin
d- Ciprofolaxacin
e- Chloramphicol
f- Other
Will you use Cycloplegic drops:a- Yes
b- No
c- I am not sure
Will you use Bandage contact lens:a- Yes
b- No
How will you manage pain in such a patient present?a- I will prescribe topical analgesics/anesthetic
b- I will prescribe oral analgesics
c- There is no need for pain management.
Prescribing patch to the affected eye for corneal abrasiona- I never recommend it
b- I always recommend it
c- I do recommend it in certain situation
When will you see this patient on a follow-up visit.?a- After 24 hours
b- 2-3 days.
c- No need for further follow up.
d- I will refer patient for ophthalmologist for follow up.
If you will refer the patient to Ophthalmologist when will be that followup be the scheduled?a- Out patient in 1-2 days
b- Out patient referral in 1-2 weeks
c- Out patient referral in 4-6 month
d- Ophthalmology consult follow-up as an emergency
I am aa- Emergency physician (board certified)
b- Emergency physician resident in training
c- General practitioner at ER
d- Family physician (board certified)
e- Family Medicine resident in training
f- General practitioner at Primary Health Care Centre
How many eye case you see per monthHow many patient you see per shift in a regular day.How many physician work together in the same shift at your institute
References 
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