Dog bites, steroids, and injection pain under review

Ophthalmic manifestations of facial dog bites 

Bratton EM, Golas L, Wei LA, Davies BW and Durairaj VD

Ophthalmic Plast Reconstr Surg 2018;34:106-109

 

Review

Retrospective chart review of children aged under 18 years presenting at a large tertiary paediatric hospital following dog bites over an 11-year period.

A total of 1,989 children between the ages of two months and 17 years were identified with facial dog bites of which 16% had ophthalmic manifestations. Of those, 99% had eyelid injuries and 20% sustained canalicular damage, but fewer than 2% suffered corneal abrasions. The most frequent complications were epiphora and upper lid ptosis and, less commonly, prominent scar formation. 

Given these patients were seen at a tertiary paediatric hospital, the study does not represent the distribution of injuries and complications that would be seen in the community, a general hospital or an eye department. 

 

Comment 

Children are by far the most common victims of dog bite, with the vast majority of bites (80%) being caused by ‘familiar’ dogs, such as a family pet, and affecting the head and neck regions. The scarcity of corneal injuries attests to the protection of the globe afforded by the structure of the orbit, along with eyelid anatomy and physiology.

 

Intravenous steroid with antibiotic treatment for children with orbital cellulitis

Chen C, Silverman N, Wu A and Shinder R

Ophthalmic Plast Reconstr Surg 2018;34:205-208

 

Review

Prospective, comparative, non-randomised trial to compare the outcomes of children with orbital cellulitis treated with IV dexamethasone and antibiotics to a cohort treated with antibiotics alone. 

The study included 43 children under 18, 65% of whom had a combination of IV steroids and antibiotics on admission and 35% who received IV antibiotics alone. Children who received IV steroids had significantly shorter hospital stays; close to half the time the antibiotic group required. This was also true for those undergoing surgery for abscess drainage. No patients had troublesome complications or changes in their baseline health related to the steroid use. 

The main weakness of the study is that although being prospective, it was not randomised with respect to treatment groups. All patients started on IV antibiotics, but the children’s parents were given the choice as to whether steroids were used as well. So, there may have been less enthusiasm for steroid use in the more severe cases of infection from both the parents and the attending medical staff. A further weakness was the relatively small sample size.

 

Comment 

Although it may seem counterintuitive to give steroids for an acute orbital infection, this treatment is widely used in sinus infections and acute bacterial meningitis. In the latter condition, systemic steroid use is associated with lower mortality, less hearing loss and reduced neurologic sequelae. Given that orbital cellulitis commonly occurs secondary to sinus disease and that sinusitis is generally treated with a combination of antibiotics and steroids, the extrapolation to treat orbital infection in a similar manner does not seem unreasonable. The anti-inflammatory effect of steroids is known to hasten resolution of swelling which, in the orbit, reduces proptosis as well as helping with pain management.

 

 

Reducing local anaesthetic injection pain methods in periocular surgery

Gostimir M, Hussain H

Ophthalmic Plast Reconstr Surg 2019;35:113-125

 

Review 

Literature search of large medical databases to identify relevant experimental and observational studies, published in the past 72 years, regarding the outcomes of specific interventions used to reduce pain associated with the administration of local anaesthesia during periocular surgery.

Twenty-three articles fit the selection criteria, representing 1135 patients, with multiple pain reduction methods identified. Useful techniques found, included solution modification (buffering, warming, dilution), application of subconjunctival topical anaesthetics, skin cooling with ice, vibration for distraction and a decrease in the rate of injection. Buffering is produced by adding sodium bicarbonate solution to the anaesthetic, increasing its pH. 

 

Comment 

Although this paper’s title concerns treatments to reduce pain from local anaesthesia delivered in the periocular region, the evidence extracted from the studies was largely related to non-specific injection sites and then extrapolated. The skin in the periocular region is different from that in other areas, due to its thinness and lack of subcutaneous fat. Therefore, the results from LA injections into other areas of the body may well be less relevant to the eyelids and adjacent skin.  

Many techniques have been used to try to reduce the pain inflicted while injecting local anaesthetic. In addition to the results above, smaller bore needles were associated with reduced pain while interestingly blunter needles performed superiorly to sharp needles. So, in summary, to minimise pain associated with periocular injections, the optimal strategy seems to be: use a relatively blunt, small gauge needle to slowly inject warmed and buffered anaesthetic either sub-conjunctively, following the application of lignocaine gel, or through pre-cooled skin while pressing a vibration device near to the injection site. 

Dr Paul Rosser is an oculoplastic surgeon who has worked in both public and private practice for more than 25 years. His new Auckland practice Eyes and Eyelids focuses on cosmetic and reconstructive eyelid surgery.

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