Diagnosis and Management of Corneal Abrasion Perception of (Primary Health Care Physicians and Emergency Physicians) and its Determinants in Saudi Arabia - A Survey.

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. Copyright:

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.[67] 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.

Table 1

Profile of the participants

	n (percentage proportion)
Nationality
Saudi	116 (49.4)
Non-Saudi	119 (51.6)
Region of Saudi Arabia
Riyadh	38 (16.2)
East	10 (4.3)
West	168 (71.5)
North	4 (1.7)
South	7 (3.0)
Other	8 (3.4)
Type of work
Emergency physician (certified)	57 (24.3)
Emergency physician trainee	25 (10.6)
GP	29 (12.3)
Family physician certified	48 (20.4)
Family physician trainee	27 (11.5)
GP at PHC	49 (20.9)

GP: General practitioner, PHC: Primary health center

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%).

Table 2

Work pattern and resources at work station

	n (percentage proportion)
Workload of general patient per shift
<10	93 (39.6)
10-30	84 (35.7)
30-50	37 (15.7)
>50	21 (8.9)
Workload of eye patient per month
<10	161 (68.5)
10-30	58 (24.7)
31-50	11 (4.7)
>50	5 (2.1)
Availability of slit lamp at workplace
Yes	51 (21.7)
No	184 (78.3)
Using slit lamp
Yes	49 (96.1)
No	2 (3.9)
Fluorescein dye available
Yes	188 (80)
No	47 (20)

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 score

The 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 determinants

	Good + excellent practice (n=50), n (%)	Poor practice (n=285), n (%)	Validation
Nationality
Saudi	25 (21.6)	91 (87.4)	P=0.7
Non-Saudi	25 (19.4)	104 (80.6)
Type of work
Emergency physician (certified)	23 (40.4)	34 (59.6)	χ2=20Df=6P<0.001
Emergency physician trainee	5 (20.0)	20 (80.0)
GP	6 (20.7)	23 (79.3)
Family physician certified	11 (22.9)	37 (77.1)
Family physician trainee	3 (11.1)	24 (88.9)
GP at PHC	2 (4.1)	47 (95.9)
Location in Saudi Arabia
Central	17 (44.7)	21 (55.3)	χ2=13.4Df=6P<0.001
East	2 (20)	8 (80)
West	30 (52)	138 (48)
North	0	4 (100)
South	0	7 (100)
Other	1 (12.5)	7 (87.5)
Presence of slit lamp
Yes	14 (27.5)	37 (72.5)	P=0.2
No	36 (19.6)	148 (80.4)

GP: General practitioner, PHC: primary health center

The 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

	n (%)
Diagnosis of corneal abrasion (n=188)
Naked eye examination	33 (14.0)
Fluorescein but no light	10 (4.3)
Fluorescein and regular light	26 (11.1)
Fluorescein and blue light	94 (40.0)
Call ophthalmologist	25 (10.6)
Treatment strategy
No treatment and assurance	16 (6.8)
Topical antibiotic and lubricant	105 (44.7)
Topical antibiotics only	38 (16.2)
Lubricant only	12 (5.1)
Urgent reference to ophthalmologist	64 (27.2)
Antibiotic of choice
Ofloxacin	94 (40.0)
Moxifloxacin	17 (7.2)
Gentamicin	31 (13.2)
Ciprofloxacin	34 (14.5)
Chloramphenicol	39 (16.6)
Erythromycin	9 (3.8)
Fucithalmic	5 (2.1)
Tobramycin	1 (0.4)
None	5 (2.1)
Use of cycloplegic
Yes	45 (19.1)
No	124 (52.8)
Not sure	66 (28.1)
Use bandage contact lens
Yes	50 (21.3)
No	185 (78.7)
Pain management
Topical anesthetic/analgesic	98 (41.7)
Oral analgesic	116 (49.4)
None	21 (8.9)
Patching the eye (n=233)
Never	127 (54.5)
Always	66 (28.3)
In some indication	40 (17.2)
When next follow-up
After 24 h	59 (25.1)
2-3 days	45 (19.1)
No follow-up needed	12 (5.1)
Refer to ophthalmologist	119 (50.6)
Follow-up by ophthalmologist (n=233)
1-2 days	151 (64.3)
1-2 weeks	39 (16.6)
4-6 months	43 (18.3)
Follow-up in emergency	0

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.