Q: A 25-year-old male patient experienced a staged coma and significant closed head trauma following a motor vehicle accident. Now, his ocular concerns are refractory filamentary keratitis and ptosis. How should we best treat this condition to preserve corneal function?

A: “When patients are placed or fall into a coma, the eyelids are usually closed or in close apposition,” says Andrew S. Gurwood, O.D., of Pennsylvania College of Optometry at Salus University. In this state, Bell’s phenomenon (when the eyes reflexively roll upward under the upper eyelid for protection from drying and foreign matter) may be lost, he says.

“Typically, to avoid epitheliopathy in these patients, lubricating or mild antimicrobial ointments may be placed into the inferior cul-de-sac to provide moisture protection against drying and complications like keratopathy or symblepharon,” says Marc D. Myers, O.D., of the Coatesville VA Hospital, Pennsylvania. “Ointments can be used, as they provide the advantage of greater contact time. Even if the lids are slightly open, the reservoir of ointment that gathers within the palpebral aperture serves as an adequate protective barrier against evaporative consequences.”

But, filaments may still form in a comatose individual’s eye, secondary to natural or iatrogenic mucus exaggeration. “This diagnosis would require skill; most filamentary keratitis (FK) cases are diagnosed secondary to signs and symptoms exposed by conscious and functioning subjects,” says Dr. Gurwood. “Nevertheless, since there would be no symptoms from a sedated patient, corneal protection and lubrication would be the primary concern. Using bandage contact lenses or anti-inflammatory regimens in patients in a constant supine position with artificially altered tear flow is not a recommended practice.”

Lubrication with ointments may be successful in the short term, but filaments may still recur. “If the issue becomes chronic, the addition of a hypertonic solution, such as sodium chloride 5%, may be considered,” suggests Dr. Myers. “Topical antibiotic ointments or solutions should be enlisted if the cornea is sufficiently exposed or compromised.”

Or, another option to consider is punctal occlusion. “This non-surgical modality addresses aqueous deficiency and may facilitate a healthier cornea. However, this is not a standard bedside approach,” Dr. Gurwood says.

Topical drops may also be of assistance, but such a regimen does require thorough caregiver education. Restasis (cyclosporine 0.05%, Allergan) may reduce ocular surface inflammation associated with aqueous-deficient dry eye syndrome. Or, the topical mucolytic agent N-acetylcysteine effectively dissolves corneal filaments. (The branded formulation, Mucomyst, by Mead Johnson, is not commercially available in the U.S. But, appropriate formulations of N-acetylcysteine can be obtained from a compounding pharmacist.) “Since the compound has an unpleasant smell and must be manufactured as a non-preserved formula (with about a 30-day shelf life), family members and staff must be educated,” says Dr. Myers.

Ptosis, on the other hand, should resolve with emergence from the coma. “Until then, since it is a natural and exceptional protective mechanism, no intervention should be attempted to reverse it,” says Dr. Gurwood. “So long as there is no permanent neurologic or traumatic (mechanical or structural) damage, the ptosis of coma should disappear upon recovery. If it does not, neuro-ophthalmologic and oculoplastic consultation should be obtained to understand the underlying cause and devise a suitable plan, such as a ptosis crutch or lid lift.”

What’s the bottom line for this patient’s functional and visual outcome? “As long as the vision-related structures—cornea, lens, vitreous, retina, nerve, visual pathway and occipital visual cortex—have remained intact and uninvolved with the inciting injury, there should be no residual functional deficit,” says Dr. Gurwood. “When deficits are recognized, they must be investigated to uncover the underlying cause.”