• Letters

    Thoughts From Your Colleagues

    Download PDF

    Correction. In “Ischemic Optic Neuropathy Following Cataract Surgery” (Journal Highlights, December), EyeNet removed part of the quote from Heather Moss, MD, PhD, for reasons of space. Important content was lost in the abridgment. In the online version of the article, the full quote has been reinstated (aao.org/eyenet/correction). EyeNet regrets the error.


    Tetanus From Ocular Injuries

    The incidence and mortality of tetanus has exhibited a marked decrease since 1924 after the introduction of tetanus toxoid vaccine and postexposure prophylaxis (T-PEP), which con­sists of the tetanus booster and, in some cases, tetanus immu­noglobulin.1 T-PEP has not been properly addressed in the ophthalmic literature, and current practices vary by emer­gency department. We are writing to clarify T-PEP following ophthalmic trauma.

    It is extremely unlikely that superficial nonpenetrating trauma, including corneal abrasions, lead to a risk of tetanus infection. No cases of tetanus have ever been reported following corneal abrasion, and a single animal study in 1993 showed no cases of tetanus following topical inoculation of Clostridium tetani following superficial injuries.2 We rec­ommend that patients with corneal abrasions and corneal foreign bodies without penetration into the anterior chamber not receive T-PEP.

    The CDC guidelines recommend that a tetanus booster be administered after a clean wound if less than three tetanus vaccinations in a series were administered, or if the last booster was more than 10 years ago.1 For all other wounds, tetanus toxoid is recommended if the last booster took place more than five years previously. If tetanus vaccination status is unknown or there are fewer than three tetanus vaccina­tions in a series for a patient with a contaminated wound, both tetanus toxoid and tetanus immunoglobulin should be administered.1 As with any vaccine, it takes time for tetanus toxoid to stimulate an immune response, with B-cell pro­tection reaching a maximum one to two weeks following tetanus toxoid administration.

    Previously reported ophthalmic cases that resulted in tet­anus infection include open globe injury and periorbital dog bite.3,4 Our experience has been that a reliable tetanus vacci­nation history is infrequently available for acute ophthalmic trauma patents. For patients with contaminated, high-risk wounds with either unknown tetanus vaccination history or less than three tetanus vaccinations in a series, we advise administration of 500 IUs of tetanus immunoglobulin (TIG) along with tetanus toxoid, especially if there is devitalized tissue or a delay to surgical repair. If TIG is unavailable, 200 to 400 mg/kg of intravenous immuno­globulin may be substituted.3

    In summary, tetanus is a highly preventable fatal disease that may re­sult from penetrating ocular injuries. It is imperative to ask about tetanus vaccine history and consider admin­istration of T-PEP when treating patients with open globe injuries, intraocular foreign bodies, and perior­bital skin trauma.

    Sitara H. Hirji, MD, Danielle F. Trief, MD, and James D. Auran, MD
    Edward S. Harkness Eye Institute,
    Columbia University Irving Medical Center, New York

    Fasika A. Woreta, MD, MPH
    Wilmer Eye Institute
    Johns Hopkins University School of Medicine, Baltimore

    ___________________________

    1 www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html. html. Accessed Oct. 28, 2021.

    2 Benson WH et al. Am J Emerg Med. 1993;11(6):677-683.

    3 Erickson BP et al. Orbit. 2019;38(1):43-50.

    4 Iyer MN, Kranias G, Daun ME. Am J Ophthal­mol. 2001;132(1):116-117.

    CDC Recommendations for T-PEP

    The table below shows CDC recommendations for T-PEP following “clean” and “all other” wounds.1 Of note, the distinction between “clean” and “all other” wounds in CDC recommendations remains poorly defined.

    History of tetanus immunization Clean, minor wounds All other wounds*
    Tetanus-containing vaccine TIG Tetanus-containing vaccine TIG
    Unknown or if less than 3 doses in vaccine series Yes No Yes Yes
    3 or more doses in vaccine series and less than 5 years since last booster dose No No No No
    3 or more doses in a vaccine series and between 5 and 10 years since last booster dose No No Yes No
    3 or more doses in vaccine series and more than 10 years since last booster dose Yes No Yes No
    * Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.
    1 www.cdc.gov/tetanus/clinicians.html. Accessed Oct. 28, 2021.
    WRITE TO US. Send your letters of 150 words or fewer to us at EyeNet Magazine, American Academy of Oph­thalmology, 655 Beach Street, San Francisco, CA 94109; e-mail eyenet@aao.org; or fax 415-561-8575. (EyeNet Magazine reserves the right to edit letters.)