Author:
TracyMacIntosh
YasuharuOkuda
Description
- A tear or defect in the corneal epithelium
- May be traumatic, spontaneous, due to foreign body, or contact lens wear
Etiology
- Traumatic:
- Human fingernail
- Contact lens manipulation
- Environmental elements: Branches, sand /stones
- Chemical burn
- Airbag deployment
- Pepper spray
- Makeup applicator
- Foreign body related:
- Wood
- Glass
- Metal
- Rust
- Plastic
- Fiberglass
- Vegetable matter
- Eyelid foreign body
- Contact lens related:
- Overworn
- Improperly fitting or cleaned
- Flash burn
- Spontaneous:
- Usually previous traumatic corneal abrasion or an underlying defect in the corneal epithelium
Signs and Symptoms
- Severe ocular pain
- Foreign body sensation
- Tearing
- Blepharospasm
- Photophobia (particularly if secondary traumatic iritis present)
- Conjunctival injection
- Diminished or blurred vision
History
- Direct trauma to the globe
- Known or potential foreign body
- Contact lens use
- History of previous corneal abrasion
- Ocular/periocular surgery
- Pre-existing visual impairment
- Time of onset
- Associated symptoms or concomitant injury
- Treatment before visit
- Occupational risks: Use of safety glasses (pounding, drilling, grinding metal) or eyeglasses
- Systemic disease (diabetes, autoimmune disorders)
- Tetanus status
Pediatric Considerations |
- Signs and symptoms may differ:
- Younger than 12 mo:
- Frequently no history of eye trauma
- Might present as the crying inconsolable infant
- In 1-12 wk old may be an incidental finding and not the cause of their irritability or crying
- Older than 12 mo:
- More often will have history of minor eye trauma
- Positive eye signs
|
Physical Exam
- If indicated, evaluate for other life-threatening injuries with attention to the primary survey
- Complete eye exam:
- Focus is to evaluate for evidence of penetrating injury and /or infection
- Gross visual inspection
- Visual acuity
- Penlight exam to evaluate for conjunctival injection, the pupil shape/reactivity, and for any evidence of corneal infiltrate or opacity
- Evert upper lids to check for retained foreign body
- Slit-lamp exam to evaluate for foreign body, anterior chamber reaction, infiltrate, corneal laceration, and penetrating trauma
- Fluorescein dye to identify size and location of corneal epithelium defect
- Application of topical anesthetic drops typically improves symptoms
Essential Workup
Complete eye exam to rule out globe rupture and including visual acuity, gross inspection, and fluorescein
Diagnostic Tests & Interpretation
Pediatric Considerations |
| Hand held slit-lamp and Wood lamp: Helpful in exam of pediatric eye |
Differential Diagnosis
- Conjunctivitis, viral, or bacterial
- Corneal ulcer
- Glaucoma
- Herpes zoster
- Keratitis, viral or bacterial, or ultraviolet induced
- Recurrent corneal erosion syndrome
- Uveitis
- More extensive pathology than corneal abrasion:
- Laceration of cornea
- Perforation of cornea
- Hyphema
- Hypopyon
- Iris prolapse
- Lens disruption
- Globe rupture
Initial Stabilization/Therapy
Instill topical anesthetic (proparacaine/tetracaine)
ED Treatment/Procedures
- Removal of superficial foreign body:
- A residual rust ring does not need emergent removal. It can be removed at 24-48 hr
- Oral pain control:
- Oral acetaminophen, NSAID, or narcotic: Most small abrasions ( ≤4 mm) will heal overnight
- Topical anesthetic agents:
- Current evidence is controversial and currently not recommended; short-term complications may include decreased visual acuity, photophobia, pain, tearing, corneal infiltrates, and edema
- Topical pain medications:
- Studies have demonstrated efficacy; however, there are scattered reports of adverse effects
- Avoid in patients with other ocular surface disease and in postoperative patient
- Topical diclofenac or ketorolac
- Cycloplegic (optional - consider duration of action 24-36 hr vs. side effects): Inhibit pupillary constriction, thereby preventing pain and photophobia in response to light
- Topical antibiotic:
- Ointment better than drops because also a lubricant
- Discontinue antibiotics once symptom free for 24 hr
- Contact lens wearers must have antipseudomonal coverage
- Eye patch:
- Does not improve pain or healing, not recommended
- More research needed to evaluate efficacy of patching in abrasions >10 mm
- Contact lens:
- No contact lens wear till abrasion healed and eye feels normal for a week without medication
- Tetanus prophylaxis:
- Routine tetanus not necessary for abrasions
- Update tetanus if abrasion caused by, or contaminated with, organic matter or dirt
- Emergent ophthalmologic consultation required for retained intraocular foreign body, penetrating injury to globe (or other more serious injury), corneal infiltrate, white spot or opacity to suggest ulceration, hypopyon
Medication
- Topical antibiotics:
- Erythromycin: 0.5% ointment q.i.d
- Ciprofloxacin: 0.35% solution 1 drop q.i.d
- Sulfacetamide: 10% ointment q.i.d and q.h.s or solution 1-2 drops q3h
- Contact lens wearers must have anti-pseudomonal coverage:
- Ciprofloxacin: 0.3% ointment t.i.d or solution 1 drop q.i.d
- Ofloxacin: 0.3% solution 2 drops q.i.d
- Gentamicin: 0.3% ointment t.i.d or solution 2 drops q6h
- Tobramycin: 0.3% ointment q6h or solution 2 drops q6h
- Cycloplegics:
- Homatropine: 2.5-5% solution 1 drop per day
- Cyclopentolate: 0.5% or 1% 1 drop b.i.d
- Analgesics:
- Diclofenac: 0.1% solution 1 drop q.i.d
- Ketorolac: 0.5% solution 1 drop q.i.d
- Proparacaine: 0.5% solution 1 drop once only
- Tetracaine: 1% solution 1 drop once only
Disposition
Admission Criteria
Associated injuries requiring admission
Discharge Criteria
All simple corneal abrasions
Issues for Referral
No studies on optimal follow-up. Practice recommendations however dictate all corneal abrasions require follow-up to ensure healing without infection or scarring, particularly given a history of significant trauma, worsening symptoms despite treatment, infiltrate around the abrasion, recurrent erosion syndrome
Follow-up Recommendations
- Follow-up with ophthalmologist in 24 hr for large defects, purulent discharge, significant drop in vision, pediatric abrasion with persistent drainage, and unwilling to keep eye open
- Uncomplicated abrasion can be re-evaluated in 48-72 hr
- Al-MaskariA, LarkinDFP. The cornea. In: Riordan-EvaP, AugsburgerJJ. eds. Vaughan & Asbury's General Ophthalmology. 19th ed.New York: McGraw-Hill; 2018.
- JacobsDS. Corneal abrasions and corneal foreign bodies . www.uptodate.com. Accessed December 1, 2017.
- LimCH, TurnerA, LimBX. Patching for corneal abrasion . Cochrane Database Syst Rev. 2016; (7):CD004764.
- PargamentJ, CorrêaZM, AugsburgerJJ. Ophthalmic trauma. In: Riordan-EvaP, AugsburgerJJ. eds. Vaughan & Asbury's General Ophthalmology. 19th ed.New York: McGraw-Hill; 2018.
- PulsH, CabreraD, MuradMH, et al. Safety and effectiveness of topical anesthetics in corneal abrasions: Systematic review and meta-analysis . J Emerg Med. 2015;49(5):816-824.
- ShopeTR, RiegTS, KathiriaNN. Corneal abrasions in young infants . Pediatrics. 2010;125(3):e565-e569.
See Also (Topic, Algorithm, Electronic Media Element)
ICD9
918.1 Superficial injury of cornea
ICD10
S05.00XA Inj conjunctiva and corneal abrasion w/o fb, unsp eye, init
S05.01XA Inj conjunctiva and corneal abrasion w/o fb, right eye, init
S05.02XA Inj conjunctiva and corneal abrasion w/o fb, left eye, init
SNOMED
85848002 Corneal abrasion (disorder)
314506004 Traumatic corneal abrasion
371066008 Contact lens related corneal abrasion