Corneal abrasion

Background

• Must rule-out intraocular foreign body and corneal laceration

Clinical Features

• Foreign body sensation
• Photophobia (+/- consensual)
• Decreased vision
  • If associated iritis or if abrasion occurs in visual axis
• Eye pain
  • Relief of pain with topical anesthesia
    • Virtually diagnostic of corneal abrasion

Corneal Abrasions from Airbag Deployment

Corneal Abrasions from Airbag Deployment

Differential Diagnosis

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses ^^Critical diagnoses

Evaluation

• A complete eye exam should be conducted
• Eyelid Exam
  • Flip upper lid and exam lower lid for foreign body
  • If concern for foreign body despite normal exam, consider orbital CT or MRI if certain foreign body is nonmetallic
• Fluorescein Exam
  • Apply 1 gtt of flourescein or use strip with anesthetic
  • Use Wood's lamp or slit lamp with cobalt blue light
  • Fluorescein will fill corneal defects and glow
  • Multiple vertical abrasions suggests foreign body embedded under the upper lid
• Topical anesthetic (ie proparacaine or tetracaine) may assist in patient cooperation with exam once open globe excluded.
  • Repeated doses or Rx for topical anesthesia is controversial given concerns for impaired healing

Additional Considerations

• Contact lens wearer
  • If white spot or opacity on exam concerning for infiltrate or Corneal ulcer refer for same day ophtho appt
• Fluorescein Examination
  • Seidel sign (streaming of fluorescein) indicates penetrating trauma
  • Branching/Dendritic pattern suggests possible Herpes Zoster Ophthalmicus
• Visual acuity
  • If poor, consider corneal edema versus infectious infiltrate
• Pupil shape and reactivity
  • Irregular or nonreactive pupil suggests pupillary sphincter injury and possible penetrating trauma
• Hyphema or hypopyon
  • Hyphema suggests possible penetrating injury
  • If present then same same-day ophtho consult is required
• Extruded ocular contents
  • If yes then place eye shield and obtain emergent ophtho referral
• Corneal Ulcer
  • Grayish white lesion
  • Worsening symptoms >1day

Corneal abrasion vs. corneal ulcer

Characteristic	Corneal abrasion	Corneal ulcer
History	*Acute pain immediately after injury	*Delayed pain frequently 2-3 days or more after initial event
Lesion viewable on fluorescein exam	*Yes	*Yes
Lesion viewable on white light exam	*No	*Yes
Lesion morphology	*Frequently linear, punctate, patterned, and/or irregular	*Commonly circular

Management

Antibiotics

Does Not Wear Contact Lens

• Erythromycin ointment qid x 3-5d OR
• Ciprofloxacin 0.3% ophthalmic solution 2 drops q6 hours OR
• Ofloxacin 0.3% solution 2 drops q6 hours OR
• Sulfacetamide 10% ophthalmic ointment q6 hours

Wears Contact Lens

Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones

• Levofloxacin 0.5% solution 2 drops ever 2 hours for 2 days THEN q6hrs for 5 days OR
• Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
• Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR
• Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
• Gentamicin 0.3% solution 2 drops six times for 5 days

Analgesia

• Systemic NSAIDs or opioids
• Cycloplegics can be consider for patients with large abrasions (>2mm) and/or severe pain
  • Cyclopentolate 1% 1 drop q6-8hr
• Ophthalmic NSAIDs
  • Ketorolac 0.4% 1 drop q6hr x 2-3d
• Topical anesthetics
  • Tetracaine 1% 1 drop q30min has been found to be safe in the first 24 hrs
  • Proparacaine 0.05% ophthalmic (dilute 1 mL of proparacaine 0.5% with 9 mL of NS in flush syringe then place 3 mL in bottle) 1-2 drops in eye Q30 min PRN pain for 24-48 hours only

Other

• Tetanus prophylaxis not indicated (unless penetrating injury)
• Patch is not routinely recommended and can prolong healing time

Disposition

• Ophtho follow up in 48h for routine cases
• Minor abrasions will heal in 48-72h

See Also

• Eye Algorithms (Main)