Corneal abrasion: Difference between revisions

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==Diagnosis==
==Background==
#Visual acuity
*Must rule-out intraocular foreign body and corneal laceration
##If substantially subnormal evaluate for corneal edema versus infectious infiltrate 
#Pupil shape and reactivity
##Irregular or nonreactive pupil suggests pupillary sphincter injury
###Evaulate for penetrating injury
#Hyphema or hypopyon?
##If yes then same same-day ophtho consult is required
##Hyphema suggests possible penetrating injury
#Extruded ocular contents?
##If yes then place eye shield and obtain emergent ophtho referral 
#Contact lens wearer?
##If yes and p/w corneal abrasion AND e/o white spot or opacity on exam concerning for infiltrate or ulceration then refer for same day ophtho appt
#Fluorescein Examination
##Seidel sign (streaming of fluorescein caused by leaking aqueous humor)
###Indicates penetrating trauma (globe microperforation)
##Branching pattern suggests possible herpes keratitis
#Corneal Ulcer?
##Grayish white
##Worsening symptoms
##> 1day
#Intraocular foreign body?
##If concern for foreign body but none visualized on external exam consider CT orbit


==Foreign Body Removal Techniques==
==Clinical Features==
#Irrigation
*Foreign body sensation
#Cotton swab
*Photophobia (+/- consensual)
#18-25G needle
*Decreased vision
**If associated iritis or if abrasion occurs in visual axis
*Relief of pain with topical anesthesia
**Virtually diagnostic of corneal abrasion
[[File:Airbag-corneal-abrasion1.png|thumb|Corneal Abrasions from Airbag Deployment]]
[[File:Airbag-corneal-abrasion2.png|thumb|Corneal Abrasions from Airbag Deployment]]


==Treatment==
==Differential Diagnosis==
#Antibiotics - Indicated for all abrasions
{{Unilateral red eye DDX}}
##Ointment is better than drops due to its lubricant effect
###Erythromycin ointment qid x 3-5 days
##If treatintg contact lens associated abrasion must cover pseudomonas
###E.g.  Cipro/ofloxacin or tobramycin drops qid x 3-5 days
#Analgesia
##Cycloplegics
###Consider for patients with large abrasions and photophobia
####Cyclopentolate 0.5-1% bid or homatropine 2.5-5% daily for up to 48 hours
##Systemic opiods
##Never give Rx for topical anesthetics
#Tetanus prophylaxis
##Only indicated for penetrating injuries, not for abrasions or foreign bodies


===Rust Ring===
==Evaluation==
Treat just like pts with corneal abrasions; obtain ophtho f/u in 24-48 hrs for removal of the rust
*A complete [[Eye Exam|eye exam]] should be conducted
*Eyelid Exam
**Flip upper lid and exam lower lid for FB
**If concern for FB despite normal exam, consider orbital CT or MRI is certain it is nonmetallic
*Fluorescein Exam
**Apply 1 gtt of flourescein or utilize strip with anesthetic
**Use Wood's Lamp or Slit Lamp with colbalt blue light
**Fluoresceine will fill corneal defects and glow
**Multiple vertical abrasions suggests foreign body embedded under the upper lid


[[Category:Ophtho]]
===Additional Considerations===
*Contact lens wearer
**If white spot or opacity on exam concerning for infiltrate or ulceration refer for same day ophtho appt
*Fluorescein Examination
**Seidel sign (streaming of fluorescein) indicates [[Globe rupture|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
*[[Traumatic hyphema|Hyphema]] or hypopyon
**Hyphema suggests possible penetrating injury
**If present then same same-day ophtho consult is required
*[[Globe rupture|Extruded ocular contents]]
**If yes then place eye shield and obtain emergent ophtho referral 
*[[Corneal Ulcer]]
**Grayish white lesion
**Worsening symptoms >1day
 
==Management==
===Antibiotics===
{{Corneal Abrasion Antibiotics}}
 
===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<ref>Waldman N, et al. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med. 2014; 21(4):374-82.</ref>
 
===Other===
*Tetanus prophylaxis not indicated (unless penetrating injury)<ref>Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.</ref>
*Patch is not routinely recommended<ref>Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.</ref> and can prolong healing time<ref>Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.</ref>
 
==Disposition==
*Ophtho follow up in 48h for routine cases
*Minor abrasions will heal in 48-72h
 
==References==
<references/>
 
==See Also==
*[[Eye Algorithms (Main)]]
 
[[Category:Ophthalmology]]

Revision as of 20:24, 28 August 2017

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
  • 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

^Emergent diagnoses ^^Critical diagnoses

Evaluation

  • A complete eye exam should be conducted
  • Eyelid Exam
    • Flip upper lid and exam lower lid for FB
    • If concern for FB despite normal exam, consider orbital CT or MRI is certain it is nonmetallic
  • Fluorescein Exam
    • Apply 1 gtt of flourescein or utilize strip with anesthetic
    • Use Wood's Lamp or Slit Lamp with colbalt blue light
    • Fluoresceine will fill corneal defects and glow
    • Multiple vertical abrasions suggests foreign body embedded under the upper lid

Additional Considerations

  • Contact lens wearer
    • If white spot or opacity on exam concerning for infiltrate or ulceration refer for same day ophtho appt
  • Fluorescein Examination
  • 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

Management

Antibiotics

Does Not Wear Contact Lens

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
  • Ophthalmic NSAIDs
  • Topical anesthetics
    • Tetracaine 1% 1 drop q30min has been found to be safe in the first 24 hrs[1]

Other

  • Tetanus prophylaxis not indicated (unless penetrating injury)[2]
  • Patch is not routinely recommended[3] and can prolong healing time[4]

Disposition

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

References

  1. Waldman N, et al. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med. 2014; 21(4):374-82.
  2. Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.
  3. Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.
  4. Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.

See Also