Corneal laceration

For full-thickness corneal lacerations see globe rupture

Background

Eye anatomy.

• Traumatic injury to the eye, most often associated with penetrating injury or impact with debris.
• Must rule out full-thickness corneal laceration (i.e., globe rupture), which is a medical emergency

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

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

Workup

• 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 (i.e., proparacaine or tetracaine) may assist in patient cooperation with exam once open globe excluded.
  • Repeated doses or prescriptoin for topical anesthesia is controversial given concerns for impaired healing

Corneal laceration (non full-thickness) vs Globe Rupture

• Fluorescein Examination
  • Seidel sign (streaming of fluorescein) indicates globe rupture
• If high-risk metallic foreign body injury (e.g., hammering a nail, grinding metal), perform ocular CT on all patients
• Normal ocular pressure (do not perform if high suspicion of globe rupture) supports simple (non full-thickness) corneal laceration diagnosis

Diagnosis

• Typically determined on clinical exam +/- ocular CT (if high risk)

Management

See globe rupture for full thickness lacerations.

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

(Assuming no globe rupture)

• Ophtho follow up in 48h for routine cases

See Also

• Corneal abrasion
• Ocular foreign body
• Open globe
• Eye Algorithms (Main)