para>Patients with contact lenses may have colonization of the cornea with Pseudomonas and other gram-negative bacteria and should be treated with ophthalmic quinolones or aminoglycosides to prevent corneal ulceration and infection (1)[A]. á
- Viral infections, especially herpes
- Fungal infections (Candida, Aspergillus, Fusarium, Acanthamoeba) in agricultural workers or associated with ocular corticosteroid use
- Autoimmune disorders, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and scleroderma, are the usual cause of peripheral ulcerative keratitis.
- Vitamin A deficiency may cause corneal necrosis or keratomalacia.
RISK FACTORS
- Any abrasive injury
- Foreign body in eye
- Contact lenses (especially soft lenses and extended-wear lenses)
- Blepharitis
- Dry eye syndrome
- Entropion (with lashes scratching cornea)
- Chronic topical steroid use
- Abuse of topical anesthetics
- Autoimmune disorders
- Vitamin A deficiency
- Chronic corneal exposure (e.g., Bell palsy, exophthalmos)
- Recent eye surgery: Trendelenburg position is newly identified as a risk factor for corneal abrasion (2).
- Immunosuppression and trigeminal nerve abnormalities
- Flash burn (welding burn or prolonged gazing directly at bright sunlight; symptoms often begin several hours after exposure)
GENERAL PREVENTION
- Eye protection to avoid injury during work, crafts, and sports
- Proper contact lens handling
- Do not sleep while wearing contact lens.
- Artificial tears for those with inability to blink or known dry eyes
- Lenses to block UV rays (e.g., welding helmets)
COMMONLY ASSOCIATED CONDITIONS
- Chronic ulcerations may be associated with neurotrophic keratitis due to lack of 5th nerve innervation of the cornea. Individuals with thyroid disease, diabetes, or immunosuppressive conditions are particularly at risk.
- Any cause of fat malabsorption may be associated with vitamin A deficiency.
DIAGNOSIS
HISTORY
- Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection
- Abrasions and ulcerations are usually unilateral.
- History remarkable for contact lens use, dry eyes, rubbing eye, history of trauma from foreign body, or chemical burn
- History of connective tissue disorder
PHYSICAL EXAM
- Visual acuity may be decreased if abrasion or ulcer is centrally located.
- Conjunctival injection
- Increased lacrimation on affected side
- Photophobia
- Blepharospasm
- Lesion seen on slit-lamp exam and area of damage shows fluorescein uptake; staining seen using Wood lamp or cobalt blue slit lamp:
- "Dendritic"Ł staining pattern with fluorescein indicative of viral keratitis
- Examine for foreign body under eyelids or in cornea ("rust ring"Ł)
DIFFERENTIAL DIAGNOSIS
- Foreign body in eye
- Unilateral iritis
- Acute or chronic glaucoma
- Keratitis
- Scleritis with corneal melting
- Herpes simplex or zoster
- Bilateral or true idiopathic lesions may suggest basement membrane dystrophy.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Culture ulcer and contact lens, if applicable.
- Pretreatment with topical antibiotics may alter culture results.
Diagnostic Procedures/Other
Scrapings of the corneal ulcer for culture and sensitivity ideally should be obtained before beginning local antibiotics. The sample should be plated directly onto the culture medium. á
Test Interpretation
Scrapings for Gram and Giemsa stain may demonstrate bacteria, yeast, or intranuclear inclusions that may aid in the diagnosis. á
TREATMENT
GENERAL MEASURES
- Simple corneal abrasions can be managed by primary care physicians, But consider referral for lesions larger than 4 mm. See indications for referral in the following text.
- All patients with corneal ulceration should be referred immediately to an ophthalmologist. Corneal cultures should be obtained before starting antibiotics. If immediate referral is not possible, it is reasonable to start antibiotics without delay.
- Flash burns from welding or prolonged exposure to sunlight may be treated like corneal abrasions (3)[C].
- Topical ophthalmic steroids should be avoided: may delay healing of corneal abrasions (4)[C]. Use of topical anesthetics outside of clinical settings should be avoided: may develop corneal toxicity with prolonged use (5)[A]
MEDICATION
First Line
- Eye patching does not reduce pain or speed the healing process (6)[A].
- Topical NSAIDs have been proven to reduce eye pain (6)[A].
- Ophthalmic NSAIDs: Diclofenac 0.1% QID helps relieve moderate pain:
- Alternatives include ketorolac 0.5% and bromfenac 0.09%
- Caution: Ophthalmic NSAIDs may rarely cause corneal melting and perforation.
- Ophthalmic antibiotics may help prevent further infection and ulceration of corneal abrasions (3)[C].
- Some ophthalmic antibiotics include ciprofloxacin 0.3%, ofloxacin 0.3%, gentamicin 0.3%, erythromycin 0.5%, polymyxin B/trimethoprim (Polytrim), and tobramycin 0.3%:
- Ointment preparations may be more soothing to the eye than solutions.
- Topical antibiotics should be continued until eye pain is resolved.
- Chloramphenicol should be avoided due to high risk of toxicity and Stevens-Johnson syndrome.
- Large corneal abrasions (>4 mm) or very painful abrasions should be treated with a combination of topical antibiotic and topical NSAID.
- Reevaluate in 24 hours. If improving, no need for further follow-up (3)[C].
- Fungal keratitis is treated with a protracted course of topical antifungal agents (by ophthalmologist).
- A combination of cryotherapy and antifungal agents for treatment of fungal corneal ulcer could help facilitate the practice of fungal keratitis treatment in the future (7).
- Herpetic keratitis should be referred promptly to ophthalmologist and treated initially with trifluridine:
- Vidarabine and acyclovir are alternatives.
Second Line
- Oral analgesic medication (hydrocodone and other opioids) if topical analgesia not adequate
- Supplemental topical cycloplegics (i.e., homatropine 5% and cyclopentolate 1%) have not been found to be beneficial in relieving pain in corneal abrasion (8)[B].
- Topical 0.3% HA provided a promising treatment for superficial corneal abrasion caused by mechanical damage (9).
- Sodium hyaluronate reduces reepithelialization time when used after mechanical abrasions of the cornea (10).
- In the management of traumatic corneal abrasions, the administration of an eye gel containing sodium hyaluronate and xanthan gum is able to reduce the length of occlusive patching (11).
ISSUES FOR REFERRAL
- Consultation with an ophthalmologist is recommended for all ulcers to help determine appropriate therapy. Moreover, ulcers need corneal cultures to be taken directly onto culture media.
- Also refer to ophthalmologist if there is history of the following:
- Significant ocular trauma
- Corneal infection is suspected (including viral keratitis).
- Recurrent or nonhealing abrasion is encountered despite standard treatment.
- Severe ocular pain not explained by apparent pathology (e.g., traumatic iritis)
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Contact lens wearer should be monitored daily with slit lamp for signs of secondary infection.
- Minor abrasion should be reevaluated only if it becomes more painful (3)[C].
- Large abrasion (>4 mm) should be reevaluated in 24 hours, and if improving, no need to follow further unless symptoms worsen again (3)[C].
PATIENT EDUCATION
- Prevention of abrasions and proper handling of contact lenses can prevent recurrence of corneal ulcers.
PROGNOSIS
- Corneal abrasions and ulcerations should improve daily and heal with appropriate therapy.
- If healing does not occur within 24 to 48 hours or the lesion extends, obtain an ophthalmology consultation.
COMPLICATIONS
- Recurrence
- Scarring of the cornea
- Loss of vision
- Corneal perforation
REFERENCES
11 Dargin áJM, Lowenstein áRA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199-216, viii.22 Segal áKL, Fleischut áPM, Kim áC, et al . Evaluation and treatment of perioperative corneal abrasions. J Ophthalmol. 2014;2014:901901.33 Fraser áS. Corneal abrasion. Clin Ophthalmol. 2010;4:387-390.44 Tomas-Barberan áS, Fagerholm áP. Influence of topical treatment on epithelial wound healing and pain in the early postoperative period following photorefractive keratectomy. Acta Ophthalmol Scand. 1999;77(2):135-138.55 Duffin áRM, Olson áRJ. Tetracaine toxicity. Ann Ophthalmol. 1984;16(9):836, 838.66 Turner áA, Rabiu áM. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;(2):CD004764.77 Chen áY, Yang áW, Gao áM, et al. Experimental study on cryotherapy for fungal corneal ulcer. BMC Ophthalmol. 2015;15:29.88 Carley áF, Carley áS. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Mydriatics in corneal abrasion. Emerg Med J. 2001;18(4):273.99 Lin áT, Gong áL. Sodium hyaluronate eye drops treatment for superficial corneal abrasion caused by mechanical damage: a randomized clinical trial in the People's Republic of China. Drug Des Devel Ther. 2015;9:687-694.1010 Moreira áLB, Scalco áR, Hara áS. Corneal reepithelialization time with instillation of eye drops containing sodium hyaluronate and carboxymethylcellulose [in Portuguese]. Arq Bras Oftalmol. 2013;76(5):292-295.1111 Faraldi áF, Papa áV, Santoro áD, et al. A new eye gel containing sodium hyaluronate and xanthan gum for the management of post-traumatic corneal abrasions. Clin Ophthalmol. 2012;6:727-731.
ADDITIONAL READING
- Ehlers áJP, Shah áCP, Fenton áGL. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Baltimore, MA: Lippincott Williams & Wilkins; 2008.
- Watson áSL, Barker áNH. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2007;(4):CD001861, revised in Cochrane Database Syst Rev. 2012;(9):CD001861.
- Wilhelmus áKR. Therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev. 2008;(1):CD002898.
- Wipperman áJL, Dorsch áJN. Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114-120.
CODES
ICD10
- S05.00XA Inj conjunctiva and corneal abrasion w/o fb, unsp eye, init
- H16.009 Unspecified corneal ulcer, unspecified eye
- H16.049 Marginal corneal ulcer, unspecified eye
- H16.019 Central corneal ulcer, unspecified eye
- H16.012 Central corneal ulcer, left eye
- H16.003 Unspecified corneal ulcer, bilateral
- H16.013 Central corneal ulcer, bilateral
- S05.01XA Inj conjunctiva and corneal abrasion w/o fb, right eye, init
- H16.011 Central corneal ulcer, right eye
- H16.043 Marginal corneal ulcer, bilateral
- H16.001 Unspecified corneal ulcer, right eye
- H16.041 Marginal corneal ulcer, right eye
- H16.002 Unspecified corneal ulcer, left eye
- S05.02XA Inj conjunctiva and corneal abrasion w/o fb, left eye, init
- H16.042 Marginal corneal ulcer, left eye
ICD9
- 918.1 Superficial injury of cornea
- 370.00 Corneal ulcer, unspecified
- 370.01 Marginal corneal ulcer
- 370.03 Central corneal ulcer
SNOMED
- 85848002 Corneal abrasion (disorder)
- 91514001 Corneal ulcer (disorder)
- 47398006 Marginal corneal ulcer (disorder)
- 7426009 Central corneal ulcer
CLINICAL PEARLS
- Contact lens use should be discontinued until corneal abrasion or ulcer is healed and pain is fully resolved.
- Eye patching is not recommended.
- Prescribe topical and/or oral analgesic medication for symptom relief and consider ophthalmic antibiotics.
- Prompt referral to an ophthalmologist should be made with suspicion of an ulcer, recurrence of abrasion, retained foreign body, viral keratitis, significant visual loss, or lack of improvement despite therapy.