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Corneal Abrasion, Emergency Medicine

Basics

Description

- Contact lens related: - Over-worn - Improperly fitting or cleaned

- 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 anterior chamber reaction, infiltrate, corneal laceration, and penetrating trauma - Fluorescein dye to identify size and location of corneal epithelium defect

- 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 - Iris prolapse - Lens disruption

- Topical pain control: - 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

- Topical antibiotic: - This practice has not been rigorously studied. - Concern is for superinfection - Ointment better than drops because also a lubricant - Discontinue antibiotics once symptom free for 24 hr - Contact lens wearers must have anti-Pseudomonal coverage: - Ciprofloxacin - Erythromycin - Gentamicin - Sulfacetamide - Tobramycin/Tobradex - Polytrim

- Eye patch: - Does not appear to improve healing or reduce pain particularly in the 1st 24 hr - Not recommended for small abrasions - Never patch the patient who wears contact lens - Never patch infection-prone injury (organic matter is at high risk) - More research needed to evaluate efficacy of patching in abrasions >10 mm

- Tetanus prophylaxis: - Routine tetanus not necessary - Update tetanus if abrasion caused by or contaminated with organic matter or dirt

  • Any tear or defect in the corneal epithelium
  • May be traumatic, spontaneous, due to foreign body, or contact lens related

Etiology

  • Traumatic:Human fingernailBranchesHairbrushes/combsSand/stonesSnowPens/pencilsToysChemical burnAirbag deploymentPepper sprayPaper/cardboardMake-up applicatorAnimal paws
  • Foreign body related:WoodGlassMetalRustPlasticFiberglassVegetable matterEyelid foreign body
  • Contact lens related:Over-wornImproperly fitting or cleaned
  • Spontaneous:Usually previous traumatic corneal abrasion or an underlying defect in the corneal epithelium

Diagnosis

Signs and Symptoms

  • Severe ocular pain
  • Gritty (scratchy) discomfort
  • Tearing
  • Blepharospasm
  • Foreign body sensation
  • Photophobia (particularly if secondary traumatic iritis present)
  • Conjunctival injection
  • Diminished or blurred vision
  • Headache

History

  • Any direct trauma to the globe
  • Any known or potential foreign body
  • Contact lens use
  • Any history of previous corneal abrasion
  • Ocular/periocular surgery
  • Pre-existing visual impairment
  • Time of onset
  • Associated symptoms or concomitant injury
  • Treatment before visit
  • Use of safety glasses (pounding, drilling, grinding metal) or eyeglasses
  • Systemic disease (diabetes, autoimmune disorders)
  • Tetanus status
  • Signs and symptoms may differ:
  • Younger than 12 mo:Frequently no history of eye traumaMight present as the crying inconsolable infantIn 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 traumaPositive 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 infectionGross visual inspectionVisual acuityPenlight exam to evaluate for conjunctival injection, the pupil shape/reactivity, and for any evidence of corneal infiltrate or opacityEvert upper lids to check for retained foreign bodySlit-lamp exam to evaluate for anterior chamber reaction, infiltrate, corneal laceration, and penetrating traumaFluorescein dye to identify size and location of corneal epithelium defect

Diagnosis Tests & Interpretation

Handheld 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 corneaPerforation of corneaHyphemaIris prolapseLens disruption

Treatment

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 narcotics or NSAID or acetaminophen
  • Topical pain control:Studies have demonstrated efficacy; however, there are scattered reports of adverse effectsAvoid in patients with other ocular surface disease and in postoperative patientTopical diclofenac or ketorolac
  • Cycloplegic (optional):Cyclopentolate (mydriasis 1-2 days)Tropicamide (mydriasis 6 hr)Homatropine 5%
  • Topical antibiotic:This practice has not been rigorously studied.Concern is for superinfectionOintment better than drops because also a lubricantDiscontinue antibiotics once symptom free for 24 hrContact lens wearers must have anti-Pseudomonal coverage:CiprofloxacinErythromycinGentamicinSulfacetamideTobramycin/TobradexPolytrim
  • Eye patch:Does not appear to improve healing or reduce pain particularly in the 1st 24 hrNot recommended for small abrasionsNever patch the patient who wears contact lensNever patch infection-prone injury (organic matter is at high risk)More research needed to evaluate efficacy of patching in abrasions >10 mm
  • Contact lensNo contact lens wear till abrasion healed and eye feels normal for a wk without medicationMight consider bandage contact lens in severe pain. Be certain no infection and will need daily follow-up
  • Tetanus prophylaxis:Routine tetanus not necessaryUpdate 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) and any patient with a corneal infiltrate, white spot, or opacity

Medication

  • Ciprofloxacin: 0.35% 1 drop QID
  • Cyclopentolate: 0.5%, 1%, or 2% drops (mydriasis 1 or 2 drops TID)
  • Diclofenac: 0.1% drops 1 drop QID
  • Erythromycin: 0.5% ointment QID
  • Gentamicin: 0.3% ointment QID
  • Gentamicin: 0.3% 2 drops q6h
  • Homatropine: 5% solution 2 drops BID
  • Ketorolac: 0.5% drops 1 drop QID
  • Proparacaine: 0.5% 1 drop once
  • Sulfacetamide: 10% drops 2 drops QID
  • Sulfacetamide: 10% ointment QID
  • Tobradex: Suspension 0.1%/0.3% 2 drops q4-6h
  • Tobramycin: 0.3% drops 2 drops q6h
  • Tobramycin: 0.3% ointment q6h
  • Tropicamide: 0.5%, 1% drops (mydriasis 6 hr) 1 drop q4h

Follow-Up

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.

Follow-Up Recommendations

  • Follow-up with ophthalmologist for re-exam and ongoing care in 24 hr if in contact lens wearer, the eye has been patched or bandage contact lens applied
  • Follow-up with ophthalmologist if central or large abrasion in 24 hr; otherwise follow-up can be in 48-72 hr

Pearls and Pitfalls

  • Always diligently evaluate for penetrating trauma to the globe.
  • Always diligently evaluate for evidence of infection.
  • Do not discharge the patient with any topical anesthetic. It is felt to be toxic to the epithelium and retards healing, although a recent small study indicated it might be safe to discharge with dilute proparacaine.
  • Do not use a mydriatic agent on a patient with a history of glaucoma.
  • Do not recommend return to contact use until followed up and cleared by ophthalmology.

Additional Reading

  • Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: Meta-analysis of randomized trials. Acad Emerg Med. 2005;12:467-473.
  • Ehlers JP, Shah CP, eds. The Wills Eye Manual. 5th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2008.
  • Jacobs DS. (2012). Corneal abrasions and corneal foreign bodies. Retrieved from www.uptodate.com
  • Koenig KL. (2010). Dilute proparacaine for pain from corneal abrasion. Retrieved from Journal Watch Specialties (online).
  • Turner A, Rabiu M. (2009). Patching for corneal abrasion. Retrieved from Cochrane Database Syst Rev.
  • Van Niel CW. (2010). Corneal abrasions in crying infants: A red herring. Retrieved from Journal Watch Specialties (online).
  • Verma A. (2011). Corneal abrasion. Retrieved from www.emedicine.com

See Also (Topic, Algorithm, Electronic Media Element)

  • Conjunctivitis
  • Corneal Burn
  • Corneal Foreign Body
  • Red Eye
  • Ultraviolet Keratitis

Codes

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