Corneal Abrasion, Emergency Medicine

Basics

Description

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

Etiology

Traumatic:
- Human fingernail
- Branches
- Hairbrushes/combs
- Sand/stones
- Snow
- Pens/pencils
- Toys
- Chemical burn
- Airbag deployment
- Pepper spray
- Paper/cardboard
- Make-up applicator
- Animal paws
Foreign body related:
- Wood
- Glass
- Metal
- Rust
- Plastic
- Fiberglass
- Vegetable matter
- Eyelid foreign body
Contact lens related:
- Over-worn
- Improperly 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:
- Excessive crying
Younger than 12 mo:
- Frequently no history of eye trauma
- Might present as the crying inconsolable infant
- In 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 trauma
- Positive 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 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

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 cornea
- Perforation of cornea
- Hyphema
- Iris prolapse
- Lens 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 effects
- Avoid in patients with other ocular surface disease and in postoperative patient
- Topical 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 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
Contact lens
- No contact lens wear till abrasion healed and eye feels normal for a wk without medication
- Might consider bandage contact lens in severe pain. Be certain no infection and will need daily follow-up
Tetanus prophylaxis:
- Routine tetanus not necessary
- Update 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

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

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