Corneal Abrasion


Article Author:
Emilissa Domingo


Article Editor:
Christopher Zabbo


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
2/19/2019 12:52:54 PM

Introduction

A corneal abrasion (scratched cornea or scratched eye) is one of the most common eye injuries. A scratched cornea often causes significant discomfort, eye erythema, and photophobia. Corneal abrasions result from a disruption or loss of cells in the top layer of the cornea, called the corneal epithelium. Corneal abrasions can be classified as traumatic, including foreign body related and contact lens-related, or spontaneous.[1]

Etiology

Traumatic causes, such as tree branches, makeup brushes, workplace debris, sports equipment all can cause corneal abrasions. Traumatic events do not cause many corneal abrasions. Sand and other small particles can cause a corneal abrasion, especially if you rub your eyes. Damaged contact lenses or prolonged use of contacts lenses may increase your risk of a scratched cornea.[1]

Epidemiology

Corneal abrasions are common eye injuries across all age groups. They are particularly common in the workplace, with an annual incidence of 15 per 1000 employees in US autoworkers. In primary care clinics, eye complaints are responsible for 2% of visits.

History and Physical

Difficulty opening the eye, photophobia, foreign body sensation associated with eye pain can be due to a corneal injury. Many times, an eye injury is not reported. It is important to ask if the patient works with wood or metal because small pieces can get caught under the eyelid and cause injury to the cornea. On exam, corneal abrasions can be associated with redness, light sensitivity, excessive lacrimation, decreased visual acuity. Fluorescein staining is the most helpful clinical tool to assess for corneal abrasion. Dye will get caught in the corneal abrasion and fluoresce under cobalt blue light.

Evaluation

Start the eye exam with a penlight. An abnormally shaped pupil could be a sign of globe rupture. Topical anesthetics are helpful to facilitate the examination. Conjunctival injection is typically present. A corneal opacity or infiltrate may occur with corneal ulcers or infection. A hazy cornea is a sign of edema from excessive rubbing. Inspect the anterior chamber for hyphema or hypopyon. The presence of hyphema or hypopyon requires an immediate ophthalmologic referral. Abrasions over the center of the cornea will cause a decrease in visual acuity. Significant decreases in visual acuity require referral to an ophthalmologist. Document extraocular movements.

Fluorescein staining helps identify a corneal epithelial defect. Apply a drop of a topical anesthetic into the eye or on a fluorescein strip and then apply it to the conjunctiva. The fluorescein dye passes over normal cornea tissue but gets stuck in any cornea defects. The dye appears green under cobalt blue light. Traumatic corneal abrasions typically have linear or geographic shapes. If a patient wears contact lenses, the abrasion may have several punctate lesions that coalesce into a round, central defect. Herpes keratitis has dendritic dye uptake and requires immediate treatment. Foreign bodies on the inner eyelid typically cause vertical linear cornea lesions; therefore, everting the eyelids is necessary to assess for foreign bodies.

Treatment / Management

The administration of topical antibiotics and, for large abrasions, cycloplegics have been the mainstay of therapy, along with daily follow-up until the eye is healed. Patching was previously routine but is no longer recommended for most patients.[2] Tetanus prophylaxis is only necessary for penetrating eye injuries not simple corneal abrasions.[3]

If a corneal foreign body is detected, an attempt can then be made to remove the foreign body with a swab or irrigation under direct visualization. Foreign bodies under the lid should be removed after flipping the lid. If irrigation or a cotton swab fail to remove the foreign body, a metal instrument is needed. Instill topical anesthetic. A 25-gauge needle or an eye spud can be used to remove the object. If the metal instrument fails, then ophthalmology referral within 24 hours is needed for foreign body removal. Initiate topical antibiotics (erythromycin).

There are several antibiotic options. Ointment formulations provide lubrication to the injured eye. Contact lens wearers will need coverage for Pseudomonas with a fluoroquinolone or aminoglycoside.[4] Erythromycin ointment is to be used 4 times daily for 5 days for the non-contact lens wearing patients. Drops are available for sulfacetamide 10%, polymyxin/trimethoprim, ciprofloxacin, or ofloxacin. Aminoglycoside antibiotics should be avoided in non-contact lens wearing patients. Duration of therapy is variable, but a patient can discontinue therapy entirely if the eye is symptom-free for 24 hours. Continued symptoms beyond three days warrant evaluation by an ophthalmologist. Never use topical corticosteroids due to delayed healing and increased risk of infection.[5][6]

Regarding pain control, small abrasions (less than 4 mm) rarely require analgesia.  Mild to moderate pain can typically be controlled with oral nonsteroidal anti-inflammatory drugs (NSAIDs). Ophthalmic topical NSAID solutions provide pain relief. 

In the few patients with small abrasions that fail to heal despite these treatments, oral opioid medications may be required. A 1- to 2-day oxycodone prescription should be adequate. 

Cycloplegic medications can relieve photophobia. Like the opiate medications, 2 days of cycloplegic drops should be enough to manage the photophobia. There are side effects to cycloplegics, such as difficulty with reading. If a cycloplegic agent is going to be utilized, cyclopentolate is a good choice because of its short duration of action.[7]

Differential Diagnosis

  • Conjunctivitis
  • Dry eye syndrome
  • Acute angle closure glaucoma
  • Uveitis
  • Infective keratitis (bacterial, fungal, herpetic)
  • Corneal ulcer
  • Recurrent erosion syndrome

Prognosis

Small cornea abrasions usually heal without difficulty. Larger abrasions, visual disturbance, and abrasions caused by a contact lens will require close outpatient monitoring by an ophthalmologist.

Complications

Corneal abrasion complications include corneal ulcers, bacterial keratitis, recurrent erosion syndrome, and traumatic iritis.

Consultations

  • Open globe injuries require immediate ophthalmology involvement
  • Hyphema, hypopyon, a decrease in visual acuity (more than two lines from the good eye on Snellen chart) require urgent ophthalmologic follow-up
  • Subacute follow-up with ophthalmology for corneal abrasions not healed after 4 days

Deterrence and Patient Education

Use safety glasses when using power tools.

Pearls and Other Issues

Most corneal abrasions heal regardless of therapy in 1 to 3 days. Vision should return to normal in that time although ointment antibiotic formulations may cause and an iatrogenic decrease in vision.

Contact lens wearers who present with a corneal epithelial defect should be examined with the penlight to look for a corneal infiltrate, which is a white spot or opacity, or an ulcer, representing a surface breakdown, thinning, or necrosis that occurs in an area of infiltration. An ophthalmologist should see any patient with such a finding the same day.  An ointment (such as erythromycin ophthalmic ointment) is theoretically better than drops because it functions as a lubricant and may reduce disruption of the remaining and newly generated epithelium. Ointments are preferred to drops in children because they do not sting during application.

Due to the risk of sight-threatening bacterial keratitis, patients with corneal abrasions and history of recent contact lens wear but without a corneal infiltrate receive timely topical antibiotics that are effective against Pseudomonas species (such as the fluoroquinolone class). These patients warrant timely referral to an ophthalmologist or optometrist for daily follow-up care. Patients with uncomplicated, small, traumatic or foreign body corneal abrasions should not undergo patching.

As far as pain control for small corneal abrasions (less than or equal to one-fourth of the corneal surface area, for example, circular abrasion 4 mm in diameter, the use oral analgesias such as ibuprofen or acetaminophen-oxycodone combination medication with or without topical nonsteroidal anti-inflammatory ophthalmic drops (such as ketorolac) is typically sufficient. Large abrasions can require oral opioid analgesia, for example, acetaminophen-oxycodone combination medication, cycloplegic drops, and, in selected patients such as those with abrasions covering greater than 50% corneal surface, eye patching.

Because of the possibility of overuse (greater than 24 hours) and the risk of inappropriate administration to patients with conditions other than simple corneal abrasions, use topical anesthetics or other means of pain control. Most small corneal abrasions heal within 24 to 48 hours. Follow-up may not be necessary for older children, adolescents, and adults as long as symptoms resolve and anticipatory guidance is provided.

After initial treatment, urgent referral to an ophthalmologist is indicated for patients with the following: larger epithelial defects at 24 hours, purulent discharge, or decrease in vision of more than 1 to 2 lines (20/20 to 20/60), corneal abrasions that have not healed after 3 to 4 days, or children who are unwilling to open the affected eye after 24 hours.

Enhancing Healthcare Team Outcomes

Corneal abrasions are a common injury typically seen in urgent care centers and emergency departments. Most of the time, they will heal on their own with the assistance of topical antibiotics to prevent infection. It is important to identify signs of more serious injury that would necessitate urgent ophthalmologic follow-up. The most dangerous injury would be an open globe. It is also important to get follow-up within 24 hours for large abrasion or a decrease in visual acuity. Regions of the country that do not have ophthalmology coverage available to them will need to establish follow-up or have a low threshold for transferring to a tertiary care center. Daily follow-up by an ophthalmic nurse or an ophthalmologist is required for large abrasions, abrasions from the contact lens, abrasions associated with decreased vision, and abrasions in young children The majority of small corneal abrasions heal within a few days and full recovery is the norm. Large corneal lesions may take some time to heal but visual recovery is not always guaranteed.[8][9] (Level V)


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Corneal Abrasion - Questions

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Which of the following statements is true regarding corneal injuries?



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A diagnosis of corneal abrasions can best be accomplished in the office with which of the following?



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What is not a recommended evaluation and treatment for a corneal abrasion?



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A corneal abrasion is most clearly visualized with which of the following?



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Which of the following statements about a corneal injury is incorrect?



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A fluorescein test identifies a fresh corneal abrasion. What is the most proper management of this condition?



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People wearing contact lenses for a long time are at risk of which of the following?



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What is the best way to diagnose corneal abrasion?



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Which of the following results from a scrape of the outer surface of the eye?



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A 17-year-old complains of severe pain in her right eye for the past 2 days. She feels like that is a foreign body in the eye. Her vision is blurred and she has become sensitive to light. She has been wearing contact lenses for over 5 years. Physical exam reveals ciliary injection, pupillary constriction, and an erythematous eye. Slit lamp exam with fluorescein reveals corneal abrasion. Which of the following treatment is not recommended for this patient?



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Which of the following is true in a patient with a corneal injury?



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Corneal Abrasion - References

References

Wipperman JL,Dorsch JN, Evaluation and management of corneal abrasions. American family physician. 2013 Jan 15     [PubMed]
Benson WH,Snyder IS,Granus V,Odom JV,Macsai MS, Tetanus prophylaxis following ocular injuries. The Journal of emergency medicine. 1993 Nov-Dec     [PubMed]
Calder LA,Balasubramanian S,Fergusson D, Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2005 May     [PubMed]
Wakai A,Lawrenson JG,Lawrenson AL,Wang Y,Brown MD,Quirke M,Ghandour O,McCormick R,Walsh CD,Amayem A,Lang E,Harrison N, Topical non-steroidal anti-inflammatory drugs for analgesia in traumatic corneal abrasions. The Cochrane database of systematic reviews. 2017 May 18     [PubMed]
Kaiser PK, A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology. 1995 Dec     [PubMed]
Clemons CS,Cohen EJ,Arentsen JJ,Donnenfeld ED,Laibson PR, Pseudomonas ulcers following patching of corneal abrasions associated with contact lens wear. The CLAO journal : official publication of the Contact Lens Association of Ophthalmologists, Inc. 1987 May-Jun     [PubMed]
Ball IM,Seabrook J,Desai N,Allen L,Anderson S, Dilute proparacaine for the management of acute corneal injuries in the emergency department. CJEM. 2010 Sep     [PubMed]
Jolly R,Arjunan M,Theodorou M,Dahlmann-Noor AH, Eye injuries in children - incidence and outcomes: An observational study at a dedicated children's eye casualty. European journal of ophthalmology. 2018 Oct 1;     [PubMed]
Tsai CC,Kau HC,Kao SC,Liu JH, A review of ocular emergencies in a Taiwanese medical center. Zhonghua yi xue za zhi = Chinese medical journal; Free China ed. 1998 Jul;     [PubMed]

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