Corneal Abrasion

Aka: Corneal Abrasion

1. Epidemiology
   1. Account for 8% of primary care eye presentations
2. Etiology
   1. Eye Trauma (foreign body)
   2. Extensive UV Light Exposure (Sunlamp, welder's arc)
   3. Contact Lens wear
   4. Chemical burn
3. Symptoms
   1. Eye Pain (exacerbated by eye movement)
   2. Photophobia
   3. Foreign body sensation (or gritty sensation)
   4. Excessive eye tearing
   5. Blurred Vision
   6. Headache
   7. Blepharospasm
4. Signs
   1. Penlight exam
      1. Oblique illumination of the Cornea
         1. Irregularity in normally smooth, glistening surface
      2. Direct illumination of the Cornea
         1. Shadow on surface of iris
         2. Shadow moves opposite direction of light source
      3. Observe for foreign body
         1. Rust rings and foreign bodies must be removed
   2. Fluorescein exam (with cobalt blue light)
   3. Slit Lamp exam
      1. Vertical linear superficial excoriations (appears as etching the Corneal surface)
         1. Suspect Retained Foreign Body under lid and re-inspect carefully
5. Differential Diagnosis
   1. Corneal Ulcer
   2. Retained Corneal Foreign Body
   3. Conjunctivitis
   4. Acute Angle-Closure Glaucoma
   5. Dry Eye Syndrome (sicca syndrome)
   6. Recurrent erosion syndrome
   7. Uveitis
   8. Keratitis
      1. Herpes Simplex Keratitis
      2. Fungal or Bacterial Keratitis
6. Management
   1. Rule-out Retained Foreign Body in Cornea or upper lid
      1. Evert the upper lid and carefully examine for foreign body
      2. If not able to visualize, consider Running swab over the lid surface to pick-up translucent debris
   2. Do not wear Contact Lens until lesion fully healed
   3. Topical Antibiotics
      1. General
         1. Ointments are more lubricating than drops
            1. Some have suggested that ointments delay healing
         2. Continue antibiotic for 3-5 days
            1. May discontinue when asymptomatic for at least 24 hours
         3. Use anti-pseudomonal agent for complicated cases
            1. Contact Lens related Corneal Trauma
            2. Scratch from organic matter such as a branch
      2. Standard agents
         1. Bacitracin 500 units/gram ointment 1/2 inch two to four times per day
         2. Erythromycin 0.5% ointment 1/2 inch ribbon two to four times per day
         3. Polymixin B - Trimethoprim (Polytrim) 1 drop four times per day
      3. Extended spectrum agents (Anti-Pseudomonal agents, see indications above)
         1. Ciprofloxacin (Ciloxan) 0.3% solution 2 drops every 4 hours
         2. Ciprofloxacin (Ciloxan) 0.3% ointment apply 1/2 inch ribbon four times daily
         3. Ofloxacin (Ocuflox) 0.3% solution 2 drops every 4 hours
         4. Avoid topical Aminoglycosides (gentamycin, tobramycin) in Corneal Abrasion due to toxicity risk
      4. Other agents
         1. Chloramphenicol 1% ointment 2 drops q3 hours
            1. Reduces risk of Corneal Ulcer
            2. Upadhyay (2001) Br J Ophthalmol 85:388-92 [PubMed]
   4. Brief patch protocol
      1. Contraindicated in infection or higher risk of infection (e.g. Contact Lens wearing patient)
      2. Apply Erythromycin 0.5% ointment 1/2 inch ribbon at time of exam
      3. Patch eye and patient removes patch in 4 hours
      4. Start prescribed antibiotic drops for 48-72 hours
   5. Analgesics
      1. Topical NSAIDS (preservatives may delay healing time, do not use longer than 2 weeks)
         1. Preparations
            1. Diclofenac Ophthalmic (Voltaren Ophthalmic) 0.1% solution in eye four times daily as needed
            2. Ketorolac Ophthalmic (Acular LS) 0.4% solution in eye four times daily
         2. Efficacy
            1. Several articles have supported use
            2. Scucs (2000) Ann Emerg Med 35(2):131-7 [PubMed]
            3. Smith (2012) Can Fam Physician 58(7): 748-9 [PubMed]
         3. However 2017 Cochrane review noted insufficient evidence to recommend
            1. Wakai (2017) Cochrane Database Syst Rev 5:CD009781 +PMID: 28516471 [PubMed]
      2. Oral Analgesics
         1. NSAIDs
         2. Vicodin
      3. Cycloplegics (Mydriatics)
         1. Not recommended in uncomplicated Corneal Abrasion
         2. Dilating drops used to decrease ciliary spasm
         3. One drop of Mydriatic placed in clinic or emergency department lasts 24 to 36 hours
         4. Examples (patch with use)
            1. Cyclogyl 1% one drop OR
            2. Homatropine 5% one drop
   6. Options to avoid in general
      1. Mantra has been to avoid home prescription of Topical Anesthetic (but evidence of safety is growing)
         1. Rationale of avoid Topical Anesthetics
            1. Delays re-epithelialization
            2. Suppresses normal Blink Reflex
         2. Initial studies have shown safety and efficacy of outpatient dilute proparacaine 1% in Corneal Abrasion
            1. However, this is considered only investigational and not recommended by eye specialists
            2. Ball (2010) CJEM 12(5): 389-96 +PMID:20880433 [PubMed]
         3. Additional studies support the safe, short term use of Topical Antibiotics in uncomplicated Corneal Abrasion
            1. Tetracaine 1% solution has been used safely for up to 24 hours in simple Corneal Abrasion
            2. Simple, small, non-pentrating, non-lacerating Traumatic Eye Injury onset within prior 2 days
            3. Not due to chemical or Contact Lens and no infection, contamination or Retained Foreign Body
            4. Waldman (2017) Ann Emerg Med +PMID: 28483289 [PubMed]
      2. Pressure Patch no longer recommended (except for brief use with protocol above)
         1. Adverse effects
            1. Delays healing process
            2. Exacerbates Eye Pain
            3. Interferes with routine activities
            4. Severe anaerobic infections in contact wearers
            5. Le Sage (2001) Ann Emerg Med 28:129-34 [PubMed]
         2. Technique (listed for historical purposes)
            1. Apply 3-5, 1 inch tape strips
            2. Superior end over medial forehead
            3. Inferior end over lateral cheek
7. Complications
   1. Recurrent Corneal Erosion (10%)
      1. Spontaneous sudden Eye Pain weeks after healing
      2. Refer to ophthalmology
      3. Lubricant drops during day and ointment at night
   2. Secondary infection
   3. Corneal Ulcer
8. Course
   1. Small uncomplicated abrasion heals in 3-4 days
   2. Large abrasions (involve 50% of Cornea) heal in 5 days
   3. Recurrent symptoms may persist for 3 months
9. Follow-up
   1. Second visit at 24 hours, examine for
      1. Healing
      2. Signs infection
      3. Corneal Ulcer
      4. Missed foreign body
   2. Third visit at 3-4 days in Contact Lens wearers
      1. Observe for Corneal Ulcer or infection
   3. Referral to Ophthalmology for:
      1. Chemical burn
      2. Large (>4mm long) or deep abrasions
      3. Suspected Herpes Keratitis
      4. Penetrating injury
      5. Abrasion edge is gray or white suggesting infection
      6. Suspected recurrent Corneal Erosion
      7. Corneal Ulcer or infection (haze at abrasion)
      8. Hyphema
      9. Hypopyon
      10. Continued pain after 48 hours
      11. Inadequate healing by 72 hours
      12. Retained Foreign Body or rust ring
      13. Vision Loss more than 20/40
10. Prevention
    1. See Eye Protection
    2. Careful fitting, placement and care of Contact Lenses
    3. Keep Fingernails short
    4. Perioperative Corneal Abrasion risk (lag-ophthalmos)
       1. Tape Eyelids closed during surgery or
       2. Instill aqueous gels or soft contacts
    5. Ventilated and sedated patients in ICU
       1. Remove all Contact Lenses
       2. Use lubricating ointment q4 hours
11. References
    1. Wilson (2004) Am Fam Physician 70:123-30 [PubMed]
    2. Wipperman (2013) Am Fam Physician 87(2): 114-20 [PubMed]