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