AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Corneal abrasion is a scraping away or denuding of the corneal surface resulting from external forces physically applied to the corneal surface.

For related information, see Medscape's Cornea and External Disease Resource Center.

Pathophysiology

The cornea of the eye and, commonly, the bulbar conjunctiva, are affected. Minor or superficial abrasions involve only the corneal epithelium. Severe injuries also involve the deeper, thicker stromal layer.

Frequency

United States

Corneal abrasions are a common ophthalmologic cause of ED visits.

Mortality/Morbidity

Death is uncommon. Significant morbidity is uncommon but is mostly observed in conjunction with infectious complications or allergies to medications used in treatment. Recurrent erosions are a common complication of abrasions, particularly in patients with epithelial basement membrane dystrophy.

Age

Incidence of corneal abrasion is more common in younger, active individuals. Occurrence is unusual in elderly adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Eye pain (occasionally severe), tearing, and foreign-body sensation are present.
• Photophobia with blepharospasm is common, particularly if the abrasion is large or the presentation is delayed.
• A history of blunt or sharp trauma can usually be elicited.
• A history of extended contact lens wear is not uncommon.
• Unconscious patients are prone to iatrogenic corneal abrasions.

Physical

• Bulbar conjunctival injection is usually present.
• Visual acuity is usually normal, unless the abrasion lies within the central visual axis or is large (with the usual corneal endothelial folds and anterior chamber reaction associated with such abrasions).
• Corneal fluorescein staining: Examination with a cobalt blue slit lamp or a Wood light reveals fluorescein uptake whenever corneal epithelial cells are damaged or lost.

Causes

• Injury (eg, fingers, fingernails, paper, mascara brushes, tree branches, self-inflicted rubbing, pepper-spray exposure, automotive frontal air bags)
• Blowing dust, sand, or debris
• Extended contact lens wear
• Ocular foreign bodies imbedded under an eyelid
• Iatrogenic - Unconscious patients, accidental injury by health care workers, improper eyelid patching in patients with Bell palsy, and other neuropathies in which the eyelid cannot be closed voluntarily
• Other causes or risk factors
• • Corneal foreign bodies - Objects difficult to see (eg, small glass fragments)
  • Corneal perforation - Distorted pupil (sometimes), leaking aqueous humor (sometimes leaks from corneal perforations become visible when fluorescein is applied), low intraocular pressure (IOP), history of high-velocity injury (eg, lawn mowers, string trimmers), or metal-on-metal hammering
  • Corneal ulcer (microbial keratitis) - Fluorescein stain with an additional underlying or surrounding corneal infiltrate (eg, white spot, haze)
  • Keratitis or keratoconjunctivitis - Diffuse punctate fluorescein staining of the cornea, with or without conjunctivitis

  • Recurrent epithelial erosion - Rather sudden onset (usually on awakening) of abrasionlike symptoms, days to weeks after a healed abrasion caused by shearing injury (eg, fingernail, mascara brush)
  • Ultraviolet keratitis - History of exposure to electric arc welding or tanning beds without proper eye protection, history of prolonged exposure to bright sunlight without sunglasses (eg, "snow blindness"), delayed onset of symptoms (several hours); diffuse punctate fluorescein staining of cornea

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Corneal foreign bodies
Corneal perforation - (See Causes and Corneal Laceration.)
Keratitis or keratoconjunctivitis (eg, epidemic keratoconjunctivitis [EKC])
Recurrent epithelial erosion
Conjunctivitis - Injection of both bulbar and lid conjunctiva without corneal stain uptake (See Conjunctivitis.)
Iritis - Nonstaining cornea, with flare and cells in anterior chamber (See Iritis and Uveitis.)
Acute angle-closure glaucoma - Nonstaining cornea, increased intraocular pressure (IOP) (See Glaucoma, Acute Angle-Closure.)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• If a corneal ulcer (eg, microbial keratitis) is suspected (prolonged symptoms, contact lens wear), consider obtaining bacterial cultures before instilling antibiotics.

Imaging Studies

• If ocular penetration with a retained foreign body is suspected, such as in a high-velocity injury (eg, lawn mower, string trimmer, hammering metal), then an ocular CT scan, ocular MRI (nonmetallic), or both, are indicated.

Procedures

• Slit-lamp examination
• • A topical anesthetic (ie, proparacaine, tetracaine) may facilitate the examination.
  • Severe photophobia that causes blepharospasm may require instillation of a cycloplegic agent (ie, Cyclogyl, homatropine) 20-30 minutes prior to examination.
  • Perform fluorescein instillation and examination with blue light.
  • Examine anterior chamber for evidence of iritis (flare, cells).
• Perform an examination by using a Wood lamp with fluorescein if a slit lamp is not available.
• Evert the eyelid to look for blepharoconjunctival foreign bodies.
• Fluorescein can permanently stain soft contact lenses; remove them prior to staining.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

If ocular penetration is a possibility, protect with an eye shield. Limit vomiting if possible. Do not remove perforating foreign bodies.

Emergency Department Care

• Apply topical anesthetic and/or cycloplegic for the patient's comfort and to facilitate the examination.
• Tetanus immunization
• • Tetanus associated with corneal injuries may rarely occur. Follow the Centers for Disease Control and Prevention (CDC) guidelines for tetanus toxoid (Td for adults, DT for children <7 y) and tetanus immunoglobulin (TIG).
  • Corneal injuries produced by organic matter or dirt, as well as those associated with tissue necrosis and those associated with entrance of dirt or organic material into the conjunctival sac, should be considered dirty (ie, tetanus-prone) injuries and require boosters within 5 years.
  • Corneal injuries caused by metallic foreign bodies associated with minimal tissue destruction should be considered clean (ie, non–tetanus-prone) injuries and require boosters within 10 years. (As of January 2005, no case reports in the literature indicate clinical tetanus developing from a simple corneal abrasion.)
• In a 1998 meta-analysis in the Journal of Family Practice, Flynn et al examined patching for corneal abrasions. Six studies evaluated pain. No difference was found in 4 studies, while 2 favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. Flynn et al noted: "Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, the route of harmless nonintervention in treating corneal abrasions is recommended."¹
• In a 2002 randomized trial in children in the Annals of Emergency Medicine, Michael et al found no difference in the rate of healing, discomfort, or complications, other than a greater difficulty walking in the patch group.²

Consultations

Emergent ophthalmologic consultation is warranted for suspected retained intraocular foreign bodies. Urgent consultation is needed for suspected corneal ulcerations (microbial keratitis).

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Topical antibiotics are often used to treat corneal abrasions. Oral analgesics also may be indicated.

Drug Category: Antibiotics

Routine use of topical antibiotics for corneal abrasions remains controversial. Many emergency physicians have stopped using these agents for minor injuries, although others continue treating corneal abrasions with broad-spectrum antibiotic ointments for infection prophylaxis and lubrication. Antibiotic use persists despite unproved efficacy and evidence that ointments may retard corneal epithelial healing.

For large or dirty abrasions, many practitioners prescribe broad-spectrum antibiotic drops, such as trimethoprim/polymyxin B (Polytrim) or sulfacetamide sodium (Sulamyd, Bleph-10), which are inexpensive and least likely to cause any complications. Alternatives are an aminoglycoside or a fluoroquinolone.

Contact lens-associated abrasions warrant antibiotic treatment due to their propensity for developing infectious corneal ulcers (microbial keratitis). Coverage for gram-negative organisms (especially pseudomonads) is recommended with agents such as gentamicin (Garamycin), tobramycin (Tobrex), norfloxacin (Chibroxin), or ciprofloxacin (Ciloxan).

Avoid antibiotics containing neomycin (eg, Neosporin) because of the higher incidence of allergy to neomycin in the general population.

Antibiotic drops are more comfortable than ointments but must be administered every 2-3 h. Ointments that retain their antibacterial effect longer can be used less often (every 4-6 h) but are more uncomfortable due to visual blurring.

Drug Category: Topical anesthetics

These agents are used for analgesia to facilitate an adequate examination. These agents should never be prescribed for home use because they may cause a secondary keratitis, compromise epithelial wound healing, and block effective corneal protective reflexes and sensation.

Drug Category: Topical analgesics

Some ophthalmologists are advocating that diclofenac (Voltaren) or ketorolac (Acular) drops and a disposable soft contact lens be used in addition to antibiotic drops. This therapy may prove to be an effective alternative to patching, permitting the patient to maintain binocular vision during treatment. Compared with patching, the contact lens used with the NSAID may reduce pain.

Weaver et al found 3 recent good to strong studies that showed NSAIDs, when used alone, are effective at diminishing pain in patients with corneal abrasions who are required to return to immediate work, particularly where potential medication-induced sedation is contraindicated.³

Drug Category: Systemic analgesics

All but the most minor abrasions usually require a strong oral narcotic analgesic.

Drug Category: Cycloplegics and mydriatics

No good evidence exists in the literature to support the common practice of using cycloplegics/mydriatics for the treatment of routine corneal abrasions. However, most ophthalmologists believe that the instillation of a long-acting cycloplegic agent can provide significant relief in patients who have extensive corneal abrasions, a large degree of photophobia, and blepharospasm. These agents relax any ciliary muscle spasm that may cause a deep, aching pain and photophobia.

Cycloplegic agents are mydriatics; thus, to prevent an acute angle-closure attack, ensure that the patient does not have narrow-angle glaucoma.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Minor abrasions should heal within 24-48 hours and do not require follow-up if completely asymptomatic at 48 hours. Reexamine large abrasions every 2 days until reepithelialization has occurred and the potential for infection no longer exists. Many emergency physicians refer patients with large abrasions to an ophthalmologist for follow-up care.
• Advise eye rest (ie, no reading or work that requires significant eye movement that might interfere with reepithelialization).
• Avoid light or wear sunglasses for comfort if significant photophobia exists.

In/Out Patient Meds

• Antibiotics should be continued until the patient is asymptomatic.
• Narcotic analgesics (eg, oxycodone, hydrocodone) frequently are needed for severe pain until pain can be managed with over-the-counter analgesics.
• Cycloplegics may be required twice a day for large abrasions with significant photophobia, blepharospasm, or both, until healing is nearly complete.

Deterrence/Prevention

• Encourage patients to wear protective eyewear when working at jobs that have an increased risk of corneal abrasion or UV exposure or when hiking through areas of tall foliage.
• Tape eyelids closed in unconscious patients and in those who cannot voluntarily close their eyelids (eg, Bell palsy, other neuropathies).

Complications

• Recurrent epithelial erosion sometimes occurs days to weeks after a formerly healed abrasion caused by shearing injury (eg, fingernail, mascara brush). These erosions may be caused by damage to the basement membrane (to which the newly healed overlying cells do not adhere well) and subsequent slough due to mild hypoxia that occurs during sleep. Patients typically are awakened in the early morning by the same symptoms as those of a corneal abrasion. Ophthalmologic follow-up care and observation are indicated.
• Corneal ulcerations (microbial keratitis) secondary to infected abrasions are more common after contact lens–related abrasions.
• Ocular tetanus (rare)
• Allergic conjunctivitis, secondary to ocular medications, particularly neomycin
• Acute narrow-angle glaucoma precipitated by using mydriatics in patients with glaucoma

Prognosis

• In the vast majority of patients, the prognosis is excellent with full recovery including visual acuity.
• Some deep abrasions (involving the corneal stromal layer) within the central visual axis (ie, the central area of the cornea directly over the pupil) heal but leave a scar. In these instances, a permanent loss of visual acuity may occur.
• Healing of minor abrasions is expected within 24-48 hours. More extensive or deeper abrasions may require a week to heal.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Corneal Abrasion; Foreign Body, Eye; and Eye Injuries.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider the possibility of an intraocular foreign body or ocular perforation if history warrants (eg, string trimmer use, metal-on-metal hammering)
• Failure to identify corneal ulceration and treat with appropriate antibiotics
• Use of mydriatics in patients with known glaucoma or failure to obtain history

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Flynn CA, D'Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. Oct 1998;47(4):264-70. [Medline].
2. Michael JG, Hug D, Dowd MD. Management of corneal abrasion in children: a randomized clinical trial. Ann Emerg Med. Jul 2002;40(1):67-72. [Medline].
3. Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing?. Ann Emerg Med. Jan 2003;41(1):134-40. [Medline].
4. Benson WH, Snyder IS, Granus V, Macsai MS. Tetanus prophylaxis following ocular injuries. J Emerg Med. Nov-Dec 1993;11(6):677-83. [Medline].
5. Brown L, Takeuchi D, Challoner K. Corneal abrasions associated with pepper spray exposure. Am J Emerg Med. May 2000;18(3):271-2. [Medline].
6. Brown MD, Cordell WH, Gee AS. Do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing?. Ann Emerg Med. Oct 1999;34(4 Pt 1):526-34. [Medline].
7. Brunette DD, Ghezzi K, Renner GS, Rosen P, eds. Ophthalmologic disorders. In: Emergency Medicine: Concepts and Clinical Practice. 4^th ed. 1997:2432-2440.
8. Carley F, Carley S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Mydriatics in corneal abrasion. Emerg Med J. Jul 2001;18(4):273. [Medline].
9. Duma SM, Jernigan MV, Stitzel JD, et al. The effect of frontal air bags on eye injury patterns in automobile crashes. Arch Ophthalmol. Nov 2002;120(11):1517-22. [Medline].
10. Goyal R, Shankar J, Fone DL, Hughes DS. Randomised controlled trial of ketorolac in the management of corneal abrasions. Acta Ophthalmol Scand. Apr 2001;79(2):177-9. [Medline].
11. Hersh PS, Shingleton BJ, Kenyon KR. Anterior segment trauma. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. 1994:3384-85.
12. Hulbert MF. Efficacy of eyepad in corneal healing after corneal foreign body removal. Lancet. Mar 16 1991;337(8742):643. [Medline].
13. Janda AM, Tintinalli JE, eds. Eye, ear, nose, throat, and oral surgery. In: Emergency Medicine: A Comprehensive Study Guide. 4^th ed. 1997:1060-1061.
14. Kirkpatrick JN, Hoh HB, Cook SD. No eye pad for corneal abrasion. Eye. 1993;7 ( Pt 3):468-71. [Medline].
15. Moos DD, Lind DM. Detection and treatment of perioperative corneal abrasions. J Perianesth Nurs. Oct 2006;21(5):332-8; quiz 339-41. [Medline].
16. Mukherjee P, Sivakumar A, Mackway-Jones K. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. Jan 2003;20(1):62-4. [Medline].
17. Ostler HB. Risk of tetanus from corneal injuries. JAMA. 1988;260:553.
18. Patterson J, Fetzer D, Krall J. Eye patch treatment for the pain of corneal abrasion. South Med J. Feb 1996;89(2):227-9. [Medline].
19. Salz JJ, Reader AL, Schwartz LJ, Van Le K. Treatment of corneal abrasions with soft contact lenses and topical diclofenac. J Refract Corneal Surg. Nov-Dec 1994;10(6):640-6. [Medline].
20. Schein OD. Contact lens abrasions and the nonophthalmologist. Am J Emerg Med. Nov 1993;11(6):606-8. [Medline].
21. Thyagarajan SK, Sharma V, Austin S, Lasoye T, Hunter P. An audit of corneal abrasion management following the introduction of local guidelines in an accident and emergency department. Emerg Med J. Jul 2006;23(7):526-9. [Medline].
22. Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev. Apr 19 2006;(2):CD004764. [Medline].

Article Last Updated: Jul 27, 2007