Definition
A.A corneal abrasion is the defect of corneal epithelial tissue, either superficial or deep.
Incidence
A.In the United States, there are 2,000 work-related eye injuries daily.
B.One-third of these eye injuries require treatment in an emergency department (ED) or by an ophthalmologist.
Pathogenesis
A.Injury from trauma occurs to the epithelial tissue of the cornea.
Predisposing Factors
A.Trauma to the eye caused by a human fingernail, tree branches, wood or metal particles, children’s toys, or sports injuries.
B.A history of surgical trauma, causing globe weakening.
C.A history of spontaneous corneal erosions.
Common Complaints
A.Sudden onset of eye pain.
B.Foreign-body sensation in the eye.
C.Watery eye.
D.Mild photophobia.
Other Signs and Symptoms
A.Change in vision/blurred vision.
B.Redness, swelling, inability to open the eye.
Subjective Data
A.Elicit onset, duration, and course of symptoms; note any past history of similar symptoms.
B.Question the patient regarding visual changes (blurred, double, or lost vision, or loss of a portion of the visual field).
C.Question the patient regarding the mechanism of injury and how much time has elapsed since the injury (minutes, hours, or days). Ask: What is his or her occupation, what sports are involved, or what hobbies predispose him or her to injury? Were goggles being worn, and are they routinely worn during the sport or activity?
D.Review the patient’s history of exposure to herpetic outbreaks.
E.Determine the degree of pain, if any, and check for headache, photophobia, redness, itching, or tearing.
F.Ascertain whether the patient wears contact lenses or glasses and for what length of time.
G.Ask if the patient has tried any treatments before presentation to the office. If so, what?
H.Rule out the presence of any other infections, such as sinus infection. Conjunctival discharge signifies an infectious etiology.
I.Ask about foreign body sensations.
J.Rule out farm injury because of risk of bacterial keratitis.
Physical Examination
A.Vital signs: Blood pressure, pulse, temperature.
B.Inspect:
1.Observe both eyes.
2.Test visual acuity and pupil reactivity and symmetry.
3.Observe cornea surface with direct illumination, noting shadow on surface of iris.
4.Perform funduscopic exam.
5.Evert eyelids for cornea inspection.
6.Inspect for foreign body and remove if indicated.
7.Fluorescein stain to visualize changes in epithelial lining. Cobalt blue light or Wood’s lamp should be used for visualization.
8.Consider slit-lamp examination to rule out traumatic hyphema or open globe injuries.
Diagnostic Tests
A.Perform fluorescein stain test: An epithelial defect that stains with fluorescein is the hallmark symptom.
Differential Diagnoses
A.Corneal abrasion.
B.Corneal foreign body.
C.Acute-angle glaucoma.
D.Herpetic infection (herpes simplex virus [HSV]): HSV is associated with decreased corneal sensation.
E.Recurrent corneal ulceration.
F.Ulcerative keratitis.
G.Spontaneous corneal erosion.
Plan
A.General interventions:
1.Superficial or smaller corneal abrasions should not be patched.
2.For deeper or larger abrasions and if a foreign body is ruled out, apply a patch that prevents lid motion for 24 hours.
3.Pressure patch is no longer recommended.
B.Patient teaching:
1.Discuss the use of protective eyewear and prevention of future ocular trauma for patients with a history of use of power tools or hammering.
2. 
See Section III: Patient Teaching Guide How to Administer Eye Medications.
3.Advise that the patient should not use/wear contact lenses until the eye is completely healed.
C.Pharmaceutical therapy:
1.Antibiotic drops or ointment. Never instill antibiotic ointment if there is a possibility of a perforation. Patch the eye and refer the patient to a physician or ophthalmologist:
a.Erythromycin 0.5% ointment, 1/2-inch ribbon twice a day to four times a day for 7 days.
b.Sulfacetamide sodium ophthalmic solution 10% (Sulamyd), one to two drops instilled into the lower conjunctival sac every 2 to 3 hours during the day; may instill every 6 hours during the night for 5 to 7 days.
c.Sulfacetamide’s sodium (Sulamyd) ophthalmic solution or ointment interacts with gentamicin. Avoid using them together.
d.Para-aminobenzoic acid (PABA) derivatives decrease sulfacetamide’s action. Wait one half to 1 hour before instilling sulfacetamide.
e.Sulfacetamide precipitates when used with silver preparations. Avoid using them together.
f.Polymyxin B sulfate (Polytrim) 10,000 u, bacitracin zinc 500 U/g ophthalmic ointment (Polysporin), a small ribbon of ointment applied into the conjunctival sac one or more times daily or as needed.
g.Bacitracin 500 U/g ointment, 1/2-inch ribbon twice a day to four times a day for 7 days.
h.Contact lens wearers are often colonized with Pseudomonas, and should be treated with either a fluoroquinolone or an aminoglycoside. Ciprofloxacin 0.3% solution, 1 to 2 drops four times a day, for 3 to 5 days; gentamycin 0.3% solution 1 to 2 drops, four times a day, for 3 to 5 days; or tobramycin (Tobrex) ointment or drops, four times a day for 3 to 5 days.
2.Analgesics: Oral NSAIDs or topical analgesics should be used sparingly. Diclofenac (Voltaren) 0.1% solution to eye four times a day as needed, or ketorolac (Acular) 0.5% solution in eye four times a day as needed.
3.Avoid use of home prescriptions that will interfere with the healing process.
4.Avoid the use of medications containing steroids. These products may increase the risk of superinfection and may slow down the healing process.
Follow-Up
A.Reevaluate the patient within 24 hours. Cornea usually heals within 24 to 48 hours.
B.Ophthalmic ointment or drops should be continued for 4 days after reepithelialization occurs to help in the healing process.
C.If the patient is still symptomatic in 48 hours, a same-day referral to an ophthalmologist is warranted.
Consultation/Referral
Immediate referral to an ophthalmologist is required for large or central lesions or deep or penetrating wounds. If ophthalmology referral cannot be arranged, the patient should be treated through the ED.
Individual Considerations
A.Pregnancy:
1.Retinal detachment should be considered as a source of eye pain and visual loss, especially in a woman with severe pregnancy-induced hypertension (HTN).
B.Adults:
1.Encourage protective eyewear for sports (including hockey, soccer, baseball, and basketball) and when using any power equipment or tools.
2.Patients with corneal abrasions secondary to contact lenses are at higher risk for bacterial keratitis. Injuries secondary to contact lenses should be evaluated to rule out a corneal infiltrate or ulcer. If this condition is observed, the patient is at risk for pseudomonas keratitis, an ocular emergency.
3.These patients should never receive an eye patch, should be covered with a topical ophthalmic agent that has pseudomonas coverage, and should be evaluated by an ophthalmologist.
C.Geriatrics:
1.Research indicated that eye surgery is successful for majority of older adult patients, secondary to the advancement of technological microsurgery procedures. However, as demand for refractory surgery rises, corneal abrasions are also increasing as a complication of postsurgical ocular procedures.
2.Treat mild corneal abrasions (≤1 mm) with antibiotics for 4 to 5 days and viscous lubricants (GenTeal® or Allergan®) 4 to 5 days/PRN. For moderate to severe corneal abrasions (≥2 mm) treat pain, begin antibiotics and lubricants, and quickly refer to ophthalmologist to further evaluate for a possible developing ulcer or other impediments.