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Corneal abrasions are a common ophthalmic problem presenting to accident and emergency departments (A&E). A&E doctors and emergency nurse practitioners (ENPs) are expected to perform basic ophthalmic examination, provide treatment, and judge the need for specialist attention. For most cases of corneal abrasion, this primary episode of care is all that is needed. However, for A&E doctors and ENPs unfamiliar or untrained in ophthalmology, even the most straightforward cases may involve anxiety and mismanagement.[rx]
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.[rx]
Causes of Corneal Abrasions
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.[rx]
- Abrasion and Foreign Body – Corneal abrasions may be caused by any number of objects including fingernails, contact lens wear, branches, foreign objects blown into the eyes, or objects that drop into the eye while working overhead.
- Perforation – Cases of corneal laceration and perforation typically involve activities that cause high-speed projectiles such as saws, grinders, and pounding metal objects.
- Burns – Exposure-related burns of the eye can be categorized into chemical (acid and alkali burns), radiation burns from ultraviolet (UV) sources, and thermal burns. Alkali corneal injuries are more common than acid due to the prevalence of household cleaning agents containing ammonia and lye. Acidic burns are typically work-related injuries involving industrial processes. Radiation burns result in ultraviolet keratitis from tanning beds, high-altitude environments, welding arcs, and the occasional solar eclipse. Thermal burns are distinctly uncommon but can occur with objects such as curling irons and with fire-related injuries.
- Infants who scratch their eyes– unintentionally with untrimmed fingernails
- School children who play with pencils – pens and other pointed objects
- Athletes who play sports – without using some form of eyewear to protect against dust, sand or an accidental scratch from another player’s finger. More eye injuries occur in baseball and football than in other sports.
- People who have hobbies – or crafts that use pointed tools, such as sewing and wood carving, or that produce dust, such as woodworking and gardening
- Workers who are exposed – to eye hazards on the job, especially those involved in farming or construction
- Anyone who inserts contact– lenses without properly cleaning their hands and their lenses beforehand
- A corneal injury – may occur when something gets into your eye, for example, when the wind blows a dried leaf particle into your eye or when paint chips fall into your eye while you are scraping off old paint. This material may scratch the cornea.
- A foreign body – such as a piece of sand or wood, may lodge under the inside of the upper lid and cause scratches of the corneal surface every time that you blink.
- In addition to causing corneal injury – high-speed particles may penetrate your eye and injure deeper structures. An example of this would be a small metal fragment flying into the eye when a person is using a grinding wheel without protective eyewear. This may cause a serious injury that demands immediate medical attention to guard against permanent loss of vision.
- A hot cigarette ash flying – into the eye may cause a corneal abrasion.
- A common cause of a corneal abrasion – is a young child accidentally poking you in the eye with her fingernail.
- You may cause a corneal abrasion – when you rub your eyes excessively when they are irritated.
- Wearing contact lenses – longer than recommended may injure the corneal surface and cause a corneal abrasion.
- Certain eye infections – may also cause injury to the surface of the cornea. This injury, although not technically considered a corneal abrasion, may be temporary or permanent.
- Exposure of the unprotected eye – to ultraviolet light from sun lamps or welding arcs can cause changes in the corneal surface resembling corneal abrasions.
Symptoms of Corneal Abrasions
Diagnosis of Corneal Abrasions
History—ask in addition to your usual history questions
- Document time – place and activity during injury
- Document the complaint – common abrasion symptoms: foreign body sensation/painful eye/watery eye and secondary blurred vision/photophobia
- Is it a recurrent problem – Did they wake up with it?
- Past ophthalmic history – Do they wear contact lenses? Any previous eye problems? Any eye surgery?
- Past medical history – arthritis? Atopy?
- Drugs – any drops?
- Must record visual acuities both eyes—use the patient’s own glasses and then add the pinhole on top of that
- Must use the slit lamp or direct ophthalmoscope on high magnification—ask a senior if necessary
- Must examine both eyes
- Is there any purulent discharge from the eyes?
- Check under the lids
- Instil fluorescein dye (with topical local anaesthetic) and examine with cobalt blue light
- Draw a diagram of the eye with abrasion (the area of staining)
- Describe the position and size of abrasion. Is it in the centre or periphery of the cornea? Is it clear or is there associated infiltrate?
- Look at the anterior chamber looking for cells or pus
Treatment of Corneal Abrasions
The treatment of corneal abrasions aims to prevent bacterial superinfection, speed healing, and provide symptomatic relief.[rx] If a foreign body is found, it needs to be removed.
- Positioning – The person is laid in a comfortable position with the affected eye closest to the physician. Loupes can be used if available and the eye can be illuminated with a medical light or, alternatively, with an ophtalmoscope held in the non-dominant hand. The person is then asked to focus on a particular point on the ceiling so that the foreign body sits as centrally between the eyelids as possible. This accounts for a more sterile procedure by keeping the eyelashes as far as possible, and reduces the chance of eliciting a blink reflex. If necessary, the eyelids can be kept open using an eyelid speculum, the examiner’s fingertips, a cotton tip or an assistant.
- Anaesthetic and pupil dilator – Local anaesthetic is instilled into both eyes in order to reduce blepharospasm. Topical oxybuprocaine 0.4% is the preferred choice as it has an onset of action of 20 seconds and a half-life of 20 minutes. A drop of topical pupil dilator such a cyclopentolate 1%, if available, can be helpful to reduce ciliary spasm after removal of the foreign body. Atropine is generally avoided due to its long-lasting mydriatic effects.
- Removal techniques – There are mainly two types of techniques, the choice of which will depend on the nature of the foreign body. The first technique is the cotton tip removal, which is indicated in superficial foreign bodies with no surrounding corneal reaction, and the second is the hypodermic needle or nº15 blade removal with which the complete foreign body and any surrounding rust ring can be removed.
- Irrigation of the ocular surface – and upper and lower fornices can be performed after the procedure to wash out any residual loose foreign body material. A 10 mL ampoule of sterile saline is usually sufficient.
Current recommendations stress the need to use topical and/or oral analgesia and topical antibiotics. One review has found that eye drops to numb the surface of the eye such as tetracaine improve pain; however, their safety is unclear.[rx] Another review did not find evidence of benefit and concluded there was not enough data on safety.[rx]
- CHLORAMPHENICOL ointment BD to the affected eye for 5 days
- If they are very photophobic, put 1 drop of CYCLOPENTOLATE in the eye
- Advise ibuprofen or, if required, give co‐dydramol
- Patch the eye for 4–6 hours if the abrasion is very painful, never patch an ulcer
- Advise them to not wear contact lens for 2 weeks
- Give them the corneal abrasion leaflet. Advise them it may be painful for 2 days
Most corneal abrasions can be discharged without any follow up. However some cases do need follow up. There is an infected ulcer (if you see any discharge, infiltrate in the abrasion or pus in the anterior chamber)—ring ophthalmology on‐call for advice. Reasons for follow‐up in ERS clinic
- The abrasion is affecting the patient’s “only‐seeing” eye
- The patient gives a history of recurrent abrasion in the same eye
- The patient is a contact lens wearer
- Ask the patient to return to A&E if they do not feel any improvement (vision or pain) in 72 hours or if the eye becomes sticky
What to Do if You Suspect Corneal Abrasion
What To Do
- Instill topical anesthetic drops to eliminate any pain or blepharospasm and thereby permit examination (e.g., proparacaine [Ophthetic], tetracaine [Pontocaine])
- Perform a complete eye examination (including assessment of best-corrected visual acuity, funduscopy, anterior chamberbright-light examination, and inspection of conjunctival sacs for a foreign body).
- Perform the fluorescein examination by wetting a paper strip impregnated with dry, orange fluorescein dye and touching this strip into the tear pool inside the lower conjunctival sac. After the patient blinks, darken the room and examine her eye under cobalt-blue filtered or ultraviolet light. (The red-free light on the ophthalmoscope does not work.) Areas of denuded or dead corneal epithelium will fluoresce green and confirm the diagnosis.
If a foreign body is present, remove it and irrigate the eye.
- When a corneal abrasion is present, treat the patient with antibiotic drops, such as trimethoprim plus polymyxin B(Polytrim), 10 mL, 1 drop q2-6h, while awake. Some physiciansprefer ophthalmic ointment preparations, which may last longer but tend to be messy. If ointment is preferred, erythromycin0.5%, 3.5 g, or polymyxin B/bacitracin, 3.5 g, applied inside the lower lid (1- to 2-cm ribbon) qid is effective and least expensive. In patients who wear contact lenses or who were injured by organic material (such as a tree branch), an antipseudomonal antibiotic (e.g., ciprofloxacin [Ciloxan] 0.3%, 1 to 2 drops q1-6h, or ofloxacin [Ocuflox] 0.3%, 1 to 2 drops q1-6h, should be used. Contact lens wearing should be discontinued until the abrasion is healed.
- Analgesic nonsteroidal anti-inflammatory drug (NSAID) eye dropsof diclofenac (Voltaren), 0.1%, 5 mL, or ketorolac (Acular), 0.5%, 5 mL, 1 drop instilled qid, provide pain relief and do not inhibit healing.
- If iritis is present (as evidenced by consensual photophobia or, in severe cases, an irregular pupil or miosis and a limbic flush in addition to conjunctival injection), consult the ophthalmologic follow-up physician about starting treatment with topical mydriatics and steroids (see Chapter 20).
- Even when there are no signs of iritis, one instillation of a short-acting cycloplegic, such as cyclopentolate 1% (Cyclogyl), will relieve any pain resulting from ciliary spasm.
- Although not likely to be available to the non–contact lens user, a soft, disposable contact lens (e.g., NewVue, Acuvue) in combination with antibiotic and nonsteroidal anti-inflammatory drops can provide further comfort as well as the ability to see out of the affected eye. As with any contact lens worn overnight, there is probably an increased risk for infectious keratitis; so, this should be provided in concert with an ophthalmologist.
- Prescribe analgesics (e.g., oxycodone, ibuprofen, naproxen) as needed, and administer the first dose when appropriate. Most abrasions heal without significant long-term complications; therefore pain relief should be our primary concern with uncomplicated abrasions. This treatment of pain should be guided by an individual patient’s age, concomitant illness, drug allergy, ability to tolerate NSAIDs, potential for opioid abuse, and employment conditions, such as driving and machine operation.
- Make an appointment for ophthalmologic or primary care follow-up to reevaluate the abrasion the next day. If the abrasion has not fully healed, the patient should be evaluated again 3 to 4 days later, even if he feels well.
- Instruct patients about the importance of wearing eye protection. This is particularly needed for persons in high-risk occupations (e.g., miners, woodworkers, metalworkers, landscapers) and those who participate in certain sports (e.g., hockey, lacrosse, racquetball). Other preventive measures include keeping the fingernails of infants and children clipped short and removing objects such as low-hanging tree branches from the home environment.
- Wear sunglasses
- Use antibiotic eye drops as prescribed
- Use a cool compress to relieve swelling, pain and discomfort
- Keep face and eyelids clean
- Return to the doctor discharge from the eye appears
- Rest the eyes and minimize strain
- Rub the eye
- Try to remove debris from the eye other than by blinking or flushing it with water or saline
- Use a cotton swam or tweezers to remove anything from the eye
- Patch the eye unless directed by your medical team
- Wear contact lenses until cleared to do so by an ophthalmologist
- Wear eye makeup