4-01: Corneal Abrasion

Introduction

Open Globe with Prolapsed Iris. Prolapsed iris seen at 10 o’clock and peaked pupil pointing to the prolapse indicating an open globe after trauma. The patient was hammering nails into a tree trunk when one ricocheted back at him. (Photo contributor: Timothy M. Brenkert, MD.)

Clinical Summary

Corneal abrasions present with acute onset of eye discomfort, tearing, and often a foreign-body sensation. A “ciliary flush” (conjunctival injection hugging the limbus) may be seen. Large abrasions or those in the central visual axis may affect visual acuity. Photophobia and headache from ciliary muscle spasm may be present. Associated findings or complications include traumatic iritis, hypopyon, or a corneal ulcer. Fluorescein examination, preferably with a slit lamp, highlights the defect.

Management and Disposition

Instillation of topical anesthetic drops (eg, tetracaine 0.5%, proparacaine 0.5%) facilitates examination while relieving pain and blepharospasm. Brief outpatient treatment of corneal abrasions with topical anesthetics in selected patients has been shown to be safe and effective. Consider using a short-acting cycloplegic (eg, cyclopentolate 1% or homatropine 5%) to reduce pain from ciliary spasm in patients who complain of headache or photophobia. Consider oral opioid or nonsteroidal anti-inflammatory drug (NSAID) analgesics for pain control. NSAID eye drops (eg, diclofenac or ketorolac) are equally effective and avoid systemic side effects. Neither treatment with topical antibiotics, nor patching, nor tetanus prophylaxis for uncomplicated corneal abrasions has scientific validation. Artificial tears are safe and especially helpful for the dry eye symptoms that commonly occur after the corneal defect has healed. Emergency department and/or ophthalmologist follow-up is advised for any patient with complications or who is still symptomatic after 24 hours.

Pearls

1. Mucus may simulate fluorescein uptake, but its position changes with blinking.

2. Multiple linear corneal abrasions, the “ice-rink sign,” may result from an embedded foreign body adhered to the upper lid. Always evert the lid to evaluate this.

3. Whenever the mechanism includes grinding or striking metal, or high-velocity injuries from mowers or string trimmers, maintain a high index of suspicion for penetrating injury. Fluorescein streaming away from an “abrasion” (Seidel test) may be an indication of a corneal perforation.

4. Routine prophylactic treatment with topical antibiotics remains controversial. When used, inexpensive, broad-spectrum antibiotic drops (sulfacetamide sodium or trimethoprim/polymyxin B) allow clearer vision than lubricating ointments, which may feel better, but blur vision. Avoid topical neomycin antibiotics because of a high risk of irritant allergy symptoms.

5. An “abrasion” in a contact lens wearer should alert one to suspect a corneal ulcer. Consult ophthalmology while the patient is in the emergency department.