Corneal Abrasions
Nilesh Shah
BasicsDescription
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Removal or scraping away of the superficial layers of the cornea (stratified squamous epithelium) without penetration of Bowman's membrane.
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In some cases, the bulbar conjunctiva is also involved.
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In the general population, injury usually results from contact lens misuse but also can be attributed to foreign bodies, tangential shearing injuries, and contusion to the globe.
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In the workplace, both physical trauma and chemical trauma may be an etiology for corneal abrasions.
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In sports, the mechanism is more commonly direct trauma.
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Severe corneal injuries also can involve the deeper, thicker stromal layer; in this situation, the term corneal ulcer may be used.
Epidemiology
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Most common eye injury after soft tissue injuries
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More common in sports with projectiles/balls
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More common in collision sports
Risk Factors
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Collision/contact sports
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Contact lens use, especially soft lenses
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Failure to wear eye protection
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Sports with projectiles/balls
General Prevention
Single-piece-construction protective eyewear with 3-mm polycarbonate lenses will reduce the risk of eye injuries.
Commonly Associated Conditions
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Hyphema (blood in the anterior chamber)
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Scleral rupture: Look for vitreous leak.
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Intraocular foreign body
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Rust ring
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Perforation: Look for vitreous leak.
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Orbital fracture
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Iridodialysis: Defect of the iris caused by its separation from the scleral spur
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Superinfection
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Recurrent erosion syndrome
DiagnosisHistory
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Mechanism of injury guides physical exam for associated injuries and delineates the need for further studies.
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History of previous injuries: Possible viral keratitis or recurrent erosion syndrome
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Contact lens history (hard, soft, overuse): Symptoms are usually better with contact in place, acting as a bandage.
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Risk of foreign body: Particular sports, windy conditions, etc.
Physical Exam
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Signs and symptoms include:
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Pain
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Redness
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Lacrimation
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Foreign-body sensation
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Photophobia
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Blepharospasm
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Physical examination includes:
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General bony orbital exam
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Cranial nerve assessment
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Ocular movements
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Topical anesthetic and cycloplegic agents: May be needed to decrease pain and photophobia for optimal exam
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Visual acuity
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Loupe with good light or slit lamp (preferable)
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Fluorescein drops/strips: Sharply demarcates defects in corneal epithelium and helps to differentiate from herpes keratitis (dendritic pattern)
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Anterior chamber and corneal exam: Slit lamp preferred to rule out associated injuries (hyphema, perforation)
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Eversion of upper and lower lids: Identify any foreign bodies under tarsal plate.
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Intraocular pressure (IOP): Unless perforation/scleral rupture is suspected
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Diagnostic Tests & Interpretation
Imaging
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Orbital series: Only if history or physical exam suggests fracture
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US (B-scan)/CT scan/MRI: If occult intraocular foreign body is suspected
Differential Diagnosis
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Foreign body
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Corneal laceration
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Perforation
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Viral keratitis (usually herpes)
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Conjunctivitis: Infectious/allergic
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Iridocyclitis
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Optic neuritis
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Retinal detachment
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Keratitis
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Scleritis/episcleritis
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Blepharitis
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Keratoconjunctivitis
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Canaliculitis
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Globe injury
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Orbital fracture
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Photokeratitis/retinitis
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Periorbital cellulitis
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Trichiasis
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Intraocular foreign body
Treatment-
Long-term treatment
Alert
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Long-term use of topical anesthetics may compromise epithelial healing.
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Acute treatment
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Analgesia:
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Topical anesthesia: For exam only; see warning above. These agents should not be prescribed for home use because they can cause secondary keratitis, compromise healing of the epithelial wound, and block protective corneal reflexes and sensation.
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Oral analgesia as needed
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Medication
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Antibiotics:
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Broad-spectrum topical antibiotics: Aid with lubrication and are used for infection prophylaxis (eg, sulfacetamide/quinolones)
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Contact lens–associated: Gram-negative coverage is essential (eg, gentamicin/cefazolin); also consider coverage for Pseudomonas (eg, gentamicin/quinolones).
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Water sport–associated: Pseudomonal coverage (eg, gentamicin/quinolones)
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Topical NSAIDs (1)[A]: May be used for pain associated with the corneal abrasion
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Anticholinergic medications: Long-acting cycloplegic agents can provide relief from photophobia and blepharospasm. Caution should be used in patients with narrow angles because mydriatic medications can lead to acute angle-closure glaucoma.
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Oral analgesics: Oral anti-inflammatory medications and narcotic pain medications may be used for pain control.
Additional Treatment
General Measures
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Daily monitoring until reepithelialization (48–72 hr) and no infection potential exists
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Topical antibiotics continued for 1 wk after reepithelialization
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Watch for recurrent erosion—sudden pain, redness, tearing—which may lead to recurrent erosion syndrome, requiring débridement and further specialized treatment.
Referral
Referral for recurrent abrasions, erosions, larger abrasions, infections, and corneal ulcers
P.105
Additional Therapies
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Cycloplegic agent for comfort, optional (initially given for first few days and then discontinued). Examine to exclude narrow angles.
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Pressure patch: Patching is for patient comfort and prevents retearing of healing epithelium. However, most corneal abrasions do not need patching. For small, uncomplicated corneal abrasions, patching has not been shown to decrease pain or increase healing rates. Patching also creates loss of binocular vision. Patching should not be used if the injury is contact lens-induced because of the potential for harboring of infecting organisms and promoting infection.
Ongoing CareFollow-Up Recommendations
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Hyphema
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Intraocular foreign body/rust ring
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Perforation
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Recurrent erosion syndrome
Patient Monitoring
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Eye rest (ie, minimize reading or heavy computer work that requires substantial eye movement): This helps to minimize interference with reepithelialization.
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Avoid light or wear sunglasses for comfort owing to photophobia.
Patient Education
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Eye protection during the healing process is important, especially in patients whose jobs put them at increased risk of corneal abrasions or ultraviolet (UV) exposure.
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If the patient is unconscious or cannot voluntarily close his or her eyelids (eg, Bell palsy or other neuropathies), eyelids may be taped closed and use of lubrication considered.
Prognosis
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The prognosis is usually good, with healing and full recovery of vision if prompt evaluation and treatment are initiated.
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Some deep abrasions heal with a scar. If this occurs in the central visual axis (the central area of the cornea directly over the pupil), visual acuity may be permanently lost. Deep abrasions within the central visual axis should be considered for ophthalmologic referral.
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Healing of minor abrasions is expected within 24–48 hr. Extensive or deep abrasions may require a week to heal.
Complications
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Deep corneal involvement may result in facet formation in the epithelium or scar formation in the stroma.
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Progression of abrasions into corneal ulcers may lead to devastating outcomes.
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Abrasions involving exposure to vegetable matter are at risk of fungal ulcers.
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Abrasions from contact lens use are at risk for pseudomanas and amoebic keratitis.
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Recurrent erosions
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Allergic reactions to treatment medications
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Loss of school and work time/productivity
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Use of mydriatics in patients with glaucoma may lead to acute angle-closure glaucoma.
References
1. 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. 2003;41:134–140.
2. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Protective eyewear for young athletes. Pediatrics. 2004;113:619–622.
Additional Reading
Aslam SA, Sheth HG, Vaughan AJ. Emergency management of corneal injuries. Injury. 2006.
Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005;12:467–473.
Hart A, White S, Conboy P, et al. The management of corneal abrasions in accident and emergency. Injury. 1997;28:527–529.
Heimmel MR, Murphy MA. Ocular injuries in basketball and baseball: what are the risks and how can we prevent them? Curr Sports Med Rep. 2008;7:284–288.
Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;CD004764
Watson SL, Barker NH. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2007;CD001861.
Wilson SA, Last A. Management of corneal abrasions. Am Fam Physician. 2004;70:123–128.
Zagelbaum BM. Treating corneal abrasions and lacerations. Physician Sports Med. 1997;25:38–44.
CodesICD9
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370.00 Corneal ulcer, unspecified
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371.82 Corneal disorder due to contact lens
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918.1 Superficial injury of cornea
ICD10
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E91.4 Corneal foreign body
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H16.0 Corneal ulcer, unspecified
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H18.9 Corneal disorder, unspecified
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H19.2 Corneal keratitis
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H19.2 Herpes zoster keratoconjunctivitis
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S05.0 Corneal abrasion
Clinical Pearls
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Return to play is based on patient comfort. Once the pain is under control and the patient is not having any visual difficulties, he or she may return to play.
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Patients may wear their contact lenses again when the abrasion has healed fully without complications (usually 3–5 days). Furthermore, if the abrasion is related to old, worn contact lenses, they need to be replaced and new ones not started until complete healing of the abrasion has occurred.
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There is no increased risk of another corneal abrasion after an initial injury, but anyone in a collision/contact sport or a sport with a projectile/ball may want to wear protective eyewear.
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Optimal protective eyewear is made of a sturdy frame single-piece construction that will not allow posterior dislocation of the lens of the eyewear. The lenses should have a 2–3-mm center thickness and be made of polycarbonate. Different sports have differing eyewear regulations. They should have American Society for Testing and Materials (ASTM) certification (2).