This action might not be possible to undo. Are you sure you want to continue?
Article Last Updated: Jul 27, 2007
AUTHOR AND EDITOR INFORMATION
Author: Robert M Howell, MD, FACEP, Associate Clinical Professor, Department of Family Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center/Saint Joseph Hospital Robert M Howell is a member of the following medical societies: American College of Emergency Physicians Editors: Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Douglas Lavenburg, MD, Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Barry E Brenner, MD, PhD, FACEP, Program Director, Department of Emergency Medicine, University Hospitals, Case Medical Center Author and Editor Disclosure Synonyms and related keywords: corneal abrasion, scratched cornea, scraped eye, scraped cornea, eye trauma, scratched eye, corneal surface
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.
Age Incidence of corneal abrasion is more common in younger. tearing. Physical • • Bulbar conjunctival injection is usually present. are affected. commonly. CLINICAL History • • • • • Eye pain (occasionally severe). Photophobia with blepharospasm is common. Frequency United States Corneal abrasions are a common ophthalmologic cause of ED visits.The cornea of the eye and. . Severe injuries also involve the deeper. Significant morbidity is uncommon but is mostly observed in conjunction with infectious complications or allergies to medications used in treatment. the bulbar conjunctiva. A history of blunt or sharp trauma can usually be elicited. Visual acuity is usually normal. thicker stromal layer. Minor or superficial abrasions involve only the corneal epithelium. particularly if the abrasion is large or the presentation is delayed. particularly in patients with epithelial basement membrane dystrophy. Unconscious patients are prone to iatrogenic corneal abrasions. Recurrent erosions are a common complication of abrasions. active individuals. Occurrence is unusual in elderly adults. and foreign-body sensation are present. Mortality/Morbidity Death is uncommon. A history of extended contact lens wear is not uncommon. 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).
sand. fingernail. or metalon-metal hammering Corneal ulcer (microbial keratitis) . small glass fragments) Corneal perforation .Unconscious patients. "snow blindness").History of exposure to electric arc welding or tanning beds without proper eye protection. accidental injury by health care workers. delayed onset of symptoms (several hours). days to weeks after a healed abrasion caused by shearing injury (eg. low intraocular pressure (IOP). or debris Extended contact lens wear Ocular foreign bodies imbedded under an eyelid Iatrogenic .Diffuse punctate fluorescein staining of the cornea. haze) Keratitis or keratoconjunctivitis . leaking aqueous humor (sometimes leaks from corneal perforations become visible when fluorescein is applied). history of high-velocity injury (eg. Causes • • • • • • Injury (eg.Objects difficult to see (eg. white spot.Distorted pupil (sometimes). mascara brushes. fingers.Rather sudden onset (usually on awakening) of abrasionlike symptoms. tree branches. mascara brush) Ultraviolet keratitis .• 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. diffuse punctate fluorescein staining of cornea DIFFERENTIALS Conjunctivitis Corneal Laceration Corneal Ulceration and Ulcerative Keratitis . self-inflicted rubbing. fingernails. history of prolonged exposure to bright sunlight without sunglasses (eg. lawn mowers. string trimmers). automotive frontal air bags) Blowing dust. and other neuropathies in which the eyelid cannot be closed voluntarily Other causes or risk factors • o o o o o o Corneal foreign bodies . with or without conjunctivitis Recurrent epithelial erosion . paper. pepper-spray exposure.Fluorescein stain with an additional underlying or surrounding corneal infiltrate (eg. improper eyelid patching in patients with Bell palsy.
Acute Angle-Closure Iritis and Uveitis Other Problems to be Considered Corneal foreign bodies Corneal perforation . then an ocular CT scan. hammering metal).Glaucoma. • o • . Imaging Studies • If ocular penetration with a retained foreign body is suspected.Injection of both bulbar and lid conjunctiva without corneal stain uptake (See Conjunctivitis. epidemic keratoconjunctivitis [EKC]) Recurrent epithelial erosion Conjunctivitis .) WORKUP Lab Studies • If a corneal ulcer (eg. or both. string trimmer. contact lens wear). cells). Procedures • Slit-lamp examination A topical anesthetic (ie. o Perform fluorescein instillation and examination with blue light. lawn mower. o Examine anterior chamber for evidence of iritis (flare. Cyclogyl. are indicated. ocular MRI (nonmetallic).) Keratitis or keratoconjunctivitis (eg.Nonstaining cornea.) Acute angle-closure glaucoma . tetracaine) may facilitate the examination. microbial keratitis) is suspected (prolonged symptoms. such as in a high-velocity injury (eg. proparacaine. consider obtaining bacterial cultures before instilling antibiotics. Perform an examination by using a Wood lamp with fluorescein if a slit lamp is not available. Acute Angle-Closure. increased intraocular pressure (IOP) (See Glaucoma. o Severe photophobia that causes blepharospasm may require instillation of a cycloplegic agent (ie.) Iritis .(See Causes and Corneal Laceration.Nonstaining cornea. homatropine) 20-30 minutes prior to examination. with flare and cells in anterior chamber (See Iritis and Uveitis.
"1 In a 2002 randomized trial in children in the Annals of Emergency Medicine. • o • • . protect with an eye shield. o Corneal injuries caused by metallic foreign bodies associated with minimal tissue destruction should be considered clean (ie. Limit vomiting if possible. (As of January 2005. No difference was found in 4 studies. should be considered dirty (ie. no case reports in the literature indicate clinical tetanus developing from a simple corneal abrasion. tetanus-prone) injuries and require boosters within 5 years.) In a 1998 meta-analysis in the Journal of Family Practice. TREATMENT Prehospital Care If ocular penetration is a possibility. Flynn et al examined patching for corneal abrasions. non– tetanus-prone) injuries and require boosters within 10 years. as well as those associated with tissue necrosis and those associated with entrance of dirt or organic material into the conjunctival sac. No differences in complication rates were noted between the patched and nonpatched groups. remove them prior to staining. Given the theoretical harm of loss of binocular vision and possible increased pain. Michael et al found no difference in the rate of healing. DT for children <7 y) and tetanus immunoglobulin (TIG). Follow the Centers for Disease Control and Prevention (CDC) guidelines for tetanus toxoid (Td for adults. 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. Flynn et al noted: "Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. o Corneal injuries produced by organic matter or dirt. Fluorescein can permanently stain soft contact lenses. while 2 favored not patching.• • Evert the eyelid to look for blepharoconjunctival foreign bodies. the route of harmless nonintervention in treating corneal abrasions is recommended. Do not remove perforating foreign bodies. Six studies evaluated pain.
Coverage for gram-negative organisms (especially pseudomonads) is recommended with agents such as gentamicin (Garamycin). For large or dirty abrasions. such as trimethoprim/polymyxin B (Polytrim) or sulfacetamide sodium (Sulamyd. Alternatives are an aminoglycoside or a fluoroquinolone. Avoid antibiotics containing neomycin (eg. MEDICATION Topical antibiotics are often used to treat corneal abrasions. or complications. Bleph-10). Drug Name Description Trimethoprim/polymyxin B (Polytrim) Used for treatment of ocular infections involving cornea or conjunctiva. Many emergency physicians have stopped using these agents for minor injuries. Available as solution and ointment. other than a greater difficulty walking in the patch group. Drug Category: Antibiotics Routine use of topical antibiotics for corneal abrasions remains controversial. or ciprofloxacin (Ciloxan). many practitioners prescribe broad-spectrum antibiotic drops. Contact lens-associated abrasions warrant antibiotic treatment due to their propensity for developing infectious corneal ulcers (microbial keratitis). Ointments that retain their antibacterial effect longer can be used less often (every 4-6 h) but are more uncomfortable due to visual blurring. norfloxacin (Chibroxin). tobramycin (Tobrex). which are inexpensive and least likely to cause any complications. . although others continue treating corneal abrasions with broad-spectrum antibiotic ointments for infection prophylaxis and lubrication.2 Consultations Emergent ophthalmologic consultation is warranted for suspected retained intraocular foreign bodies. 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. Oral analgesics also may be indicated.discomfort. Urgent consultation is needed for suspected corneal ulcerations (microbial keratitis). Antibiotic use persists despite unproved efficacy and evidence that ointments may retard corneal epithelial healing.
Solution: 1-2 gtt q4h in the affected eye. prolonged use of antibiotics or repeated therapy may result in bacterial or fungal overgrowth of nonsusceptible organism Sulfacetamide sodium 10% (Sulamyd. fungal diseases None reported B . viral and mycobacterial infections of the eye. and lotion. Available as solution.5-inch ribbon into conjunctival sac qid <2 months: Not established >2 months: Administer as in adults Documented hypersensitivity. while awake.Safety for use during pregnancy has not been established.Usually safe but benefits must outweigh the risks. Do not use in deep ocular infections or in those likely to become systemic.5-inch ribbon bid/tid into conjunctival sac Severe infections: Apply q3-4h <2 years: Not established Adult Dose Pediatric Dose Contraindications Documented hypersensitivity Interactions Pregnancy Precautions Drug Name Description Adult Dose Pediatric Dose . causing a defective bacterial cell membrane.Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Precautions Drug Name Description Solution: 1-2 gtt q2h in the affected eye while awake Ointment: Apply 0. ointment. and lotion. Caution in severely dried eye. Bleph-10) Interferes with bacterial growth by inhibiting bacterial folic acid synthesis through competitive antagonism of PABA.5-inch ribbon 1-4 times/d into conjunctival sac <2 months: Not established >2 months: Administer as in adults Effects decreased when used concurrently with gentamicin C . ointment may retard corneal epithelial healing Tobramycin (Tobrex) Aminoglycoside that interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Available as solution. ointment. less frequently at night Ointment: Apply 0. followed by less frequent intervals Ointment: Apply 0. less frequently at night Severe infections: 2 gtt q30-60min for the first 24 h. Solution: 1-3 gtt q2-3h in the affected eye. while awake.
Safety for use during pregnancy has not been established. prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms Ciprofloxacin (Ciloxan) Inhibits bacterial growth by inhibiting DNA gyrase. avoid coadministration with steroid Contraindications combinations after uncomplicated removal of a foreign body from cornea Interactions Pregnancy Precautions None reported C . prolonged use of antibiotics may result in bacterial . Do not use in deep ocular infections likely to become systemic. prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms Norfloxacin (Chibroxin) Inhibits bacterial growth by inhibiting DNA gyrase.Safety for use during pregnancy has not been established. 1-2 gtt qid for 7 d Suspected corneal ulcers: 1-2 gtt qh for first 24 h then qid for 7d <1 year: Not established >1 year: Administer as in adults None reported C . Do not use in deep ocular infections likely to become systemic. and fungal eye infections. 1-2 gtt qid for 7 d Suspected corneal ulcers: 1-2 gtt qh for first 24 h then qid for 7d <1 year: Not established >1 year: Administer as in adults Precautions Drug Name Description Adult Dose Pediatric Dose Contraindications Documented hypersensitivity Interactions Pregnancy Precautions Drug Name Description Adult Dose Pediatric Dose Documented hypersensitivity. mycobacterial. Do not use in deep-seated ocular infections or in those that may become systemic.>2 years: Administer as in adults Contraindications Documented hypersensitivity Interactions Pregnancy None reported C .Safety for use during pregnancy has not been established. viral.
Do not use to treat ocular infections that may become systemic. mycobacterial. prolonged use .5% (Ophthaine) Least irritating of all topical anesthetics. prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection Precautions Drug Category: Topical anesthetics These agents are used for analgesia to facilitate an adequate examination.Safety for use during pregnancy has not been established. Prevents initiation and transmission of impulse at the nerve cell membrane by stabilizing it and decreasing ion permeability. Solution: 1-2 gtt q4h in the affected eye. viral. while awake. patients taking steroid combinations after uncomplicated removal of a foreign body from cornea Interactions Pregnancy None reported C . followed by less frequent intervals <2 years: Not established >2 years: Administer as in adults Adult Dose Pediatric Dose Documented hypersensitivity. and fungal Contraindications infections of the eye. Anesthetic effect may last up to 10-15 min. Onset of action for this anesthetic takes place within 20 sec of application. 1-2 gtt of 0. less frequently at night Severe infections: 2 gtt q30-60min for the first 24 h. and block effective corneal protective reflexes and sensation.or fungal overgrowth of nonsusceptible organisms Drug Name Description Gentamicin (Genoptic) Aminoglycoside antibiotic used for gram-negative bacterial coverage. Drug Name Proparacaine 0. These agents should never be prescribed for home use because they may cause a secondary keratitis.Safety for use during pregnancy has not been established. Description Adult Dose Pediatric Dose Interactions Pregnancy Contraindications Documented hypersensitivity. compromise epithelial wound healing.5% solution in the eye q5-10min for 5-7 doses Administer as in adults Increases effects of phenylephrine and tropicamide C .
Caution in cardiac disease and hyperthyroidism. use may delay wound healing Description Adult Dose Pediatric Dose Interactions Pregnancy Precautions Contraindications Documented hypersensitivity 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. permitting the patient to maintain binocular vision during treatment. blocking conduction of impulse. Compared with patching. 3 Drug Name Description Adult Dose Pediatric Dose Diclofenac (Voltaren) Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase. particularly where potential medication-induced sedation is contraindicated. when used alone. This therapy may prove to be an effective alternative to patching.Precautions Drug Name Caution in cardiac disease or hyperthyroidism and those with abnormal or reduced levels of plasma esterases Tetracaine HCl 0. are effective at diminishing pain in patients with corneal abrasions who are required to return to immediate work. which results in decreased formation of prostaglandin precursors. This medication stings considerably on application.5-inch ribbon into conjunctival fornix Not established Antagonizes effect of sulfonamides and aminosalicylic acid C .Safety for use during pregnancy has not been established. continue for a maximum of 2 wk <12 years: Not established >12 years: Administer as in adults . Onset of action takes place within 1 min of application and anesthetic effect may last up to 15-20 min.5% (Pontocaine) Local anesthetic that blocks both initiation and conduction of nerve impulses by decreasing neuronal membrane's permeability to sodium ions. Available in solution and ointment. Results are inhibition of depolarization. the contact lens used with the NSAID may reduce pain. 1 gtt into affected eye qid. Solution: 1-2 gtt Ointment: Apply 0. Weaver et al found 3 recent good to strong studies that showed NSAIDs.
changes may include blurred or diminished vision. and macula degeneration Contraindications Documented hypersensitivity Interactions Pregnancy Precautions Drug Category: Systemic analgesics All but the most minor abrasions usually require a strong oral narcotic analgesic.Safety for use during pregnancy has not been established. 1 gtt into affected eye qid. cyclooxygenase. not to exceed 2.5% (Acular) Inhibits prostaglandin synthesis by decreasing activity of the enzyme.Contraindications Documented hypersensitivity Interactions Pregnancy Precautions Drug Name Description Adult Dose Pediatric Dose None reported B . corneal deposits and retinal disturbances. continue for a maximum of 2 wk <12 years: Not established >12 years: Administer as in adults None reported C . discontinue therapy if changes are noted. which results in decreased formation of prostaglandin precursors. Perform ophthalmologic studies in patients who develop eye complaints during therapy. Corneal thinning may occur Ketorolac tromethamine 0.6 g/d acetaminophen or 5 mg of hydrocodone bitartrate/dose >12 years: 750 mg PO acetaminophen q4h. which. Drug Name Description Adult Dose Hydrocodone bitartrate and acetaminophen (Vicodin ES) Drug combination indicated for the relief of moderate to severe pain. toxicity increases with CNS depressants or tricyclic antidepressants Pediatric Dose Contraindications Documented hypersensitivity Interactions . 1-2 tab or cap PO q4-6h prn <12 years: 10-15 mg/kg/dose PO acetaminophen q4-6h prn. scotomata. results in reduced inflammation. not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose Coadministration with phenothiazines may decrease analgesic effects. changes in color vision.Usually safe but benefits must outweigh the risks. in turn.
These agents relax any ciliary muscle spasm that may cause a deep. aching pain and photophobia. Tylox) Drug combination indicated for the relief of moderate to severe pain. not to exceed 5 mg/dose of oxycodone Phenothiazines may decrease analgesic effects. This results in dilation and loss of accommodation. to prevent an acute angle-closure attack. most ophthalmologists believe that the instillation of a long-acting cycloplegic agent can provide significant relief in patients who have extensive corneal abrasions. toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants C . thus. and blepharospasm. ensure that the patient does not have narrow-angle glaucoma. Drug Name Description Homatropine 2%. Roxicet. caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms. higher doses may cause liver toxicity Precautions Drug Name Description Adult Dose Pediatric Dose Contraindications Documented hypersensitivity Interactions Pregnancy Precautions 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. a large degree of photophobia. be aware of total daily dose of acetaminophen patient is receiving. which may cause hypersensitivity. Duration of action may increase in elderly persons.15 mg/kg/dose PO q4-6h or prn.Safety for use during pregnancy has not been established. 5% (Isopto Homatropine) Blocks the response of the iris sphincter muscle and the accommodative muscle of ciliary body to cholinergic stimulation. do not exceed 4000 mg/d of acetaminophen. However. Cycloplegic agents are mydriatics.Pregnancy C . caution in severe renal or hepatic dysfunction Oxycodone and acetaminophen (Percocet.05-0. Tabs contain metabisulfite.Safety for use during pregnancy has not been established. Useful for patients with dark iris. . 1-2 tab or cap PO q4-6h or prn Based on oxycodone dose: 0. Roxilox.
narrow-angle glaucoma. can cause toxic anticholinergic systemic adverse effects (common in children. if heavily pigmented irides. 1 gtt of 1% solution is usually adequate to induce cycloplegia. narrow-angle glaucoma Interactions Pregnancy Precautions Drug Name Description Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Precautions . or 2% solution to induce cycloplegia.5% into each eye q5-10min >1 year: Instill 1 gtt of a 0. toxic anticholinergic systemic adverse effects can occur.Safety for use during pregnancy has not been established. adverse effects are more common in children. elderly persons). Exercise caution in patients who may have increased IOP (eg. compressing lacrimal sac by digital pressure for 1-3 min following instillation minimizes systemic absorption Cyclopentolate HCl 1% (Cyclogyl) DOC in the treatment of cornea abrasions. instill 1 gtt of 0. compressing lacrimal sac by digital pressure for 1-3 min following application may minimize systemic absorption Pediatric Dose Contraindications Documented hypersensitivity. repeat in 15-20 min prn For prolonged cycloplegia: 1-2 gtt up to q3-4h. but are rare when used sparingly. repeat at 10-min intervals prn None reported C . These effects last up to 24 h. These effects last up to 48 h. Adult Dose Instill 1-2 gtt of 2% solution or 1 gtt of 5% solution to induce cycloplegia. Induces mydriasis in 30-60 min and cycloplegia in 25-75 min.5%. larger doses may be necessary Apply 1 gtt of 2% solution immediately before the procedure. especially infants) but incidence rare when used sparingly. repeat in 5-10 min prn Infants: Before examination.Induces mydriasis in 10-30 min and cycloplegia in 30-90 min. 1%. elderly persons). albinotic patients Decreases effects of carbachol and cholinesterase inhibitors Exercise caution in patients who may have increased IOP (eg. causing mydriasis and cycloplegia. Prevents the muscle of the ciliary body and the sphincter muscle of the iris from responding to cholinergic stimulation. repeat in 5-10 min prn Documented hypersensitivity. especially infants.
oxycodone. or both. 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. Cycloplegics may be required twice a day for large abrasions with significant photophobia. Patients typically are awakened in the early morning by the same symptoms as those of a corneal abrasion. Narcotic analgesics (eg. blepharospasm. Tape eyelids closed in unconscious patients and in those who cannot voluntarily close their eyelids (eg. hydrocodone) frequently are needed for severe pain until pain can be managed with over-the-counter analgesics. Advise eye rest (ie. Complications • • Recurrent epithelial erosion sometimes occurs days to weeks after a formerly healed abrasion caused by shearing injury (eg. other neuropathies). Ophthalmologic follow-up care and observation are indicated. fingernail. until healing is nearly complete. Corneal ulcerations (microbial keratitis) secondary to infected abrasions are more common after contact lens–related abrasions. In/Out Patient Meds • • • Antibiotics should be continued until the patient is asymptomatic. no reading or work that requires significant eye movement that might interfere with reepithelialization). Many emergency physicians refer patients with large abrasions to an ophthalmologist for follow-up care.FOLLOW-UP Further Outpatient Care • • • Minor abrasions should heal within 24-48 hours and do not require followup if completely asymptomatic at 48 hours. 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. . Reexamine large abrasions every 2 days until reepithelialization has occurred and the potential for infection no longer exists. Avoid light or wear sunglasses for comfort if significant photophobia exists. Bell palsy.
Patient Education • For excellent patient education resources. the prognosis is excellent with full recovery including visual acuity. 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 . Also. Foreign Body. string trimmer use. Eye. particularly neomycin Acute narrow-angle glaucoma precipitated by using mydriatics in patients with glaucoma Prognosis • • • In the vast majority of patients. MISCELLANEOUS Medical/Legal Pitfalls • • • Failure to consider the possibility of an intraocular foreign body or ocular perforation if history warrants (eg. see eMedicine's patient education articles Corneal Abrasion. secondary to ocular medications. the central area of the cornea directly over the pupil) heal but leave a scar. Some deep abrasions (involving the corneal stromal layer) within the central visual axis (ie. visit eMedicine's Eye and Vision Center. Healing of minor abrasions is expected within 24-48 hours. More extensive or deeper abrasions may require a week to heal. In these instances. a permanent loss of visual acuity may occur. and Eye Injuries.• • • Ocular tetanus (rare) Allergic conjunctivitis.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.