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Emergency and Acute Medicine – Corneal Abrasion
Definition and General Description
A corneal abrasion is defined as any tear, defect, or disruption of the corneal epithelium. It is a common ocular injury that may result from direct trauma, spontaneous epithelial breakdown, foreign body exposure, or contact lens use. Because the cornea is densely innervated, even small epithelial defects can cause significant pain and visual disturbance.
Etiology and Mechanisms of Injury
Traumatic corneal abrasions are most frequently caused by fingernails, tree branches, hairbrushes or combs, sand or small stones, snow, pens or pencils, toys, chemical exposures, airbag deployment, pepper spray, paper or cardboard, makeup applicators, and animal paws. Foreign body–related abrasions may occur from materials such as wood, glass, metal, rust, plastic, fiberglass, or vegetable matter, including foreign bodies trapped beneath the eyelid. Contact lens–related abrasions are associated with overwear, improper lens fit, or inadequate lens hygiene. Spontaneous corneal abrasions usually occur in patients with a history of prior corneal trauma or those with an underlying defect of the corneal epithelium, such as recurrent corneal erosion syndrome.
Clinical Presentation
Patients typically present with severe ocular pain accompanied by a gritty or scratchy sensation, excessive tearing, blepharospasm, and a persistent foreign body sensation. Photophobia is common and may be pronounced if traumatic iritis is present. Additional symptoms include conjunctival injection, blurred or diminished vision, and headache.
The history should specifically address any direct trauma to the eye, known or suspected foreign body exposure, contact lens use, previous corneal abrasions, prior ocular or periocular surgery, pre-existing visual impairment, and the timing of symptom onset. Associated injuries or symptoms should be assessed, as well as any treatment attempted before presentation. Inquiry about occupational or recreational eye protection, systemic diseases such as diabetes or autoimmune disorders, and tetanus immunization status is also important.
Pediatric Considerations
In children, the presentation may differ significantly from adults. Excessive crying may be the primary manifestation. In infants younger than 12 months, there is often no clear history of eye trauma, and corneal abrasion may present as an inconsolable crying infant. In neonates and infants aged 1–12 weeks, corneal abrasions may be incidental findings and not the cause of irritability. Children older than 12 months are more likely to have a history of minor eye trauma and demonstrate more obvious ocular signs.
Physical Examination and Diagnostic Evaluation
If clinically indicated, the initial evaluation should include assessment for other life-threatening injuries following standard primary survey principles. A focused but complete eye examination is essential and should aim to exclude penetrating injury or infection. This includes gross inspection of the eye, assessment of visual acuity, and a penlight examination to evaluate conjunctival injection, pupil shape and reactivity, and the presence of corneal opacity or infiltrate. The upper eyelids should be everted to assess for retained foreign bodies. Slit-lamp examination allows evaluation of the anterior chamber for inflammation, detection of corneal laceration or penetrating trauma, and identification of infiltrates. Fluorescein staining is used to confirm the diagnosis and determine the size and location of the epithelial defect.
In pediatric patients, handheld slit lamps and Wood lamps can be particularly helpful in facilitating examination.
Differential Diagnosis
The differential diagnosis includes viral or bacterial conjunctivitis, corneal ulcer, acute glaucoma, herpes zoster ophthalmicus, infectious or ultraviolet keratitis, recurrent corneal erosion syndrome, and uveitis. More serious ocular injuries must also be considered, including corneal laceration or perforation, hyphema, iris prolapse, and lens disruption.
Initial Management and Emergency Department Care
Initial therapy includes instillation of a topical anesthetic, such as proparacaine or tetracaine, to facilitate examination. In the emergency department, superficial foreign bodies should be removed when present. A residual rust ring does not require emergent removal and can be addressed within 24–48 hours. Pain control may be achieved with oral NSAIDs, acetaminophen, or oral opioids when necessary.
Topical NSAIDs such as diclofenac or ketorolac have demonstrated effectiveness for pain control, although there are rare reports of adverse effects; these agents should be avoided in patients with pre-existing ocular surface disease or those who have recently undergone eye surgery. Cycloplegic agents may be used selectively to relieve ciliary spasm, including cyclopentolate, tropicamide, or homatropine.
Topical antibiotics are commonly prescribed despite limited evidence, primarily to prevent secondary infection. Ointments are preferred over drops due to their lubricating properties. Antibiotics should be discontinued once the patient has been symptom free for 24 hours. Contact lens wearers require antipseudomonal coverage, such as ciprofloxacin. Eye patching does not improve healing or pain control, particularly within the first 24 hours, and is not recommended for small abrasions. Patching should never be used in contact lens wearers or in injuries with high infection risk, such as those involving organic matter. The role of patching in large abrasions greater than 10 mm remains unclear.
Contact lenses should not be worn until the abrasion has fully healed and the eye has felt normal for at least one week without medication. In cases of severe pain, a bandage contact lens may be considered, provided there is no evidence of infection and close daily follow-up is ensured. Routine tetanus prophylaxis is not required, but immunization should be updated if the abrasion is caused by or contaminated with dirt or organic material. Emergent ophthalmology consultation is required for suspected intraocular foreign bodies, penetrating globe injuries, or the presence of corneal infiltrates, white spots, or opacities.
Medications
Commonly used medications include topical ciprofloxacin 0.35% drops four times daily, erythromycin 0.5% ointment four times daily, gentamicin drops or ointment, sulfacetamide drops or ointment, and tobramycin drops or ointment. Cycloplegics such as cyclopentolate, tropicamide, or homatropine may be used as indicated. Topical NSAIDs include diclofenac 0.1% or ketorolac 0.5% drops four times daily. Proparacaine should be used only once in the emergency department and not prescribed for outpatient use.
Disposition and Follow-Up
Hospital admission is reserved for patients with associated injuries requiring inpatient care. All uncomplicated corneal abrasions may be discharged from the emergency department. Although no definitive studies define optimal follow-up, standard practice recommends follow-up for all corneal abrasions to ensure complete healing without infection or scarring. Contact lens wearers, patients with patched eyes, or those with bandage contact lenses should be re-evaluated by ophthalmology within 24 hours. Central or large abrasions also warrant ophthalmologic follow-up within 24 hours, while smaller peripheral abrasions may be rechecked within 48–72 hours.
Essential Clinical Cautions and Common Errors
Clinicians must always carefully evaluate for penetrating globe injuries and signs of infection. Patients should never be discharged with topical anesthetics, as these agents are toxic to the corneal epithelium and delay healing, despite limited evidence suggesting dilute formulations may be safe. Mydriatic agents should not be used in patients with a history of glaucoma. Contact lens use should not be resumed until the patient has been evaluated and cleared by ophthalmology.
Definition and General Description
A corneal abrasion is defined as any tear, defect, or disruption of the corneal epithelium. It is a common ocular injury that may result from direct trauma, spontaneous epithelial breakdown, foreign body exposure, or contact lens use. Because the cornea is densely innervated, even small epithelial defects can cause significant pain and visual disturbance.
Etiology and Mechanisms of Injury
Traumatic corneal abrasions are most frequently caused by fingernails, tree branches, hairbrushes or combs, sand or small stones, snow, pens or pencils, toys, chemical exposures, airbag deployment, pepper spray, paper or cardboard, makeup applicators, and animal paws. Foreign body–related abrasions may occur from materials such as wood, glass, metal, rust, plastic, fiberglass, or vegetable matter, including foreign bodies trapped beneath the eyelid. Contact lens–related abrasions are associated with overwear, improper lens fit, or inadequate lens hygiene. Spontaneous corneal abrasions usually occur in patients with a history of prior corneal trauma or those with an underlying defect of the corneal epithelium, such as recurrent corneal erosion syndrome.
Clinical Presentation
Patients typically present with severe ocular pain accompanied by a gritty or scratchy sensation, excessive tearing, blepharospasm, and a persistent foreign body sensation. Photophobia is common and may be pronounced if traumatic iritis is present. Additional symptoms include conjunctival injection, blurred or diminished vision, and headache.
The history should specifically address any direct trauma to the eye, known or suspected foreign body exposure, contact lens use, previous corneal abrasions, prior ocular or periocular surgery, pre-existing visual impairment, and the timing of symptom onset. Associated injuries or symptoms should be assessed, as well as any treatment attempted before presentation. Inquiry about occupational or recreational eye protection, systemic diseases such as diabetes or autoimmune disorders, and tetanus immunization status is also important.
Pediatric Considerations
In children, the presentation may differ significantly from adults. Excessive crying may be the primary manifestation. In infants younger than 12 months, there is often no clear history of eye trauma, and corneal abrasion may present as an inconsolable crying infant. In neonates and infants aged 1–12 weeks, corneal abrasions may be incidental findings and not the cause of irritability. Children older than 12 months are more likely to have a history of minor eye trauma and demonstrate more obvious ocular signs.
Physical Examination and Diagnostic Evaluation
If clinically indicated, the initial evaluation should include assessment for other life-threatening injuries following standard primary survey principles. A focused but complete eye examination is essential and should aim to exclude penetrating injury or infection. This includes gross inspection of the eye, assessment of visual acuity, and a penlight examination to evaluate conjunctival injection, pupil shape and reactivity, and the presence of corneal opacity or infiltrate. The upper eyelids should be everted to assess for retained foreign bodies. Slit-lamp examination allows evaluation of the anterior chamber for inflammation, detection of corneal laceration or penetrating trauma, and identification of infiltrates. Fluorescein staining is used to confirm the diagnosis and determine the size and location of the epithelial defect.
In pediatric patients, handheld slit lamps and Wood lamps can be particularly helpful in facilitating examination.
Differential Diagnosis
The differential diagnosis includes viral or bacterial conjunctivitis, corneal ulcer, acute glaucoma, herpes zoster ophthalmicus, infectious or ultraviolet keratitis, recurrent corneal erosion syndrome, and uveitis. More serious ocular injuries must also be considered, including corneal laceration or perforation, hyphema, iris prolapse, and lens disruption.
Initial Management and Emergency Department Care
Initial therapy includes instillation of a topical anesthetic, such as proparacaine or tetracaine, to facilitate examination. In the emergency department, superficial foreign bodies should be removed when present. A residual rust ring does not require emergent removal and can be addressed within 24–48 hours. Pain control may be achieved with oral NSAIDs, acetaminophen, or oral opioids when necessary.
Topical NSAIDs such as diclofenac or ketorolac have demonstrated effectiveness for pain control, although there are rare reports of adverse effects; these agents should be avoided in patients with pre-existing ocular surface disease or those who have recently undergone eye surgery. Cycloplegic agents may be used selectively to relieve ciliary spasm, including cyclopentolate, tropicamide, or homatropine.
Topical antibiotics are commonly prescribed despite limited evidence, primarily to prevent secondary infection. Ointments are preferred over drops due to their lubricating properties. Antibiotics should be discontinued once the patient has been symptom free for 24 hours. Contact lens wearers require antipseudomonal coverage, such as ciprofloxacin. Eye patching does not improve healing or pain control, particularly within the first 24 hours, and is not recommended for small abrasions. Patching should never be used in contact lens wearers or in injuries with high infection risk, such as those involving organic matter. The role of patching in large abrasions greater than 10 mm remains unclear.
Contact lenses should not be worn until the abrasion has fully healed and the eye has felt normal for at least one week without medication. In cases of severe pain, a bandage contact lens may be considered, provided there is no evidence of infection and close daily follow-up is ensured. Routine tetanus prophylaxis is not required, but immunization should be updated if the abrasion is caused by or contaminated with dirt or organic material. Emergent ophthalmology consultation is required for suspected intraocular foreign bodies, penetrating globe injuries, or the presence of corneal infiltrates, white spots, or opacities.
Medications
Commonly used medications include topical ciprofloxacin 0.35% drops four times daily, erythromycin 0.5% ointment four times daily, gentamicin drops or ointment, sulfacetamide drops or ointment, and tobramycin drops or ointment. Cycloplegics such as cyclopentolate, tropicamide, or homatropine may be used as indicated. Topical NSAIDs include diclofenac 0.1% or ketorolac 0.5% drops four times daily. Proparacaine should be used only once in the emergency department and not prescribed for outpatient use.
Disposition and Follow-Up
Hospital admission is reserved for patients with associated injuries requiring inpatient care. All uncomplicated corneal abrasions may be discharged from the emergency department. Although no definitive studies define optimal follow-up, standard practice recommends follow-up for all corneal abrasions to ensure complete healing without infection or scarring. Contact lens wearers, patients with patched eyes, or those with bandage contact lenses should be re-evaluated by ophthalmology within 24 hours. Central or large abrasions also warrant ophthalmologic follow-up within 24 hours, while smaller peripheral abrasions may be rechecked within 48–72 hours.
Essential Clinical Cautions and Common Errors
Clinicians must always carefully evaluate for penetrating globe injuries and signs of infection. Patients should never be discharged with topical anesthetics, as these agents are toxic to the corneal epithelium and delay healing, despite limited evidence suggesting dilute formulations may be safe. Mydriatic agents should not be used in patients with a history of glaucoma. Contact lens use should not be resumed until the patient has been evaluated and cleared by ophthalmology.
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