Corneal Abrasion

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

INTRODUCTION
Background
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.

Pathophysiology

The cornea of the eye and, commonly, the bulbar conjunctiva, are affected. Minor or superficial abrasions involve only the corneal epithelium. Severe injuries also involve the deeper, thicker stromal layer.

Frequency
United States Corneal abrasions are a common ophthalmologic cause of ED visits.

Mortality/Morbidity
Death is uncommon. Significant morbidity is uncommon but is mostly observed in conjunction with infectious complications or allergies to medications used in treatment. Recurrent erosions are a common complication of abrasions, particularly in patients with epithelial basement membrane dystrophy.

Age
Incidence of corneal abrasion is more common in younger, active individuals. Occurrence is unusual in elderly adults.

CLINICAL
History

Eye pain (occasionally severe), tearing, and foreign-body sensation are present. Photophobia with blepharospasm is common, particularly if the abrasion is large or the presentation is delayed. A history of blunt or sharp trauma can usually be elicited. A history of extended contact lens wear is not uncommon. Unconscious patients are prone to iatrogenic corneal abrasions.

Physical

Bulbar conjunctival injection is usually present. Visual acuity is usually normal, 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).

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.

Causes

Injury (eg, fingers, fingernails, paper, mascara brushes, tree branches, self-inflicted rubbing, pepper-spray exposure, automotive frontal air bags) Blowing dust, sand, or debris Extended contact lens wear Ocular foreign bodies imbedded under an eyelid Iatrogenic - Unconscious patients, accidental injury by health care workers, improper eyelid patching in patients with Bell palsy, and other neuropathies in which the eyelid cannot be closed voluntarily Other causes or risk factors
o o

o o

Corneal foreign bodies - Objects difficult to see (eg, small glass fragments) Corneal perforation - Distorted pupil (sometimes), leaking aqueous humor (sometimes leaks from corneal perforations become visible when fluorescein is applied), low intraocular pressure (IOP), history of high-velocity injury (eg, lawn mowers, string trimmers), or metalon-metal hammering Corneal ulcer (microbial keratitis) - Fluorescein stain with an additional underlying or surrounding corneal infiltrate (eg, white spot, haze) Keratitis or keratoconjunctivitis - Diffuse punctate fluorescein staining of the cornea, with or without conjunctivitis Recurrent epithelial erosion - Rather sudden onset (usually on awakening) of abrasionlike symptoms, days to weeks after a healed abrasion caused by shearing injury (eg, fingernail, mascara brush) Ultraviolet keratitis - History of exposure to electric arc welding or tanning beds without proper eye protection, history of prolonged exposure to bright sunlight without sunglasses (eg, "snow blindness"), delayed onset of symptoms (several hours); diffuse punctate fluorescein staining of cornea

DIFFERENTIALS
Conjunctivitis Corneal Laceration Corneal Ulceration and Ulcerative Keratitis

Glaucoma, Acute Angle-Closure Iritis and Uveitis

Other Problems to be Considered

Corneal foreign bodies Corneal perforation - (See Causes and Corneal Laceration.) Keratitis or keratoconjunctivitis (eg, epidemic keratoconjunctivitis [EKC]) Recurrent epithelial erosion Conjunctivitis - Injection of both bulbar and lid conjunctiva without corneal stain uptake (See Conjunctivitis.) Iritis - Nonstaining cornea, with flare and cells in anterior chamber (See Iritis and Uveitis.) Acute angle-closure glaucoma - Nonstaining cornea, increased intraocular pressure (IOP) (See Glaucoma, Acute Angle-Closure.)

WORKUP
Lab Studies

If a corneal ulcer (eg, microbial keratitis) is suspected (prolonged symptoms, contact lens wear), consider obtaining bacterial cultures before instilling antibiotics.

Imaging Studies

If ocular penetration with a retained foreign body is suspected, such as in a high-velocity injury (eg, lawn mower, string trimmer, hammering metal), then an ocular CT scan, ocular MRI (nonmetallic), or both, are indicated.

Procedures

Slit-lamp examination A topical anesthetic (ie, proparacaine, tetracaine) may facilitate the examination. o Severe photophobia that causes blepharospasm may require instillation of a cycloplegic agent (ie, Cyclogyl, homatropine) 20-30 minutes prior to examination. o Perform fluorescein instillation and examination with blue light. o Examine anterior chamber for evidence of iritis (flare, cells). Perform an examination by using a Wood lamp with fluorescein if a slit lamp is not available.
o

Evert the eyelid to look for blepharoconjunctival foreign bodies. Fluorescein can permanently stain soft contact lenses; remove them prior to staining.

TREATMENT
Prehospital Care
If ocular penetration is a possibility, protect with an eye shield. Limit vomiting if possible. Do not remove perforating foreign bodies.

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. Follow the Centers for Disease Control and Prevention (CDC) guidelines for tetanus toxoid (Td for adults, DT for children <7 y) and tetanus immunoglobulin (TIG). o Corneal injuries produced by organic matter or dirt, as well as those associated with tissue necrosis and those associated with entrance of dirt or organic material into the conjunctival sac, should be considered dirty (ie, tetanus-prone) injuries and require boosters within 5 years. o Corneal injuries caused by metallic foreign bodies associated with minimal tissue destruction should be considered clean (ie, non tetanus-prone) injuries and require boosters within 10 years. (As of January 2005, no case reports in the literature indicate clinical tetanus developing from a simple corneal abrasion.) In a 1998 meta-analysis in the Journal of Family Practice, Flynn et al examined patching for corneal abrasions. Six studies evaluated pain. No difference was found in 4 studies, while 2 favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. Flynn et al noted: "Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, the route of harmless nonintervention in treating corneal abrasions is recommended."1 In a 2002 randomized trial in children in the Annals of Emergency Medicine, Michael et al found no difference in the rate of healing,
o

discomfort, or complications, other than a greater difficulty walking in the patch group.2

Consultations
Emergent ophthalmologic consultation is warranted for suspected retained intraocular foreign bodies. Urgent consultation is needed for suspected corneal ulcerations (microbial keratitis).

MEDICATION
Topical antibiotics are often used to treat corneal abrasions. Oral analgesics also may be indicated. Drug Category: Antibiotics Routine use of topical antibiotics for corneal abrasions remains controversial. Many emergency physicians have stopped using these agents for minor injuries, although others continue treating corneal abrasions with broad-spectrum antibiotic ointments for infection prophylaxis and lubrication. Antibiotic use persists despite unproved efficacy and evidence that ointments may retard corneal epithelial healing. For large or dirty abrasions, many practitioners prescribe broad-spectrum antibiotic drops, such as trimethoprim/polymyxin B (Polytrim) or sulfacetamide sodium (Sulamyd, Bleph-10), which are inexpensive and least likely to cause any complications. Alternatives are an aminoglycoside or a fluoroquinolone. Contact lens-associated abrasions warrant antibiotic treatment due to their propensity for developing infectious corneal ulcers (microbial keratitis). Coverage for gram-negative organisms (especially pseudomonads) is recommended with agents such as gentamicin (Garamycin), tobramycin (Tobrex), norfloxacin (Chibroxin), or ciprofloxacin (Ciloxan). Avoid antibiotics containing neomycin (eg, 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. Ointments that retain their antibacterial effect longer can be used less often (every 4-6 h) but are more uncomfortable due to visual blurring. Drug Name Description Trimethoprim/polymyxin B (Polytrim) Used for treatment of ocular infections involving cornea or conjunctiva. Available as solution and ointment.

Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Precautions Drug Name Description

Solution: 1-2 gtt q2h in the affected eye while awake Ointment: Apply 0.5-inch ribbon into conjunctival sac qid <2 months: Not established >2 months: Administer as in adults Documented hypersensitivity; viral and mycobacterial infections of the eye; fungal diseases None reported B - Usually safe but benefits must outweigh the risks. Do not use in deep ocular infections or in those likely to become systemic; prolonged use of antibiotics or repeated therapy may result in bacterial or fungal overgrowth of nonsusceptible organism Sulfacetamide sodium 10% (Sulamyd, Bleph-10) Interferes with bacterial growth by inhibiting bacterial folic acid synthesis through competitive antagonism of PABA. Available as solution, ointment, and lotion. Solution: 1-3 gtt q2-3h in the affected eye, while awake; less frequently at night Ointment: Apply 0.5-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 - Safety for use during pregnancy has not been established. Caution in severely dried eye; ointment may retard corneal epithelial healing Tobramycin (Tobrex) Aminoglycoside that interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, causing a defective bacterial cell membrane. Available as solution, ointment, and lotion. Solution: 1-2 gtt q4h in the affected eye, while awake; less frequently at night Severe infections: 2 gtt q30-60min for the first 24 h, followed by less frequent intervals Ointment: Apply 0.5-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

>2 years: Administer as in adults Contraindications Documented hypersensitivity Interactions Pregnancy None reported C - Safety for use during pregnancy has not been established. Do not use in deep-seated ocular infections or in those that may 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. 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 - Safety for use during pregnancy has not been established. 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 Ciprofloxacin (Ciloxan) Inhibits bacterial growth by inhibiting DNA gyrase. 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; viral, mycobacterial, and fungal eye infections; avoid coadministration with steroid Contraindications combinations after uncomplicated removal of a foreign body from cornea Interactions Pregnancy Precautions None reported C - Safety for use during pregnancy has not been established. 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 Drug Name Description Gentamicin (Genoptic) Aminoglycoside antibiotic used for gram-negative bacterial coverage. Solution: 1-2 gtt q4h in the affected eye, while awake; less frequently at night Severe infections: 2 gtt q30-60min for the first 24 h, followed by less frequent intervals <2 years: Not established >2 years: Administer as in adults

Adult Dose

Pediatric Dose

Documented hypersensitivity; mycobacterial, viral, and fungal Contraindications infections of the eye; patients taking steroid combinations after uncomplicated removal of a foreign body from cornea Interactions Pregnancy None reported C - Safety for use during pregnancy has not been established. Do not use to treat ocular infections that may become systemic; 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. These agents should never be prescribed for home use because they may cause a secondary keratitis, compromise epithelial wound healing, and block effective corneal protective reflexes and sensation. Drug Name Proparacaine 0.5% (Ophthaine) Least irritating of all topical anesthetics. Prevents initiation and transmission of impulse at the nerve cell membrane by stabilizing it and decreasing ion permeability. Onset of action for this anesthetic takes place within 20 sec of application. Anesthetic effect may last up to 10-15 min. 1-2 gtt of 0.5% solution in the eye q5-10min for 5-7 doses Administer as in adults Increases effects of phenylephrine and tropicamide C - Safety for use during pregnancy has not been established.

Description

Adult Dose Pediatric Dose Interactions Pregnancy

Contraindications Documented hypersensitivity; prolonged use

Precautions Drug Name

Caution in cardiac disease or hyperthyroidism and those with abnormal or reduced levels of plasma esterases Tetracaine HCl 0.5% (Pontocaine) Local anesthetic that blocks both initiation and conduction of nerve impulses by decreasing neuronal membrane's permeability to sodium ions. Results are inhibition of depolarization, blocking conduction of impulse. Available in solution and ointment. Onset of action takes place within 1 min of application and anesthetic effect may last up to 15-20 min. This medication stings considerably on application. Solution: 1-2 gtt Ointment: Apply 0.5-inch ribbon into conjunctival fornix Not established Antagonizes effect of sulfonamides and aminosalicylic acid C - Safety for use during pregnancy has not been established. 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. This therapy may prove to be an effective alternative to patching, permitting the patient to maintain binocular vision during treatment. Compared with patching, the contact lens used with the NSAID may reduce pain. Weaver et al found 3 recent good to strong studies that showed NSAIDs, when used alone, are effective at diminishing pain in patients with corneal abrasions who are required to return to immediate work, particularly where potential medication-induced sedation is contraindicated. 3 Drug Name Description Adult Dose Pediatric Dose Diclofenac (Voltaren) Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors. 1 gtt into affected eye qid, continue for a maximum of 2 wk <12 years: Not established >12 years: Administer as in adults

Contraindications Documented hypersensitivity Interactions Pregnancy Precautions Drug Name Description Adult Dose Pediatric Dose None reported B - Usually safe but benefits must outweigh the risks. Corneal thinning may occur Ketorolac tromethamine 0.5% (Acular) Inhibits prostaglandin synthesis by decreasing activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors, which, in turn, results in reduced inflammation. 1 gtt into affected eye qid, continue for a maximum of 2 wk <12 years: Not established >12 years: Administer as in adults None reported C - Safety for use during pregnancy has not been established. Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color 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. Drug Name Description Adult Dose Hydrocodone bitartrate and acetaminophen (Vicodin ES) Drug combination indicated for the relief of moderate to severe pain. 1-2 tab or cap PO q4-6h prn <12 years: 10-15 mg/kg/dose PO acetaminophen q4-6h prn; not to exceed 2.6 g/d acetaminophen or 5 mg of hydrocodone bitartrate/dose >12 years: 750 mg PO acetaminophen q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Pediatric Dose

Contraindications Documented hypersensitivity Interactions

Pregnancy

C - Safety for use during pregnancy has not been established. Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox) Drug combination indicated for the relief of moderate to severe pain. 1-2 tab or cap PO q4-6h or prn Based on oxycodone dose: 0.05-0.15 mg/kg/dose PO q4-6h or prn; not to exceed 5 mg/dose of oxycodone Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants C - Safety for use during pregnancy has not been established. Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/d of acetaminophen; 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. However, most ophthalmologists believe that the instillation of a long-acting cycloplegic agent can provide significant relief in patients who have extensive corneal abrasions, a large degree of photophobia, and blepharospasm. These agents relax any ciliary muscle spasm that may cause a deep, aching pain and photophobia. Cycloplegic agents are mydriatics; thus, to prevent an acute angle-closure attack, ensure that the patient does not have narrow-angle glaucoma. Drug Name Description Homatropine 2%, 5% (Isopto Homatropine) Blocks the response of the iris sphincter muscle and the accommodative muscle of ciliary body to cholinergic stimulation. This results in dilation and loss of accommodation. Useful for patients with dark iris.

Induces mydriasis in 10-30 min and cycloplegia in 30-90 min. 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; repeat in 15-20 min prn For prolonged cycloplegia: 1-2 gtt up to q3-4h; if heavily pigmented irides, larger doses may be necessary Apply 1 gtt of 2% solution immediately before the procedure; repeat at 10-min intervals prn None reported C - Safety for use during pregnancy has not been established. Exercise caution in patients who may have increased IOP (eg, elderly persons); toxic anticholinergic systemic adverse effects can occur, but are rare when used sparingly; adverse effects are more common in children, especially infants; 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. Prevents the muscle of the ciliary body and the sphincter muscle of the iris from responding to cholinergic stimulation, causing mydriasis and cycloplegia. Induces mydriasis in 30-60 min and cycloplegia in 25-75 min. These effects last up to 24 h. 1 gtt of 1% solution is usually adequate to induce cycloplegia; repeat in 5-10 min prn Infants: Before examination, instill 1 gtt of 0.5% into each eye q5-10min >1 year: Instill 1 gtt of a 0.5%, 1%, or 2% solution to induce cycloplegia; repeat in 5-10 min prn Documented hypersensitivity; narrow-angle glaucoma; albinotic patients Decreases effects of carbachol and cholinesterase inhibitors Exercise caution in patients who may have increased IOP (eg, elderly persons); can cause toxic anticholinergic systemic adverse effects (common in children, especially infants) but incidence rare when used sparingly; compressing lacrimal sac by digital pressure for 1-3 min following application may minimize systemic absorption

Pediatric Dose

Contraindications Documented hypersensitivity; narrow-angle glaucoma Interactions Pregnancy

Precautions

Drug Name

Description

Adult Dose

Pediatric Dose

Contraindications Interactions Pregnancy

Precautions

FOLLOW-UP
Further Outpatient Care

Minor abrasions should heal within 24-48 hours and do not require followup if completely asymptomatic at 48 hours. Reexamine large abrasions every 2 days until reepithelialization has occurred and the potential for infection no longer exists. Many emergency physicians refer patients with large abrasions to an ophthalmologist for follow-up care. Advise eye rest (ie, no reading or work that requires significant eye movement that might interfere with reepithelialization). Avoid light or wear sunglasses for comfort if significant photophobia exists.

In/Out Patient Meds

Antibiotics should be continued until the patient is asymptomatic. Narcotic analgesics (eg, oxycodone, hydrocodone) frequently are needed for severe pain until pain can be managed with over-the-counter analgesics. Cycloplegics may be required twice a day for large abrasions with significant photophobia, blepharospasm, or both, until healing is nearly complete.

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. Tape eyelids closed in unconscious patients and in those who cannot voluntarily close their eyelids (eg, Bell palsy, other neuropathies).

Complications

Recurrent epithelial erosion sometimes occurs days to weeks after a formerly healed abrasion caused by shearing injury (eg, fingernail, 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. Patients typically are awakened in the early morning by the same symptoms as those of a corneal abrasion. Ophthalmologic follow-up care and observation are indicated. Corneal ulcerations (microbial keratitis) secondary to infected abrasions are more common after contact lensrelated abrasions.

Ocular tetanus (rare) Allergic conjunctivitis, secondary to ocular medications, particularly neomycin Acute narrow-angle glaucoma precipitated by using mydriatics in patients with glaucoma

Prognosis

In the vast majority of patients, the prognosis is excellent with full recovery including visual acuity. Some deep abrasions (involving the corneal stromal layer) within the central visual axis (ie, the central area of the cornea directly over the pupil) heal but leave a scar. In these instances, a permanent loss of visual acuity may occur. Healing of minor abrasions is expected within 24-48 hours. More extensive or deeper abrasions may require a week to heal.

Patient Education

For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Corneal Abrasion; Foreign Body, Eye; and Eye Injuries.

MISCELLANEOUS
Medical/Legal Pitfalls

Failure to consider the possibility of an intraocular foreign body or ocular perforation if history warrants (eg, string trimmer use, 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