Corneal abrasion: Difference between revisions
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==Background== | ==Background== | ||
*Must rule-out | [[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]] | ||
*Must rule-out intra[[ocular foreign body]] and corneal laceration | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Airbag-corneal-abrasion1.png|thumb|Corneal Abrasions from Airbag Deployment]] | |||
[[File:Airbag-corneal-abrasion2.png|thumb|Corneal Abrasions from Airbag Deployment]] | |||
*Foreign body sensation | *Foreign body sensation | ||
*Photophobia (+/- consensual) | *Photophobia (+/- consensual) | ||
*Decreased vision | *[[Vision loss|Decreased vision]] | ||
**If associated iritis or if abrasion occurs in visual axis | **If associated iritis or if abrasion occurs in visual axis | ||
*Relief of pain with topical anesthesia | *[[Eye pain]] | ||
**Virtually diagnostic of corneal abrasion | **Relief of [[eye pain|pain]] with topical anesthesia | ||
***Virtually diagnostic of corneal abrasion | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Unilateral red eye DDX}} | {{Unilateral red eye DDX}} | ||
== | ==Evaluation== | ||
*A complete [[Eye Exam|eye exam]] should be conducted | *A complete [[Eye Exam|eye exam]] should be conducted | ||
*Eyelid Exam | *Eyelid Exam | ||
**Flip upper lid and exam lower lid for | **Flip upper lid and exam lower lid for foreign body | ||
**If concern for | **If concern for foreign body despite normal exam, consider orbital CT or MRI if certain foreign body is nonmetallic | ||
*Fluorescein Exam | *Fluorescein Exam | ||
**Apply 1 gtt of flourescein or | **Apply 1 gtt of flourescein or use strip with anesthetic | ||
**Use Wood's | **Use Wood's lamp or [[slit lamp]] with cobalt blue light | ||
** | **Fluorescein will fill corneal defects and glow | ||
**Multiple vertical abrasions suggests foreign body embedded under the upper lid | **Multiple vertical abrasions suggests foreign body embedded under the upper lid | ||
*Topical anesthetic (ie proparacaine or tetracaine) may assist in patient cooperation with exam once open globe excluded. | |||
**Repeated doses or Rx for topical anesthesia is controversial given concerns for impaired healing | |||
===Additional Considerations=== | ===Additional Considerations=== | ||
*Contact lens wearer | *[[contact lens problems|Contact lens]] wearer | ||
**If white spot or opacity on exam concerning for infiltrate or | **If white spot or opacity on exam concerning for infiltrate or [[Corneal ulcer]] refer for same day ophtho appt | ||
*Fluorescein Examination | *Fluorescein Examination | ||
**Seidel sign (streaming of fluorescein) indicates [[Globe rupture|penetrating trauma]] | **Seidel sign (streaming of fluorescein) indicates [[Globe rupture|penetrating trauma]] | ||
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*Pupil shape and reactivity | *Pupil shape and reactivity | ||
**Irregular or nonreactive pupil suggests pupillary sphincter injury and possible penetrating trauma | **Irregular or nonreactive pupil suggests pupillary sphincter injury and possible penetrating trauma | ||
*[[Traumatic hyphema|Hyphema]] or hypopyon | *[[Traumatic hyphema|Hyphema]] or [[hypopyon]] | ||
**Hyphema suggests possible penetrating injury | **Hyphema suggests possible penetrating injury | ||
**If present then same same-day ophtho consult is required | **If present then same same-day ophtho consult is required | ||
| Line 44: | Line 47: | ||
*[[Corneal Ulcer]] | *[[Corneal Ulcer]] | ||
**Grayish white lesion | **Grayish white lesion | ||
**Worsening symptoms >1day | **Worsening symptoms >1day | ||
== | {{Corneal abrasion vs ulcer}} | ||
==Management== | |||
===Antibiotics=== | ===Antibiotics=== | ||
{{Corneal Abrasion Antibiotics}} | {{Corneal Abrasion Antibiotics}} | ||
===Analgesia=== | ===[[Analgesia]]=== | ||
*Systemic [[NSAIDs]] or | *Systemic [[NSAIDs]] or [[opioids]] | ||
* | *[[Cycloplegic]]s can be consider for patients with large abrasions (>2mm) and/or severe pain | ||
**Cyclopentolate 1% 1 drop q6-8hr | **[[Cyclopentolate]] 1% 1 drop q6-8hr | ||
*Ophthalmic [[NSAIDs]] | *Ophthalmic [[NSAIDs]] | ||
**[[Ketorolac]] 0.4% 1 drop q6hr x 2-3d | **[[Ketorolac]] 0.4% 1 drop q6hr x 2-3d | ||
*Topical anesthetics | *Topical anesthetics | ||
**[[Tetracaine]] 1% 1 drop q30min has been found to be safe in the first 24 hrs<ref>Waldman N, et al. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med. 2014; 21(4):374-82.</ref> | **[[Tetracaine]] 1% 1 drop q30min has been found to be safe in the first 24 hrs<ref>Waldman N, et al. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med. 2014; 21(4):374-82.</ref> | ||
**Proparacaine 0.05% ophthalmic (dilute 1 mL of proparacaine 0.5% with 9 mL of NS in flush syringe then place 3 mL in bottle) 1-2 drops in eye Q30 min PRN pain for 24-48 hours only<ref>Salim Rezaie, "Topical Anesthetic Use on Corneal Abrasions", REBEL EM blog, April 21, 2014. Available at: https://rebelem.com/topical-anesthetic-use-corneal-abrasions/.</ref> | |||
===Other=== | ===Other=== | ||
*Tetanus prophylaxis not indicated (unless penetrating injury)<ref>Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.</ref> | *[[Tetanus prophylaxis]] not indicated (unless penetrating injury)<ref>Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.</ref> | ||
*Patch is not routinely recommended<ref>Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.</ref> and can prolong healing time<ref>Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.</ref> | *Patch is not routinely recommended<ref>Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.</ref> and can prolong healing time<ref>Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.</ref> | ||
==Disposition== | ==Disposition== | ||
*Ophtho | *Ophtho follow up in 48h for routine cases | ||
*Minor abrasions will heal in | *Minor abrasions will heal in 48-72h | ||
==See Also== | |||
*[[Eye Algorithms (Main)]] | |||
==External Links== | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Ophthalmology]] | [[Category:Ophthalmology]] | ||
Latest revision as of 19:53, 29 May 2024
Background
- Must rule-out intraocular foreign body and corneal laceration
Clinical Features
- Foreign body sensation
- Photophobia (+/- consensual)
- Decreased vision
- If associated iritis or if abrasion occurs in visual axis
- Eye pain
- Relief of pain with topical anesthesia
- Virtually diagnostic of corneal abrasion
- Relief of pain with topical anesthesia
Differential Diagnosis
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Hemorrhagic chemosis
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Evaluation
- A complete eye exam should be conducted
- Eyelid Exam
- Flip upper lid and exam lower lid for foreign body
- If concern for foreign body despite normal exam, consider orbital CT or MRI if certain foreign body is nonmetallic
- Fluorescein Exam
- Apply 1 gtt of flourescein or use strip with anesthetic
- Use Wood's lamp or slit lamp with cobalt blue light
- Fluorescein will fill corneal defects and glow
- Multiple vertical abrasions suggests foreign body embedded under the upper lid
- Topical anesthetic (ie proparacaine or tetracaine) may assist in patient cooperation with exam once open globe excluded.
- Repeated doses or Rx for topical anesthesia is controversial given concerns for impaired healing
Additional Considerations
- Contact lens wearer
- If white spot or opacity on exam concerning for infiltrate or Corneal ulcer refer for same day ophtho appt
- Fluorescein Examination
- Seidel sign (streaming of fluorescein) indicates penetrating trauma
- Branching/Dendritic pattern suggests possible Herpes Zoster Ophthalmicus
- Visual acuity
- If poor, consider corneal edema versus infectious infiltrate
- Pupil shape and reactivity
- Irregular or nonreactive pupil suggests pupillary sphincter injury and possible penetrating trauma
- Hyphema or hypopyon
- Hyphema suggests possible penetrating injury
- If present then same same-day ophtho consult is required
- Extruded ocular contents
- If yes then place eye shield and obtain emergent ophtho referral
- Corneal Ulcer
- Grayish white lesion
- Worsening symptoms >1day
Corneal abrasion vs. corneal ulcer
| Characteristic | Corneal abrasion | Corneal ulcer |
| History | *Acute pain immediately after injury | *Delayed pain frequently 2-3 days or more after initial event |
| Lesion viewable on fluorescein exam | *Yes | *Yes |
| Lesion viewable on white light exam | *No | *Yes |
| Lesion morphology | *Frequently linear, punctate, patterned, and/or irregular | *Commonly circular |
Management
Antibiotics
Does Not Wear Contact Lens
- Erythromycin ointment qid x 3-5d OR
- Ciprofloxacin 0.3% ophthalmic solution 2 drops q6 hours OR
- Ofloxacin 0.3% solution 2 drops q6 hours OR
- Sulfacetamide 10% ophthalmic ointment q6 hours
Wears Contact Lens
Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones
- Levofloxacin 0.5% solution 2 drops ever 2 hours for 2 days THEN q6hrs for 5 days OR
- Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
- Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR
- Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
- Gentamicin 0.3% solution 2 drops six times for 5 days
Analgesia
- Systemic NSAIDs or opioids
- Cycloplegics can be consider for patients with large abrasions (>2mm) and/or severe pain
- Cyclopentolate 1% 1 drop q6-8hr
- Ophthalmic NSAIDs
- Ketorolac 0.4% 1 drop q6hr x 2-3d
- Topical anesthetics
- Tetracaine 1% 1 drop q30min has been found to be safe in the first 24 hrs[1]
- Proparacaine 0.05% ophthalmic (dilute 1 mL of proparacaine 0.5% with 9 mL of NS in flush syringe then place 3 mL in bottle) 1-2 drops in eye Q30 min PRN pain for 24-48 hours only[2]
Other
- Tetanus prophylaxis not indicated (unless penetrating injury)[3]
- Patch is not routinely recommended[4] and can prolong healing time[5]
Disposition
- Ophtho follow up in 48h for routine cases
- Minor abrasions will heal in 48-72h
See Also
External Links
References
- ↑ Waldman N, et al. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med. 2014; 21(4):374-82.
- ↑ Salim Rezaie, "Topical Anesthetic Use on Corneal Abrasions", REBEL EM blog, April 21, 2014. Available at: https://rebelem.com/topical-anesthetic-use-corneal-abrasions/.
- ↑ Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.
- ↑ Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.
- ↑ Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.