Corneal abrasion: Difference between revisions
 
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==Background==
==Background==
#Must rule-out intraocular foreign body and corneal laceration
[[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==
#Foreign body sensation
[[File:Airbag-corneal-abrasion1.png|thumb|Corneal Abrasions from Airbag Deployment]]
#Photophobia (+/- consensual)
[[File:Airbag-corneal-abrasion2.png|thumb|Corneal Abrasions from Airbag Deployment]]
#Decreased vision
*Foreign body sensation
##If associated iritis or if abrasion occurs in visual axis
*Photophobia (+/- consensual)
#Relief of pain with topical anesthesia
*[[Vision loss|Decreased vision]]
##Virtually diagnostic of corneal abrasion
**If associated iritis or if abrasion occurs in visual axis
*[[Eye pain]]
**Relief of [[eye pain|pain]] with topical anesthesia
***Virtually diagnostic of corneal abrasion


==Diagnosis==
==Differential Diagnosis==
#Visual acuity
{{Unilateral red eye DDX}}
##If substantially subnormal evaluate for corneal edema versus infectious infiltrate 
#Pupil shape and reactivity
##Irregular or nonreactive pupil suggests pupillary sphincter injury
###Evaulate for penetrating injury
#Hyphema or hypopyon?
##If yes then same same-day ophtho consult is required
##Hyphema suggests possible penetrating injury
#Extruded ocular contents?
##If yes then place eye shield and obtain emergent ophtho referral 
#Contact lens wearer?
##If yes AND e/o white spot or opacity on exam concerning for infiltrate or ulceration ###Refer for same day ophtho appt
#Fluorescein Examination
##Seidel sign (streaming of fluorescein caused by leaking aqueous humor)
###Indicates penetrating trauma (globe microperforation)
##Multiple vertical abrasions suggests foreign body embedded under the upper lid
##Branching pattern suggests possible [[Herpes Zoster Ophthalmicus]]
#[[Corneal Ulcer]]?
##Grayish white
##Worsening symptoms >1day
#Intraocular foreign body?
##If concern for foreign body but none visualized on external exam consider CT orbit


==DDx==
==Evaluation==
#[[Corneal Ulcer]]
*A complete [[Eye Exam|eye exam]] should be conducted
#[[Herpes Zoster Ophthalmicus]]
*Eyelid Exam
#Corneal laceration
**Flip upper lid and exam lower lid for foreign body
#Intra-ocular 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


==Foreign Body Removal Techniques==
===Additional Considerations===
#Irrigation
*[[contact lens problems|Contact lens]] wearer
#Cotton swab
**If white spot or opacity on exam concerning for infiltrate or [[Corneal ulcer]] refer for same day ophtho appt
#18-25G needle
*Fluorescein Examination
**Seidel sign (streaming of fluorescein) indicates [[Globe rupture|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
*[[Traumatic hyphema|Hyphema]] or [[hypopyon]]
**Hyphema suggests possible penetrating injury
**If present then same same-day ophtho consult is required
*[[Globe rupture|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 ulcer}}
 
==Management==
===Antibiotics===
{{Corneal Abrasion Antibiotics}}
 
===[[Analgesia]]===
*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
*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<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>


==Treatment==
===Other===
#Antibiotics - Indicated for all abrasions  
*[[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>
##Ointment is better than drops due to its lubricant effect
*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>
###Erythromycin ointment qid x 3-5d
##If treatintg contact lens associated abrasion must cover pseudomonas
###Cipro/ofloxacin or tobramycin drops qid x 3-5d
#Analgesia
##Cycloplegics
###Consider for patients with large abrasions (>2mm) and/or severe pain
####Cyclopentolate 1% 1 drop q6-8hr
##Systemic opiods
##Never give Rx for topical anesthetics
#Tetanus prophylaxis
##Only indicated for penetrating injuries, not for abrasions or foreign bodies
#Rust Ring
##Treat similar to pts with corneal abrasions


==Disposition==
==Disposition==
#Ophtho f/u in 48h
*Ophtho follow up in 48h for routine cases
*Minor abrasions will heal in 48-72h
 
==See Also==
*[[Eye Algorithms (Main)]]


==Source==
==External Links==
*UpToDate
*Tintinalli


==See Also==
==References==
*[[Corneal Ulcer]]
<references/>
*[[Conjunctival Abrasion]]


[[Category:Ophtho]]
[[Category:Ophthalmology]]

Latest revision as of 19:53, 29 May 2024

Background

Eye anatomy.

Clinical Features

Corneal Abrasions from Airbag Deployment
Corneal Abrasions from Airbag Deployment
  • 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

Differential Diagnosis

Unilateral red eye

^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
  • 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

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
  • Ophthalmic NSAIDs
  • 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

Disposition

  • Ophtho follow up in 48h for routine cases
  • Minor abrasions will heal in 48-72h

See Also

External Links

References

  1. ↑ 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.
  2. ↑ Salim Rezaie, "Topical Anesthetic Use on Corneal Abrasions", REBEL EM blog, April 21, 2014. Available at: https://rebelem.com/topical-anesthetic-use-corneal-abrasions/.
  3. ↑ Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.
  4. ↑ Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.
  5. ↑ Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.
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