Corneal abrasion: Difference between revisions

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(Separate diagnostic features from additional features, add topical nsaid, add topical anesthetics, reformat)
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==Diagnosis==
==Diagnosis==
#A complete [[Eye Exam|eye exam]] should be conducted
#Eyelid Exam
#*Flip upper lid and exam lower lid for FB
#*If concern for FB despite normal exam, consider orbital CT or MRI is certain it is nonmetallic
#Fluorescein Exam
#*Apply 1 gtt of flourescein or utilize strip with anesthetic
#*Use Wood's Lamp or Slit Lamp with colbalt blue light
#*Fluoresceine will fill corneal defects and glow
#*Multiple vertical abrasions suggests foreign body embedded under the upper lid
==Additional Considerations==
#Contact lens wearer
#*If white spot or opacity on exam concerning for infiltrate or ulceration refer for same day ophtho appt
#Fluorescein Examination
#*Seidel sign (streaming of fluorescein) indicates [[Globe rupture|penetrating trauma]]
#*Branching/Dendritic pattern suggests possible [[Herpes Zoster Ophthalmicus]]
#Visual acuity
#Visual acuity
##If substantially subnormal evaluate for corneal edema versus infectious infiltrate   
#*If poor, consider corneal edema versus infectious infiltrate   
#Pupil shape and reactivity
#Pupil shape and reactivity
##Irregular or nonreactive pupil suggests pupillary sphincter injury  
#*Irregular or nonreactive pupil suggests pupillary sphincter injury and possible penetrating trauma
###Evaulate for penetrating injury
#[[Traumatic hyphema|Hyphema]] or hypopyon
#Hyphema or hypopyon?
#*Hyphema suggests possible penetrating injury
##If yes then same same-day ophtho consult is required
#*If present then same same-day ophtho consult is required
##Hyphema suggests possible penetrating injury
#[[Globe rupture|Extruded ocular contents]]
#Extruded ocular contents?
#*If yes then place eye shield and obtain emergent ophtho referral   
##If yes then place eye shield and obtain emergent ophtho referral   
#[[Corneal Ulcer]]
#Contact lens wearer?
#*Grayish white lesion
##If yes AND e/o white spot or opacity on exam concerning for infiltrate or ulceration ###Refer for same day ophtho appt
#*Worsening symptoms >1day  
#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


==Differential Diagnosis==
==Differential Diagnosis==
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===Analgesia===
===Analgesia===
*Cyclopentolate 1% 1 drop q6-8hr
*Systemic NSAIDs or opiates
**Cycloplegics can be consider for patients with large abrasions (>2mm) and/or severe pain
*Cycloplegics can be consider for patients with large abrasions (>2mm) and/or severe pain
*Systemic NSAIDs or opiods
**Cyclopentolate 1% 1 drop q6-8hr
*Never give prescription for topical anesthetics
*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>


===Other===
===Other===
*Tetanus prophylaxis not indicated (unless penetrating injury)
*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>


==Disposition==
==Disposition==
#Ophtho f/u in 48h for routine cases
#Ophtho f/u in 48h for routine cases
#Minor abrasions will heal in 48h


==Source==
==Source==

Revision as of 16:18, 9 February 2015

Background

  • Must rule-out intraocular foreign body and corneal laceration
    • Evert eyelid

Clinical Features

  • Foreign body sensation
  • Photophobia (+/- consensual)
  • Decreased vision
    • If associated iritis or if abrasion occurs in visual axis
  • Relief of pain with topical anesthesia
    • Virtually diagnostic of corneal abrasion
Corneal Abrasions from Airbag Deployment
Corneal Abrasions from Airbag Deployment

Diagnosis

  1. A complete eye exam should be conducted
  2. Eyelid Exam
    • Flip upper lid and exam lower lid for FB
    • If concern for FB despite normal exam, consider orbital CT or MRI is certain it is nonmetallic
  3. Fluorescein Exam
    • Apply 1 gtt of flourescein or utilize strip with anesthetic
    • Use Wood's Lamp or Slit Lamp with colbalt blue light
    • Fluoresceine will fill corneal defects and glow
    • Multiple vertical abrasions suggests foreign body embedded under the upper lid

Additional Considerations

  1. Contact lens wearer
    • If white spot or opacity on exam concerning for infiltrate or ulceration refer for same day ophtho appt
  2. Fluorescein Examination
  3. Visual acuity
    • If poor, consider corneal edema versus infectious infiltrate
  4. Pupil shape and reactivity
    • Irregular or nonreactive pupil suggests pupillary sphincter injury and possible penetrating trauma
  5. Hyphema or hypopyon
    • Hyphema suggests possible penetrating injury
    • If present then same same-day ophtho consult is required
  6. Extruded ocular contents
    • If yes then place eye shield and obtain emergent ophtho referral
  7. Corneal Ulcer
    • Grayish white lesion
    • Worsening symptoms >1day

Differential Diagnosis

Treatment

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

Pediatric

Same topical regimens as adults

  • Erythromycin 0.5% ointment applied QID x 3-5 days (preferred in young children)
  • Moxifloxacin 0.5% ophthalmic solution 1-2 drops QID x 5 days

Analgesia

  • Systemic NSAIDs or opiates
  • 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]

Other

  • Tetanus prophylaxis not indicated (unless penetrating injury)[2]
  • Patch is not routinely recommended[3] and can prolong healing time[4]

Disposition

  1. Ophtho f/u in 48h for routine cases
  2. Minor abrasions will heal in 48h

Source

  • UpToDate
  • Tintinalli

See Also

  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. ↑ Mukherjee P, et al. Tetanus prophylaxis in superficial corneal abrasions. Emerg Med J. 2003; 20:62-64.
  3. ↑ Flynn CA, et al. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998; 47(4):264-70.
  4. ↑ Fraser, S. Corneal abrasion. Clin Ophthalmol. 2010; 4:387-390.
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