eMedicine Specialties > Emergency Medicine > Ophthalmology

Corneal Laceration

Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Nelson M Yang, MD, Staff Physician, Department of Emergency Medicine, Allegheny General Hospital

Updated: Apr 9, 2008

Introduction

Background

A corneal laceration is a partial- or full-thickness injury to the cornea. A partial-thickness injury does not violate the globe of the eye (abrasion). A full-thickness injury penetrates completely through the cornea, causing a ruptured globe. This topic discusses the full-thickness injury.

History sometimes points to a discrete event after which the patient’s symptoms started; however, this is not always the case. Small foreign bodies, digital trauma, or other more subtle sources of damage may not be quickly recalled by the patient. The physician must be meticulous in examining the cornea and periorbital structures if there is suspicion of a corneal laceration. Typically, patients who present with this type of injury complain of an intensely painful, profusely lacrimating eye. The bulbar conjunctiva will be injected with prominent blood vessels.

The first priority in evaluating a corneal injury is to include or exclude a full-thickness injury and the resulting ruptured globe. A full-thickness injury will allow aqueous humor to escape the anterior chamber, which can result in a flat-appearing cornea, air bubbles under the cornea, or an asymmetric pupil secondary to the iris protruding through the corneal defect.

For more information, see Medscape's Cornea and External Disease Resource Center and Medscape's Ophthalmology Specialty page.

Frequency

United States

The United States Eye Injury Registry (USEIR) is a terrific resource for nationwide eye trauma epidemiology, prevention techniques, and educational resources.

Penetrating eye injury can occur in individuals of any age, but data from USEIR demonstrate that the mean age of the patient with an ocular injury is 29 years (median age, 26 y), with nearly 60% being younger than 30 years.¹

The American Academy of Ophthalmology also has statistics available. These data suggest similar trends to the USEIR data.

The Centers for Disease Control and Prevention/National Institute of Occupational Safety and Health has information pertaining to work-related eye injuries.

International

International epidemiology of penetrating eye injury has similar demographics of who is likely to sustain corneal injury: males, between the ages of 25 and 30 years, associated with alcohol ingestion, injury occurring at home. Be aware of any local activities or traditions that may also predispose the local population to corneal injury.

Mortality/Morbidity

Mortality from corneal lacerations is rare. However, morbidity from corneal lacerations is significant. Corneal lacerations or subsequent secondary infection (endophthalmitis) can result in complete or partial loss of vision, loss of the eye, or systemic infection.

Sex

Males are more likely than females to have penetrating ocular injury.

Age

Although ocular trauma can occur in persons of all ages, most injuries occur in those aged 25-30 years.

Clinical

History

Document information such as the setting of the injury, changes in vision, or sensation of a foreign body on the eye. Even in the absence of foreign body sensation, evaluate whether there is a possibility of a foreign body entering the eye. Eye penetration may go unnoticed by the patient, particularly when small metal fragments break off and penetrate the eye, such as when metal is struck on metal, or when high-speed machinery is the source of the foreign body. Also, be aware that seemingly blunt objects can still cause lacerations if they contact the cornea in the right orientation. In cases like this, the patient may present for care later, after the development of increasing pain, deterioration in vision, or infection.

• Evaluation of visual acuity immediately following the injury is an important examination data point. Test visual acuity in each eye with a Snellen chart, or document the ability of the patient to distinguish number of fingers, movement, or light if the patient cannot read a Snellen chart. This will assist the ophthalmologist in determining what sort of intervention, therapy, and rehabilitation may be required.
• Obtain the patient's preinjury vision assessments as well as any history of previous ocular problems or ocular surgery.
• Document pertinent medical history, current medications, allergies, and tetanus immunization status.
• Determine information regarding the patient's last oral intake if operative intervention is anticipated.

Physical

• Assessment of visual acuity must be performed, taking care not to apply additional pressure to the globe. 
  • If possible, determine visual acuity prior to examination or treatment, and separately test each eye with corrective lenses. Pinhole testing may help differentiate refractive error from uncorrectable vision when spectacles are not available.
  • The objective of the testing is to get a visual reference as soon as possible after the injury. The examiner must be able to report the patient's vision status to the ophthalmologist.
  • Use age-appropriate vision testing devices such as the Snellen distance chart or a hand-held vision card.
  • Ask the patient to identify typed letters, the clock, or objects on the wall if the patient's condition prevents formal (standing upright) testing.
  • If a patient's vision is severely limited, determine whether the patient can count fingers, detect movement, or identify light.
• Slit lamp examination  
  • Examine the cornea using a slit beam to search for anterior chamber penetration. A shallow anterior chamber, irregularly shaped pupil (teardrop shape), hyphema (blood in the anterior chamber), bubbles in the anterior chamber, or a flat cornea can be signs of corneal perforation.
  • Aqueous humor leaking from the anterior chamber can be identified by performing a Seidel test. This test is performed by directly applying fluorescein to the suspected corneal lesion. Visualization of diluted dye under a black light (a positive test) suggests a leak. A negative Seidel test (no dilution of fluorescein) suggests a partial-thickness injury but may be seen in small or spontaneously sealing lesions. One should avoid the temptation to press on the globe to test for a self-sealing injury.
  • Be sure to evaluate for a foreign body in the anterior chamber, especially if the patient’s history suggests that the corneal laceration is from a small, high-speed object (such as from hammering metal).
• Full-thickness corneal lacerations  
  • Ophthalmology consultation is required for all types of corneal perforation.
  • Do not apply pressure to the globe.
  • Immediately place a protective shield (not a patch) over the affected eye.
  • Instruct the patient to avoid ocular movement because extraocular muscle contraction can cause extrusion of intraocular contents.
  • Full-thickness corneal lacerations often result in a loss of aqueous humor producing a shallow or flat anterior chamber.
  • Prolapse or incarceration of the iris may produce a teardrop distortion of the pupil.
  • Hyphema, or blood in the anterior chamber, can be another sign of anterior chamber penetration. Hyphema may also be seen with blunt, nonpenetrating trauma.

Causes

The causes of corneal lacerations are numerous and include but not limited to flying metal fragments, sharp objects, fingernails, air-bag deployment, fireworks, explosions, blunt force trauma, pellets, and BBs.

Differential Diagnoses

Other Problems to Be Considered

Once a diagnosis of corneal laceration is made, one must also consider the simultaneous presence of the following:

Corneal foreign body
Endophthalmitis 
Intraocular foreign body
Posterior chamber injury
Retinal injury
Orbital injury
Lens injury

Workup

Laboratory Studies

• No lab studies are useful for detecting the presence of a corneal laceration.

Imaging Studies

• Radiography, CT, or MRI may be indicated to locate intraocular or intraorbital foreign bodies or associated orbital, cranial, or facial trauma. MRI may be of some use if there is suspicion of an organic foreign body (eg, wood, plant matter). However, avoid MRI if there is any possibility of a metallic foreign body in the eye.

Other Tests

• Seidel test may be useful for detecting corneal lacerations.

Procedures

• Slit lamp biomicroscopy is essential.

Treatment

Prehospital Care

• Cover the patient's eye with an eye shield or polystyrene/paper cup and avoid any pressure to the globe.
• Instruct the patient to move the eyes as little as possible.
• Administer antiemetic and analgesic medication in order to reduce pressure on the globe.

Emergency Department Care

Perform an examination to ascertain the extent of the corneal, anterior chamber, ocular, and associated (eg, facial, cranial) injuries.

• Ophthalmologic consultation is indicated to convey the practitioner's findings and to decide on the appropriate evaluation, treatment, and timing of ophthalmologic evaluation.
• Place a protective eye shield (prefabricated or custom made) on the injured eye. This can be a commercial plastic eye shield or simply a polystyrene/paper cup taped over the eye.
• Administer antiemetics and systemic analgesic medication.
• Tetanus immunization or booster is indicated.
• In consultation with the ophthalmologist, discuss the administration of antibiotics including route (topical or intravenously) and frequency.
• In general, topical analgesia and antibiotics should be avoided if a corneal laceration is suspected. Use systemic analgesia and antibiotics. Topical anesthetics may be used, if needed, to facilitate visual acuity testing and the slit lamp examination.

Consultations

Ophthalmologic consultation is necessary. The two practitioners must decide and document when and where the consultation will occur.

Medication

Recommendations include a combination of a cephalosporin (eg, cefazolin) or vancomycin and an aminoglycoside (eg, gentamicin). In addition, add clindamycin if an intraocular foreign body is present or if vegetable matter has contaminated the wound. The most common organisms identified in posttraumatic endophthalmitis are Staphylococcus epidermidis, bacilli species, streptococci species, and gram-negative species. Fungal endophthalmitis is a relatively rare entity but should be considered in a patient who is recently post-surgical, immunocompromised, unresponsive to antibiotic treatment, or has a history of trauma with vegetable matter. Treatment should be discussed with the ophthalmology consultant if this is suspected.

Antibiotics

These agents are used in prophylaxis of endophthalmitis. Therapy must cover all likely pathogens in the context of the clinical setting.

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation cephalosporin antibiotic for gram-positive bacterial coverage. Commonly used in combination with an aminoglycoside to achieve broad-spectrum coverage.

Dosing

Adult

500-1000 mg IV q8h; not to exceed 1 g q6h for severe infection

Pediatric

25-50 mg/kg/d IV divided tid/qid; not to exceed 100 mg/kg/d divided tid/qid for severe infection

Interactions

Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test for glucose

Contraindications

Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; use of steroid combinations after uncomplicated removal of corneal foreign body

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside that provides coverage for most gram-negative organisms causing endophthalmitis.
Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not the antibiotic of first choice. Consider using this aminoglycoside when penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms.
Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution. May be administered IV or IM.

Dosing

Adult

3 mg/kg/d IV/IM divided tid; not to exceed 5 mg/kg/d for severe infections
Dosage adjustment is based upon peak/trough levels; renal function monitoring is recommended

Pediatric

7.5 mg/kg/d IV/IM divided tid
Dosage adjustment is based upon peak/trough levels; renal function monitoring is recommended

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Clindamycin (Cleocin)

Lincosamide useful as a treatment against serious skin and soft tissue infections caused by most staphylococci. Effective against aerobic and anaerobic streptococci, except enterococci.
Use in the prophylaxis of endophthalmitis when a foreign body is present or if the injury was soil or farm related to provide an effective agent against bacilli species.

Dosing

Adult

600-1200 mg/d IV divided bid/qid; not to exceed 4.8 g/d for life-threatening infections

Pediatric

20-40 mg/kg/d IV divided bid/qid

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococci species.
Can be used as an alternative to cefazolin to provide coverage for most gram-positive organisms causing endophthalmitis.
Use in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures.
To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose (drawn 0.5 h prior to next dosing). Use creatinine clearance to adjust the dose in patients with renal impairment.

Dosing

Adult

2 g/d IV divided bid/qid

Pediatric

30-40 mg/kg/d IV divided bid/qid

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; concurrent use with aminoglycosides may increase risk of nephrotoxicity above that of aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure, neutropenia; "red man" syndrome (not an allergic reaction) is caused by too rapid IV infusion (dose administered over a few min) but rarely happens when dose administered over 2-h period or PO or IP

Follow-up

Further Inpatient Care

• Follow-up care is determined at the time of the initial ophthalmologic consultation and will take place in the setting of the patient's overall condition.
• An isolated partial-thickness corneal laceration may be monitored on an outpatient basis.
• A patient who sustains a corneal laceration as part of other trauma may have to be evaluated in the hospital.

Deterrence/Prevention

• Patients that engage in activities that place their eyes at risk for trauma should be encouraged to wear protective eyewear at all times.

Complications

• Corneal lacerations frequently are complicated by corneal or intraocular foreign bodies, infections, traumatic cataracts, and secondary glaucoma.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose a corneal laceration in a patient with appropriate history or physical examination
• Failure to obtain an ophthalmology consultation and attempting to treat in the ED
• Failure to recognize a corneal injury in the setting of multiple system trauma

References

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Keywords

full-thickness corneal injury, partial-thickness corneal injury, penetrating globe injury, ocular trauma, corneal laceration, corneal abrasion, ruptured globe

Contributor Information and Disclosures

Author

Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Andrew A Aronson, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Nelson M Yang, MD, Staff Physician, Department of Emergency Medicine, Allegheny General Hospital
Disclosure: Nothing to disclose.

Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine; Consulting Staff, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Douglas Lavenburg, MD, Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems
Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

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
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Program Director, Department of Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, and Wesley S Grigsby, MD, to the development and writing of this article.

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