eMedicine Specialties > Emergency Medicine > Ophthalmology

Corneal Abrasion

Feras H Khan, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate, Kings County Hospital, Brooklyn
Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn

Updated: Jul 27, 2009

Introduction

Background

The cornea is a transparent cover over the anterior part of the eye that serves several purposes: protection, refraction, as well as filtration of some ultraviolet light. It has no blood vessels and receives nutrients through tears as well as from the aqueous humor. It is innervated primarily by the ophthalmic division of the trigeminal nerve as well as the oculomotor nerve.

Pathophysiology

The cornea is composed of 5 layers (anterior to posterior): the corneal epithelium, Bowman’s layer, corneal stroma, Descemet’s membrane, and the corneal endothelium. A corneal abrasion is a violation in the surface of the most superficial layer, the epithelium.

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

The exact frequency of emergency department visits for corneal abrasions is unknown. A survey completed in 1985 showed that around 3% of all cases to general practitioners were corneal abrasions.¹ In the United States, 65,000 work-related eye injuries and illnesses that cause missed time from work occur each year.²

International

The rates of corneal abrasions have been reported at 12.5% at eye casualty departments in the United Kingdom.³ A study by Wong et al looked at the incidence of ocular injury in US automobile workers between July 1989 and June 1992 at 33 UAW-Chrysler Corporation plants. A total of 1983 work-related eye injuries occurred, with 86.7% of cases being superficial foreign bodies and corneal abrasions.⁴

Mortality/Morbidity

Corneal abrasions can lead to lost time from work. A large study completed in the automobile industry showed that 32% of workers with eye injuries were unable to resume their normal duties for at least one day. Unfortunately, only 25% of workers in this study were wearing eye protection at the time of injury.⁴ A retrospective review from Torino, Italy, showed that ocular injuries including corneal abrasions were associated with a significant morbidity.⁵

Nevertheless, significant morbidity is uncommon but can be seen with infectious complications. Recurrent erosions are a common complication of abrasions, particularly in patients with epithelial basement membrane dystrophy.

In addition, corneal abrasions associated with contact lenses can progress to bacterial keratitis and lead to further ocular damage (including perforation or corneal scarring) if not treated promptly.⁶

Race

No evidence exists of a racial predisposition to corneal abrasions.

Sex

Looking at automotive workers, men have a higher incidence of injury when compared to women of all ages.⁴

Age

Incidence of corneal abrasion is more common in younger, active individuals. Automotive workers between the ages of 20-29 years had the highest incidence of eye injuries.⁴

Clinical

History

• Eye pain (occasionally severe), tearing, and foreign-body sensation are present.
• Patients sometimes complain of a foreign body sensation while keeping the eye shut. Other symptoms include photophobia, pain with extraocular movement, tearing, or blurred vision.
• A history of blunt or sharp trauma can usually be elicited.
• A detailed history with questions regarding recent sports activities, makeup application, excessive rubbing of the eyes, use of contact lenses (including poorly fitting lenses and duration of use), and motor vehicle accidents, should be elicited.
• The occupation of the patient should be noted because certain people exposed to metals may have penetrating globe injuries. 
• Unconscious patients, such as ICU patients who are sedated and have lost their corneal reflexes, are prone to iatrogenic corneal abrasions.

Physical

• The eyes should be opened with the lids retracted in order to get a full look at the cornea as well as conjunctiva. Extraocular movements should be assessed, and the pupillary reflex should be elicited. Occasionally, the patient may have a reactive miosis.
• If there is any history or signs of globe injury with violation of ocular contents, a plastic or metal shield should be placed and an ophthalmologist should be called urgently.
• Visual acuity should be assessed. If the abrasion affects the visual axis, then there may be a deficit in acuity that should be apparent when compared to the uninjured eye.
• If the examination is limited by pain, then a topical anesthetic such as tetracaine or proparacaine may be used. The amount of anesthetic used should be minimal, as these agents have been shown to slow wound healing.⁷
• Visual inspection for foreign objects should be performed. Both upper and lower eyelids should be flipped in order to look for foreign bodies that may be lodged in the upper eyelid causing injury with eye blinking. Also see, Foreign Body, Intraocular.
• The cornea can become hazy if there is edema due to the abrasion. Conjunctival injection usually located near the limbus may also be present.

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
  • Corneal foreign bodies - Objects difficult to see (eg, small glass fragments)

Corneal foreign body.

Corneal foreign body after removal.

• 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 metal-on-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 abrasion-like 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

Corneal keratitis and staining.

Differential Diagnoses

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
Iritis (see Iritis and Uveitis)
Acute angle-closure glaucoma

Workup

Laboratory 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.
  • Severe photophobia that causes blepharospasm may require instillation of a cycloplegic agent (ie, cyclopentolate [Cyclogyl], homatropine) 20-30 minutes prior to examination.
  • Perform fluorescein instillation and examination with blue light.
  • Examine the anterior chamber for evidence of iritis (flare, cells).
• The diagnosis of corneal abrasion is confirmed with instillation of fluorescein, which stains the basement membrane after an exposure in the corneal epithelium. This causes the abrasion to appear green using cobalt blue light or a Wood's lamp.

Corneal foreign body with cobalt blue lighting showing abrasion.

• Fluorescein is applied using a paper strip applicator that is gently placed over the inferior cul-de-sac of the eye and allowing saline or anesthetic solution to drop into the eye. Once the patient blinks, the dye is spread over the cornea and any abrasion should be visible. If the patient has suffered penetrating ocular trauma, then leaking aqueous humor may be seen (Seidel sign).
• Corneal abrasions associated with contact lenses tend to be punctate or can be larger in a round shape. 
• Multiple linear, vertical abrasions suggest a foreign body under the upper eyelid.
• 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).
  • 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.
  • 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.)
• Corneal abrasions used to be patched with the thought that a patch would promote healing and epithelial proliferation and cause less pain. However, multiple trials have shown that this practice has no benefit. A meta-analysis of 7 trials showed similar healing rates between patching and no patching.⁸ Six studies evaluated pain; no difference was found in 4 studies, whereas 2 favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. Flynn et al noted that, in patients with corneal abrasion, eye patching was not found to improve healing rates or reduce pain. They recommended no intervention when treating corneal abrasions due to the possible loss of binocular vision and possible increased pain.
• A Cochrane Database of Systematic Review article looked at 11 trials that studied a total of 1014 participants, which showed that eye patching did not reduce pain or improve wound healing.⁹ This review included pediatric patients as well.¹⁰
• Eye patches also result in a loss of binocular vision, which can lead to further traumatic injury and patient disability. Lastly, patients do not tolerate eye patches very well, and they are usually removed due to discomfort.¹¹  
• Topical nonsteroidal anti-inflammatory drugs (NSAIDs) have been found to be useful in reducing pain.¹² A systematic review and meta-analysis showed that topical NSAIDs were effective as analgesics for traumatic corneal abrasions.¹³ Also, patients were more likely to take fewer oral analgesics and return to work earlier.¹²
• In the past, mydriatics were a main part of pain control for corneal abrasions. However, there is a lack of evidence to support such a claim.¹⁴ It was thought that these medications ease spasm of the ciliary muscle in patients with corneal abrasions, but no strong evidence supports their use. Occasionally, medications such as cyclopentolate (Cyclogyl) or homatropine have been prescribed.
• Oral pain medications, such as Tylenol #3 or oxycodone and acetaminophen (Percocet), have been used as an adjunct to topical treatments. This may help the patient get rest and stop rubbing the affected eye and allow for healing to occur. No clinical trials that directly look at oral pain medications are available. Pain relief is the main goal, and a case-by-case clinical decision needs to be made in order to guide possible oral therapy. 
• Antibiotics have been a mainstay of treatment even though there is not strong evidence in favor of their use. The general principle has been to avoid superinfection of the abrasion. A non-placebo-controlled prospective cohort study showed that the use of 1% chloramphenicol ointment led to a lower rate of corneal ulceration.¹⁵ Another trial looking at fusidic acid eye drops did not improve corneal abrasion healing rates when compared to chloramphenicol ointment.¹⁶ The decision to use prophylactic antibiotics should be made by each treating clinician.
• If antibiotics are to be used, then an ointment is preferred to drops as it acts a lubricant. Choices include erythromycin or sulfacetamide ointment 4 times daily for 3-5 days.
• Patients who wear contact lenses are at risk of pseudomonal infection and should receive antibiotics (eg, ciprofloxacin, gentamicin, or ofloxacin) accordingly.¹⁷ The patient should be advised to not use contact lenses until the abrasion has healed and the patient has been reevaluated by an ophthalmologist.
• Foreign bodies should be removed using either irrigation or a cotton-tipped swab. If this does not work, then a 25- to 26-gauge needle can be used parallel to the eye while stabilizing the head to avoid patient movement during the procedure. If the foreign object cannot be removed, the patient should be seen by an ophthalmologist within 24 hours. Also see, Foreign Body Removal, Cornea.
• Patients with rust rings after metallic object removal should be treated as patients with corneal abrasions. Usually, these rust rings can be removed at a later date. 

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.

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 pseudomonas) 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.

Trimethoprim/polymyxin B (Polytrim)

Used for treatment of ocular infections involving cornea or conjunctiva.
Available as solution and ointment.

Dosing

Adult

Solution: 1-2 gtt q2h in the affected eye while awake
Ointment: Apply 0.5-inch ribbon into conjunctival sac qid

Pediatric

<2 months: Not established
>2 months: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; viral and mycobacterial infections of the eye; fungal diseases

Precautions

Pregnancy

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

Precautions

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.

Dosing

Adult

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

Pediatric

<2 months: Not established
>2 months: Administer as in adults

Interactions

Effects decreased when used concurrently with gentamicin

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 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.

Dosing

Adult

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

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Interactions

None reported

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

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.

Dosing

Adult

1-2 gtt qid for 7 d
Suspected corneal ulcers: 1-2 gtt qh for first 24 h, then qid for 7 d

Pediatric

<1 year: Not established
>1 year: Administer as in adults

Interactions

None reported

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

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.

Dosing

Adult

1-2 gtt qid for 7 d
Suspected corneal ulcers: 1-2 gtt qh for first 24 h, then qid for 7 d

Pediatric

<1 year: Not established
>1 year: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, mycobacterial, and fungal eye infections; avoid coadministration with steroid combinations after uncomplicated removal of a foreign body from cornea

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

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

Gentamicin (Genoptic)

Aminoglycoside antibiotic used for gram-negative bacterial coverage.

Dosing

Adult

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

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; patients taking steroid combinations after uncomplicated removal of a foreign body from cornea

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

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

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.

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.

Dosing

Adult

1-2 gtt of 0.5% solution in the eye q5-10min for 5-7 doses

Pediatric

Administer as in adults

Interactions

Increases effects of phenylephrine and tropicamide

Contraindications

Documented hypersensitivity; prolonged use

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 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.

Dosing

Adult

Solution: 1-2 gtt
Ointment: Apply 0.5-inch ribbon into conjunctival fornix

Pediatric

Not established

Interactions

Antagonizes effect of sulfonamides and aminosalicylic acid

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 cardiac disease and hyperthyroidism; use may delay wound healing

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.

Diclofenac (Voltaren)

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.

Dosing

Adult

1 gtt into affected eye qid, continue for a maximum of 2 wk

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

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

Precautions

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.

Dosing

Adult

1 gtt into affected eye qid, continue for a maximum of 2 wk

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

None reported

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

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

Systemic analgesics

All but the most minor abrasions usually require a strong oral narcotic analgesic.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for the relief of moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

<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

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

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

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.

Dosing

Adult

1-2 tab or cap PO q4-6h or prn

Pediatric

Based on oxycodone dose: 0.05-0.15 mg/kg/dose PO q4-6h or prn; not to exceed 5 mg/dose of oxycodone

Interactions

Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

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

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

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.

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.

Dosing

Adult

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

Pediatric

Apply 1 gtt of 2% solution immediately before the procedure; repeat at 10-min intervals prn

Interactions

None reported

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

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

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.

Dosing

Adult

1 gtt of 1% solution is usually adequate to induce cycloplegia; repeat in 5-10 min prn

Pediatric

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

Interactions

Decreases effects of carbachol and cholinesterase inhibitors

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; albinotic patients

Precautions

Pregnancy

Precautions

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

Follow-up

Further Inpatient Care

• Patients with corneal abrasions are managed on an outpatient basis.

Further Outpatient Care

• The patient should be seen by an ophthalmologist within 24-48 hours to assess for healing. Usually, abrasions heal quickly within 24 hours, and patients will not need long-term follow-up. Patients with contact lens – associated abrasions or large abrasions may need to follow up over the course of 3-5 days to ensure healing and avoid infection.
• Advise eye rest (ie, no reading or work that requires significant eye movement that might interfere with reepithelialization).
• Advise patients to avoid light or to wear sunglasses for comfort if significant photophobia exists.

Inpatient & Outpatient Medications

• 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

• Persons who work in high-risk occupations such as auto-mechanics, metalworkers, or miners should wear protective eyewear. People who participate in contact sports such as hockey, lacrosse, or racquet sports such as squash or racquetball should always wear protective eyewear.
• 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).
• Patients who wear contact lenses should make sure they fit properly and change them accordingly.

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 lens – related 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

Medicolegal 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

Multimedia

Media file 1: Corneal keratitis and staining.

Media file 2: Corneal foreign body.

Media file 3: Corneal foreign body after removal.

Media file 4: Corneal foreign body with cobalt blue lighting showing abrasion.

References

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Keywords

corneal abrasion, corneal epithelial defect, corneal abrasion treatment, scratched cornea, scraped eye, scraped cornea, eye trauma, scratched eye, corneal surface

Contributor Information and Disclosures

Author

Feras H Khan, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate, Kings County Hospital, Brooklyn
Feras H Khan, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

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, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, 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.

I would like to thank Samala Khan, OD, for supplying the visual images.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Robert M Howell, MD, to the development and writing of this article.

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