Corneal abrasion

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Loss of corneal epithelial tissue due to:

  • sub-tarsal foreign body
  • trauma (e.g. fingernail, twig, edge of paper, mascara brush)
  • contact lens related trauma
  • trichiasis (e.g. lash contact in entropion)

Predisposing factors

Contact lens wear

Corneal dystrophy

  • Epithelial Basement Membrane (EBM) dystrophy, in which epithelium is abnormal and easily traumatised

Corneal exposure

  • dry eye
  • lagophthalmos
  • facial palsy

Diabetes

Neurotrophic keratitis

Symptoms

Pain

  • ranges from mild foreign body sensation to severe pain; may be disproportionate to objective findings
  • absence of pain should alert to possibility of neurotrophic keratitis

Blepharospasm

Photophobia

Lacrimation

Redness

History of trauma

Signs

Vary according to severity of trauma

Lid oedema and erythema

Conjunctival hyperaemia

Corneal epithelial defect (stains with fluorescein)

Corneal oedema beneath defect

Visual loss (due to epithelial disruption and stromal oedema)

Possible secondary anterior uveitis (anterior ciliary injection, cells, flare)

Differential diagnosis

Infectious keratitis (all forms)

Recurrent corneal erosion

Spontaneous epithelial breakdown in EBM Dystrophy (see Clinical Management Guideline on Recurrent Erosion Syndrome)

Photokeratitis (see Clinical Management Guideline on Photokeratitis)

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Determine how the injury was caused. In particular rule out chemical injury and penetrating trauma

Evaluate abrasion using fluorescein

  • size (use length of slit beam) and location
  • depth
  • edge quality
  • oedema beneath abrasion
  • confirm no corneal foreign body present

If corneal foreign body present, (see Clinical Management Guideline on Corneal Foreign Body

Evaluate anterior chamber reaction

Evert eyelids to confirm no foreign body present

If sub-tarsal foreign body present, (see Clinical Management Guideline on SubTarsal Foreign Body)

Advise patient to return/seek further help if symptoms persist (potential for development of Recurrent Epithelial Erosion Syndrome (see CMG on Recurrent Epithelial Erosion Syndrome)

Advise on suitable eye protection

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

For large abrasions, consider therapeutic contact lens fitting

(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Do not patch or pad eye

(GRADE*: Level of evidence=high, Strength of recommendation=strong)
 

Pharmacological

Topical anaesthetic (e.g. gutt. benoxinate 0.4%) if necessary to aid examination

Systemic analgesia for first 24h (paracetamol, aspirin, or ibuprofen if no contraindications; dosage as for headache)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Topical NSAID for its analgesic and anti-inflammatory properties, e.g. gutt. diclofenac 0.1% up to four times daily for 1-3 days

RCTs do not provide strong evidence to support their use

(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

If there is a possibility of infection, prescribe a broad spectrum topical antibiotic e.g. chloramphenicol (NB risk of infection following mild trauma is low)

(GRADE*: Level of evidence=low, Strength of recommendation=weak)

For large abrasions or in associated iritis, consider cycloplegia to prevent pupil spasm, e.g. gutt. cyclopentolate 1% twice daily until healed)

(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Management category

B3: management to resolution
A2: if abrasion deep and/or contaminated with foreign material, or apparently infected, refer as emergency (same day) to Ophthalmologist

Possible management by ophthalmologist

Assess for secondary infection

Debridement if indicated

Therapeutic contact lens fitting

Plain X-ray or CT scan to exclude retained foreign body

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
 

Sources of evidence

Lim CH, Turner A, Lim BX. Patching for corneal abrasion. Cochrane Database Syst Rev. 2016;7:CD004764

Meek R, Sullivan A, Favilla M, Larmour I, Guastalegname S. Is homatropine 5% effective in reducing pain associated with corneal abrasion when compared with placebo? A randomized controlled trial. Emerg Med Australas.2010;22(6):507-13

Wakai A, Lawrenson JG, Lawrenson AL, Wang Y, Brown MD, Quirke M, Ghandour O, McCormick R, Walsh CD, Lang E, Amayem A. Topical nonsteroidal anti-inflammatory drugs for analgesia in traumatic corneal abrasions. Cochrane Database of Systematic Reviews 2017 (in press)

Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114-20

Lay summary

Abrasions of the cornea (the clear window of the eye) are common, being usually caused by a minor accidental injury, for example by a finger, mascara brush or contact lens, or by a speck of foreign matter under the upper eyelid. There are also medical conditions that make abrasions more likely, for example a condition, known as a dystrophy, in which the surface tissue of the cornea (the epithelium) is more delicate than usual; also when the cornea is exposed by failure of the normal blink reflex, or when its sensitivity to touch is reduced by damage to its nerves, as in diabetes or following shingles of the eye. Corneal abrasion can be very painful as the cornea is one of the most sensitive areas of the body.
The clinician will assess the area involved and prescribe treatment accordingly. The damage to the surface can be seen more easily if fluorescein, an orange dye, is instilled into the eye. Anti-inflammatory or antibiotic eye drops are often recommended, depending on the type and size of abrasion. Dilating eye drops are sometimes given to relieve discomfort. There is little evidence supporting the use of these drugs.
Corneal abrasions usually heal quickly and completely but if the injury is deeper, or contaminated by foreign material, or possibly infected, referral to an ophthalmologist is recommended.

Corneal abrasion
Version 11
Date of search 28.03.17
Date of revision 22.06.17
Date of publication 17.10.17
Date for review 27.03.19
© College of Optometrists 

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