Managing corneal abrasions in primary care Abstract: Corneal abrasion is a common eye injury that occurs in all age-groups. A focused history and physical exam can identify patients with corneal abrasions and improve intervention time. Minor corneal abrasions usually heal within 48 hours without complications or eye damage.
By Scott J. Saccomano, PhD, RN, GNP-BC and Lucille R. Ferrara, EdD, RN, MBA, FNP-BC
orneal abrasion is a common eye injury that occurs in all age-groups. Contact lens wearers are a particularly vulnerable population for a corneal abrasion. Aside from contact lens use, corneal abrasions usually result from tangential impacts or the presence of foreign body debris.1 They are the most common nonpenetrating eye injury in children.2 Corneal abrasions are a direct result of ocular trauma and account for more than 65,000 workrelated eye injuries.1 The majority of work-related eye injuries occur in men between ages 25 and 44, and most of these are automotive workers between ages 20 and 29.3,4
C
■ Populations affected by corneal abrasion Corneal abrasion should be among the differential diagnoses in infants and newborns with sudden onset of unexplained crying. Fingernail length and the method used to trim the fingernails are common causes of corneal abrasions in this population.5 Other differentials should also be considered to rule out more serious causes of unexplained crying. In younger children and adolescents, objects (mainly toys) are a common cause of corneal abrasions as well as sports injuries, such as those caused by paintball.6
Chronic dry eye is a common cause for corneal abrasions in older adults, which can be prevented with lubricants and ointments.7 Other causes of corneal abrasions include dust, chemicals, damaged or soiled contact lenses, sand, animal paws, and common foreign objects, such as makeup brushes. Eye injuries sustained intraoperatively during eyelid surgery have also been documented. ■ Pathophysiology The cornea is the clear, transparent, anterior surface of the eye covering the pupil and the iris that protects the eye from harmful matter, such as dust and germs (see Transverse section of the eyeball). As the outermost lens of the eye, the cornea regulates and controls the majority of the eye’s focusing function. In addition, the cornea is a filter, screening out some of the most dangerous and damaging UV waves from the sun. A constant wash of tears protects the cornea from dryness. The cornea receives light transmission through the lens to the retina and separates the anterior chamber fluid from the external environment.4,8 The cornea has five layers: the outer most layer is the epithelium, followed by the Bowman membrane, the stroma,
Keywords: abrasion, blurred vision, cornea, corneal abrasion, eye, eye pain, red eye, vision
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Management of corneal abrasions
the Descemet membrane, and the endothelium. The surface epithelial layer provides a barrier function to prevent the passage of foreign materials into the eye and other corneal layers. The Bowman layer is a thicker basement protecting the cornea from injury. The stromal layer is composed of a matrix of collagen fibers providing strength, form, and elasticity to the cornea. The Descemet layer lies between the stroma and the endothelium in an inner layer of the basement membrane and is composed of endothelial cells protecting the cornea from injury and infection. The last layer,
the endothelium, is a barrier and pump that prevents the cornea from getting too wet and also keeps it clear. The cornea’s transparency is due to the lack of blood vessels or cells. However, it is innervated by low-threshold pain fibers, meaning that even a minor injury (such as a corneal abrasion) can cause significant pain.1,4,8,9 A corneal abrasion is a defect in the superficial surface of the cornea. The injury is limited to the outer epithelium and penetrates into the Bowman layer. The term “corneal ulcer” is used in the event of severe corneal injuries
Transverse section of the eyeball Epithelium Bowman membrane Stroma Descemet membrane Endothelium
Cornea
Sphincter muscle Pigment layer Dilator muscle
Pupil Anterior chamber
Iris
Trabecular meshwork Canal of Schlemm
Conjunctiva Lens
Ciliary body
Sclera Lens
Ora serrata
Zonular fibers
Posterior chamber
B
Vitreous body
Retina
Choroid
Retinal blood vessel Optic disk
Sclera
Lateral rectus muscle
Medial rectus muscle
Optic nerve
A
Fovea centralis
The following illustration shows (A) the transverse section of the eyeball and (B) an enlargement of the anterior and posterior chambers of the eye, showing the layers of the cornea, the iris, aqueous drainage system, and the ciliary body.
Source: Porth CM. Essentials of Pathophysiology Concepts of Altered Health States. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:970.
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Management of corneal abrasions
penetrating deeper through the stromal layer. Upon injury, the epithelium adjacent to the injury multiplies to fill in the injured area. Epithelial injuries usually heal quickly and completely within 24 to 48 hours. Injuries to the depth of the Bowman layer may leave permanent scarring.10 The healing process begins as the epithelial cells undergo mitosis, enabling newly- generated cells to enter and cover the defect; healthy cells patch the injury, preventing infection and minimizing visual defects.11 Corneal abrasions within the spectrum of mechanical ophthalmic trauma can be categorized into closed and/or open globe injuries, eyelid wounds, and orbital injuries.4,12 ■ Diagnosis Clinical presentation and eye exam are key factors in diagnosing corneal abrasion. An in-depth patient history is key for arriving at an accurate diagnosis and will guide the physical exam. Monocular eye pain is a hallmark symptom associated with corneal abrasion and is the usual presenting complaint either in the office or the ED. Eye pain can range from mild to moderate depending on the severity of the abrasion. Patients may also be uncomfortable with activities, such as driving, reading, report sleep disruption, and increased time off from work. In addition to eye pain, patients can report other symptoms, such as tearing, painful extraocular eye movements, photophobia, and a scratching or gritty sensation of “foreign body” in the eye. Decreased or blurred vision and conjunctival redness may also be present in the affected eye.4,10,13
Corneal abrasion with fluorescein staining
Source: Gerstenblith AT and Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
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History and eye exam. General history should include past and present illnesses, current medications, and allergies to any medications or eye drops. The patient’s ocular history should include the following9,14,15: • Any changes in visual acuity noted? • Any vision problems prior to this incident? • Does the patient wear contact lenses? • Does the patient wear glasses? • Has there been a history of eye trauma in the past? • How did it start? • How long has eye discomfort been present? • Was the onset of symptoms sudden or gradual? • Ask the location and radiation of eye “foreign body sensation.” • Was protective eyewear being used at time of injury? • Was this a chemical injury? If so, what chemical, and what action was taken? • What is the patient’s occupation? • Has the patient been exposed to bright UV light, such as sunlight or tanning beds? • Was there recent eye trauma? • Did the patient participate recently in any sports activities? • Is there excessive eye rubbing or scratching? • Does the patient apply eye makeup? If so, how frequently and what is the application technique? The history can determine clues to the precipitating events or other possible diagnosis. Wearing contact lenses can cause trauma and dry eye if not removed when required.16 Changes in visual acuity can indicate a possible lesion, onset symptoms can aid in diagnosis, and a history of past eye problems may reveal eye distortion from previous trauma. When patients are exposed to bright UV lights such as sunlight and tanning beds, the cornea can be damaged even with closed eyelids.4 Symptoms may not necessarily occur immediately after the injury, and patients may not be aware of a specific event that may have contributed to the eye injury. Eye exam includes eye inspection, visual acuity, and eye movement. The eye exam begins with inspection. The cornea should be assessed for transparency and should be smooth, clear, and shiny. Any inflammation of the eyelids should also be assessed, including any eye redness. It is important to note the distribution of eyelashes and the presence or absence of any inflammation at the base of the eyelashes. The conjunctiva and sclera should be evaluated for any discharge. The amount and type of discharge should be noted if present. The eyes are to be inspected for any foreign body by everting the eyelids to inspect the eye for substances, such as sand, ash, dirt, sawdust, or other foreign
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Management of corneal abrasions
particles that can get trapped under the eyelid and cause pain when blinking.9,15,17,18 The Snellen chart helps assess whether or not the patient’s visual acuity is normal. Visual acuity may be affected by a corneal abrasion in the visual axis.18 A decrease in visual acuity is suggestive of more severe ocular conditions (requiring immediate referral to an ophthalmologist), such as keratitis, glaucoma, or inflammation of the iris. Visual fields by confrontation should also be included to assess for vision loss or impairment. Assessing extra ocular eye movements for the six cardinal fields of gaze is significant, and patients with corneal abrasions will report pain with extra ocular eye movements.19,20 Corneal abrasion diagnosis can be confirmed with a slit lamp and fluorescein stain but may also include pupil dilation and other specialized ophthalmic exams when corneal abrasion is not the sole differential. The slit lamp exam provides a three-dimensional view of the eye and allows the practitioner to inspect the anterior surfaces of the eye for normal or abnormal structures. It is particularly useful to view the cornea, conjunctiva, sclera, and iris. Using a slit lamp can assist in guiding the removal of a foreign body in the eye if one is present. Fluorescein (a yellow dye) is added to the eye as a drop to examine the cornea and tear layer with the slit lamp (see Corneal abrasion with fluorescein staining). Contact lenses should be removed prior to staining. The patient is instructed to blink a few Multilinear corneal abrasion This image shows a multilinear corneal abrasion in a 12-year-old boy who was hit in the eye with a tennis ball. The triangle-shaped corneal abrasion is evident superiorly with the cobalt blue light after fluorescein staining.
Source: Rapuano CJ. Color Atlas and Synopsis of Clinical Ophthalmology Wills Eye Institute – Cornea. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
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times to distribute the stain into the tear film after the stain is administered. A topical anesthetic can be used prior to staining if the patient is in pain. The stain makes it easier to detect a foreign body as well as injured or infected areas of the cornea. The fluorescein staining with cobalt light illumination can reveal epithelial damage in a corneal abrasion or scratches sustained to the epithelium from a foreign body. (See Multilinear corneal abrasion.) Corneal abrasion may not necessarily appear linear with fluorescein but may rather appear as swaths of scratches, punctuate markings, or large, circular/rectangular, irregularlyshaped areas consistent with the injury.4,21 Once the defect is identified, it can be measured, and the defect can be diagramed for location. Areas where corneal abrasions are present will be fluorescent green. Some of the disadvantages of using fluorescein stain include the following: fluorescein can stain mucus; in rare instances, patients may have an allergic reaction; the introduction of infection if proper technique is not used; and instilling too much dye can mask the results.4,21 Pupil dilation may be necessary if damage to the posterior eye is suspected. Bacterial and viral cultures should be sent if infection is suspected, since there is a disruption to the integrity of the cornea, which increases infection risk. Cultures of any lesions should be obtained to rule out suspected herpes infection. ■ Common differential diagnosis Acute narrow angle glaucoma. Acute narrow angle glaucoma is an acute rise in eye pressure due to the blockage of the drainage angle. Patients typically present with blurry vision, eye pain accompanied with headache and nausea, and vomiting. Patients may report a history of halos, and the cornea (normally clear and transparent) may appear hazy. The eye may be hard and tender with the pupil fixed and dilated, and decreased central vision may be noted.17,22 Acute iritis. Patients with acute iritis or inflammation of the iris typically present with symptoms of eye pain, tearing, floaters, decreased/blurred vision, and photophobia. Visual acuity can vary from normal to decreased.23 Conjunctivitis. Conjunctivitis is inflammation of the conjunctiva (usually bilateral) with symptoms of itchy, red eyes, grittiness or “foreign body” sensation, discharge, watery or purulent drainage with crusting of the lashes, red eye, and no changes in visual acuity.23 Keratitis. Bacterial or microbial keratitis symptoms include the following: a painful, slightly blurred red eye with foreign body sensation with or without mucopurulent drainage. Keratitis is usually related to Staphylococcus, Streptococcus, or Pseudomonas infection and is most common in
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Management of corneal abrasions
patients who are contact lens wearers, especially with use of extend-wear contact lenses.16,24 Herpes lesions. The patient with herpetic keratitis presents with unilateral watery tearing red eye, decreased vision, photophobia, and a visible dendriform pattern on the cornea. Vesicular skin rash and history of conjunctivitis may be present, and a viral swab may confirm herpes simplex infection.25,26 Recurrent corneal abrasion. The patient with recurrent corneal abrasion is usually a noncontact lens wearer with a history of corneal abrasion. The patient with recurrent corneal abrasion presents with sudden spontaneous symptoms weeks after the abrasion has healed. Patients complain of pain, photophobia, and tearing upon waking in the morning.3,27 ■ Treatment The goals of treatment are to relieve symptoms, resolve the abrasion, prevent infection, remove foreign body if present, prevent loss of function, and instruct the patient on prevention measures. Most corneal abrasions will heal over time, and the main goal of therapy is to prevent infection. The more recent practice is limiting antibiotic eye drop use for patients sustaining injuries from contact lenses.18 Treatment for corneal abrasions also includes eye rest, topical anesthetics, and eye patching. Making the clinical decision to patch should be based on the following guidelines: patching for severe eye pain for 4 to 6 hours post injury; avoiding to patch an eye that has obvious infection, as patching abrasions that have been caused by agents that harbor bacteria (fingernails, contact lens, or organic matter) can further promote bacterial growth; and not using a patch for a corneal ulcer.28 Patching the eye is not without controversy. Patching does not promote healing, and some practitioners may patch the eye for comfort. Furthermore, the patient loses some degree of depth perception with eye patching (especially with driving and ambulating) and has an increased risk of falls. Ibuprofen may be administered to manage pain if not contraindicated. In addition, opioid analgesics are sometimes necessary to control pain.4 A dilute solution of proparacaine an ophthalmic topical local anesthetic, has been shown to significantly reduce pain without affecting healing.29 Eye drops such as diclofenac, a topical nonsteroidal antiinflammatory ophthalmic solution, can be an alternative to patching because vision is maintained.4 Patient teaching should include the patient’s current treatment plan, instructions for proper medication administration, signs and symptoms of infection (pain after 72 hours of injury, sticky 5 The Nurse Practitioner
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discharge from the eye), follow-up appointments, and general information about the duration of the injury and what to expect over the next 48 to 72 hours. Antibiotic ophthalmic solutions and ointments such as fluoroquinolones (ciprofloxacin, norfloxacin, ofloxacin), macrolides (erythromycin), or aminoglycosides (tobramycin, gentamicin) are used to cover most bacterial infections, such as streptococcus, pseudomonas, and chlamydia. The fluoroquinolones are often given as first-line or first choice, as they cover a broad spectrum of bacteria and have low toxicity.4 The fluoroquinolones are indicated for the prevention and treatment of ocular infection. Fluoroquinolones are administered initially every 2 to 4 hours, decreasing to every 4 hours on or about day 3.30 Patients should be instructed not to allow the applicator to come in contact with the eye or fingers to prevent contamination. Fluoroquinolones are contraindicated in patients with hypersensitivity reactions. Common adverse reactions include burning, discomfort, sensations of foreign body in eye, itching, and blurry vision.4,30 Macrolides, primarily erythromycin ointment, are indicated as well for the treatment and prevention of ocular infection. Macrolides are administered as a topical ointment and are applied to the affected eye for 3 to 5 days.30 Adverse reactions to erythromycin are rare and may include redness or hypersensitivity reactions.4 Aminoglycocides, such as gentamicin, should be avoided, as they can cause damage to the corneal epithelium.3,17 Treatment with aminoglycosides may be considered when the abrasions are large and dirty.4 Antipseudomonal antibiotic therapy should be prescribed for corneal abrasions caused by contact lenses. However, patients should be instructed not to use contact lenses unless instructed to do so by the practitioner. Premature use of contact lenses can prolong healing time and further aggravate the corneal abrasion.31 Evidence does not support the use of mydriatics and cycloplegics for routine treatment of corneal abrasions.18 It was previously thought that mydriatics brought relief from the ciliary spasms in corneal abrasions.18 Some practitioners may administer long-acting cycloplegic agents for large corneal abrasions with associated blepharospasm and photophobia.18 Cycloplegic agents are associated with slower wound healing and can cause an acute glaucoma attack, so the patient should be assessed for history of glaucoma.3,14 Cycloplegic agents, such as tropicamide, may be used during the physical exam for the patient’s comfort. In addition, corneal abrasions should never be treated with topical corticosteroids; topical corticosteroids slow healing and increase the risk of superinfection.17
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Management of corneal abrasions
Healing usually takes 2 to 3 days; patients should be reevaluated 24 hours after diagnosis, and then again approximately 1 week later if there is no evidence of healing. Patients who are not healing or who have severe injuries should be referred to an ophthalmologist for further workup and additional treatment when the injuries or symptoms are complex.13 ■ Prevention Patients should be instructed on the prevention of corneal abrasion. Corneal abrasion prevention implies avoiding injury and protecting the cornea. The following steps can help prevent corneal trauma1,3,4: • Wearing protective eye wear in high-risk occupations and when using machinery that can send dust and other particles into the air. • Trimming fingernails of small children and infants. • Contact lenses should be cleaned as directed and removed as directed. • Using caution when applying contact lenses. • Using clean hands when handling contact lenses. • Wearing protective eye gear during contact sports. • Wearing protective eye gear outdoors for recreational activities, such as hiking or working outdoors when farming; this helps avoid wind-blown objects. • Wearing safety goggles when performing routine outdoor care to lawns and trees. • Trimming low-hanging tree branches in the yard. ■ Moving forward A focused history and physical exam can identify patients with corneal abrasions and improve intervention time. Minor corneal abrasions usually heal within 48 hours without complication or eye damage. There are few risks or adverse reactions in the treatment of corneal abrasions; however, there is always risk of infection until the abrasion is fully healed. Complications can result in permanent or partial vision loss. Patients should wear protective eyewear when required and adhere to proper guidelines for use and care of contact lenses to minimize the possibility of complications. REFERENCES 1. Bowling E, Sonsino J, Shovlin J, Sindt C. Corneal atlas. Review of Optometry; 2012:1-22. 2. Naidu K. Common eye emergencies. African Journals Online. 2007;25(10): 470-474. 3. Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. 2007;75(7):1017-1022. 4. Verma A. Corneal abrasion. The Medscape References Website. 2011. http:// emedicine.medscape.com/article/1195402-overview.
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5. Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010;125(3):e565-e569. 6. Listman DA. Paintball injuries in children: more than meets the eye. Pediatrics. 2004;113(1 Pt 1):e15-e18. 7. Krader C, McDonald M. Ointment fulfills dry eye need. Ophthalmology Times. 2011. 8. Ruberti JW, Roy AS, Roberts CJ. Corneal biomechanics and biomaterials. Annu Rev Biomed Eng. 2011;13:269-295. 9. Alexander L. Disorders and injuries of the eye and eyelid. CME Resource Course # 8049; 2011:1-74. 10. Sowka J, Gurwood A, Kabat A. The handbook of ocular disease management. Supplement to Review of Optometry; 2010:1-63. 11. DelMonte DW, Kim T. Anatomy and physiology of the cornea. J Cataract Refract Surg. 2011;37(3):588-598. 12. Aaronson A. Corneal laceration. The Medscape Referenced Website. 2011. http://emedicine.medscape.com/article/798005-overview. 13. Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199-216. 14. Khare GD, Symons RC, Do DV. Common ophthalmic emergencies. Int J Clin Prac. 2008;62(11):1776-1784. 15. Moore D. How to identify and treat eye injuries. Hospital Doctor; 2007:24-27. 16. Smit D. Complications of contact lens wear: what pharmacists should know. S Afr Pharm J. 2011;78(8):31-34. 17. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137-144. 18. Kahn F. Emergency care of corneal abrasion. The Medscape Reference Website. 2011. http://emedicine.medscape.com/article/799316-overview. 19. Sharma NS, Ooi JL, Li MZ. A painful red eye. Aust Fam Physician. 2009; 38(10):805-807. 20. Robinett DA, Kahn JH. The physical examination of the eye. Emerg Med Clin North Am. 2008;26(1):1-16. 21. Slitlamp American Academy of Ophthalmology Preferred Practice Patterns Committee: Preferred Practice Pattern Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; 2010. 22. Galor A, Jeng BH. Red eye for the internist: when to treat, when to refer. Cleve Clin J Med. 2008;75(2):137-144. 23. Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008;26(1):35-55. 24. Green M, Apel A, Stapleton F. Risk factors and causative organisms in microbial keratitis. Cornea. 2008;27(1):22-27. 25. Wang J. Ophthalmologic manifestations of herpes simples keratitis. The Medscape Referenced Website. 2010. http://emedicine.medscape.com/ article/1194268-overview. 26. Noble J, Lloyd J. Five things to know about ...the red eye. CMAJ. 2011;183(1):81. 27. Heath G. Medical management of common corneal conditions. Optometry in Practice. 2010;11(4):151-160. 28. Thyagarajan SK, Sharma V, Austin S, Lasoye T, Hunter P. An audit of corneal abrasion management following the introduction of local guidelines in an accident and emergency department. Emerg Med J. 2006;23(7):526-529. 29. Dullert C, Lewin M. Treating patients in the emergency department with dilute proparacaine for management of acute corneal injury. The Medscape Referenced Website. 2012. http://www.medscape.com/viewarticle/768476_2. 30. Roy H. Corneal abrasions empiric therapy. The Medscape Referenced Website. 2011. http://emedicine.medscape.com/article/2016881-overview. 31. Gibson A, Sommerkamp S. HEENT pitfalls. In: Goyle D, Mattu A, eds. Urgent Care Emergencies: Avoiding the Pitfalls and Improving Outcomes. Hoboken, NJ: Wiley Blackwell; 2012:1-10. Scott J. Saccomano is an assistant professor at Herbert H. Lehman College, Department of Nursing, Bronx, N.Y. Lucille R. Ferrara is an assistant professor and director at Pace University College of Health Professions, Family Nurse Practitioner Program, Pleasantville, N.Y. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000452977.99676.cf
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By Scott J. Saccomano, PhD, RN, GNP-BC and Lucille R. Ferrara, EdD, RN, MBA, FNP-BC
orneal abrasion is a common eye injury that occurs in all age-groups. Contact lens wearers are a particularly vulnerable population for a corneal abrasion. Aside from contact lens use, corneal abrasions usually result from tangential impacts or the presence of foreign body debris.1 They are the most common nonpenetrating eye injury in children.2 Corneal abrasions are a direct result of ocular trauma and account for more than 65,000 workrelated eye injuries.1 The majority of work-related eye injuries occur in men between ages 25 and 44, and most of these are automotive workers between ages 20 and 29.3,4
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■ Populations affected by corneal abrasion Corneal abrasion should be among the differential diagnoses in infants and newborns with sudden onset of unexplained crying. Fingernail length and the method used to trim the fingernails are common causes of corneal abrasions in this population.5 Other differentials should also be considered to rule out more serious causes of unexplained crying. In younger children and adolescents, objects (mainly toys) are a common cause of corneal abrasions as well as sports injuries, such as those caused by paintball.6
Chronic dry eye is a common cause for corneal abrasions in older adults, which can be prevented with lubricants and ointments.7 Other causes of corneal abrasions include dust, chemicals, damaged or soiled contact lenses, sand, animal paws, and common foreign objects, such as makeup brushes. Eye injuries sustained intraoperatively during eyelid surgery have also been documented. ■ Pathophysiology The cornea is the clear, transparent, anterior surface of the eye covering the pupil and the iris that protects the eye from harmful matter, such as dust and germs (see Transverse section of the eyeball). As the outermost lens of the eye, the cornea regulates and controls the majority of the eye’s focusing function. In addition, the cornea is a filter, screening out some of the most dangerous and damaging UV waves from the sun. A constant wash of tears protects the cornea from dryness. The cornea receives light transmission through the lens to the retina and separates the anterior chamber fluid from the external environment.4,8 The cornea has five layers: the outer most layer is the epithelium, followed by the Bowman membrane, the stroma,
Keywords: abrasion, blurred vision, cornea, corneal abrasion, eye, eye pain, red eye, vision
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Management of corneal abrasions
the Descemet membrane, and the endothelium. The surface epithelial layer provides a barrier function to prevent the passage of foreign materials into the eye and other corneal layers. The Bowman layer is a thicker basement protecting the cornea from injury. The stromal layer is composed of a matrix of collagen fibers providing strength, form, and elasticity to the cornea. The Descemet layer lies between the stroma and the endothelium in an inner layer of the basement membrane and is composed of endothelial cells protecting the cornea from injury and infection. The last layer,
the endothelium, is a barrier and pump that prevents the cornea from getting too wet and also keeps it clear. The cornea’s transparency is due to the lack of blood vessels or cells. However, it is innervated by low-threshold pain fibers, meaning that even a minor injury (such as a corneal abrasion) can cause significant pain.1,4,8,9 A corneal abrasion is a defect in the superficial surface of the cornea. The injury is limited to the outer epithelium and penetrates into the Bowman layer. The term “corneal ulcer” is used in the event of severe corneal injuries
Transverse section of the eyeball Epithelium Bowman membrane Stroma Descemet membrane Endothelium
Cornea
Sphincter muscle Pigment layer Dilator muscle
Pupil Anterior chamber
Iris
Trabecular meshwork Canal of Schlemm
Conjunctiva Lens
Ciliary body
Sclera Lens
Ora serrata
Zonular fibers
Posterior chamber
B
Vitreous body
Retina
Choroid
Retinal blood vessel Optic disk
Sclera
Lateral rectus muscle
Medial rectus muscle
Optic nerve
A
Fovea centralis
The following illustration shows (A) the transverse section of the eyeball and (B) an enlargement of the anterior and posterior chambers of the eye, showing the layers of the cornea, the iris, aqueous drainage system, and the ciliary body.
Source: Porth CM. Essentials of Pathophysiology Concepts of Altered Health States. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:970.
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Management of corneal abrasions
penetrating deeper through the stromal layer. Upon injury, the epithelium adjacent to the injury multiplies to fill in the injured area. Epithelial injuries usually heal quickly and completely within 24 to 48 hours. Injuries to the depth of the Bowman layer may leave permanent scarring.10 The healing process begins as the epithelial cells undergo mitosis, enabling newly- generated cells to enter and cover the defect; healthy cells patch the injury, preventing infection and minimizing visual defects.11 Corneal abrasions within the spectrum of mechanical ophthalmic trauma can be categorized into closed and/or open globe injuries, eyelid wounds, and orbital injuries.4,12 ■ Diagnosis Clinical presentation and eye exam are key factors in diagnosing corneal abrasion. An in-depth patient history is key for arriving at an accurate diagnosis and will guide the physical exam. Monocular eye pain is a hallmark symptom associated with corneal abrasion and is the usual presenting complaint either in the office or the ED. Eye pain can range from mild to moderate depending on the severity of the abrasion. Patients may also be uncomfortable with activities, such as driving, reading, report sleep disruption, and increased time off from work. In addition to eye pain, patients can report other symptoms, such as tearing, painful extraocular eye movements, photophobia, and a scratching or gritty sensation of “foreign body” in the eye. Decreased or blurred vision and conjunctival redness may also be present in the affected eye.4,10,13
Corneal abrasion with fluorescein staining
Source: Gerstenblith AT and Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
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History and eye exam. General history should include past and present illnesses, current medications, and allergies to any medications or eye drops. The patient’s ocular history should include the following9,14,15: • Any changes in visual acuity noted? • Any vision problems prior to this incident? • Does the patient wear contact lenses? • Does the patient wear glasses? • Has there been a history of eye trauma in the past? • How did it start? • How long has eye discomfort been present? • Was the onset of symptoms sudden or gradual? • Ask the location and radiation of eye “foreign body sensation.” • Was protective eyewear being used at time of injury? • Was this a chemical injury? If so, what chemical, and what action was taken? • What is the patient’s occupation? • Has the patient been exposed to bright UV light, such as sunlight or tanning beds? • Was there recent eye trauma? • Did the patient participate recently in any sports activities? • Is there excessive eye rubbing or scratching? • Does the patient apply eye makeup? If so, how frequently and what is the application technique? The history can determine clues to the precipitating events or other possible diagnosis. Wearing contact lenses can cause trauma and dry eye if not removed when required.16 Changes in visual acuity can indicate a possible lesion, onset symptoms can aid in diagnosis, and a history of past eye problems may reveal eye distortion from previous trauma. When patients are exposed to bright UV lights such as sunlight and tanning beds, the cornea can be damaged even with closed eyelids.4 Symptoms may not necessarily occur immediately after the injury, and patients may not be aware of a specific event that may have contributed to the eye injury. Eye exam includes eye inspection, visual acuity, and eye movement. The eye exam begins with inspection. The cornea should be assessed for transparency and should be smooth, clear, and shiny. Any inflammation of the eyelids should also be assessed, including any eye redness. It is important to note the distribution of eyelashes and the presence or absence of any inflammation at the base of the eyelashes. The conjunctiva and sclera should be evaluated for any discharge. The amount and type of discharge should be noted if present. The eyes are to be inspected for any foreign body by everting the eyelids to inspect the eye for substances, such as sand, ash, dirt, sawdust, or other foreign
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Management of corneal abrasions
particles that can get trapped under the eyelid and cause pain when blinking.9,15,17,18 The Snellen chart helps assess whether or not the patient’s visual acuity is normal. Visual acuity may be affected by a corneal abrasion in the visual axis.18 A decrease in visual acuity is suggestive of more severe ocular conditions (requiring immediate referral to an ophthalmologist), such as keratitis, glaucoma, or inflammation of the iris. Visual fields by confrontation should also be included to assess for vision loss or impairment. Assessing extra ocular eye movements for the six cardinal fields of gaze is significant, and patients with corneal abrasions will report pain with extra ocular eye movements.19,20 Corneal abrasion diagnosis can be confirmed with a slit lamp and fluorescein stain but may also include pupil dilation and other specialized ophthalmic exams when corneal abrasion is not the sole differential. The slit lamp exam provides a three-dimensional view of the eye and allows the practitioner to inspect the anterior surfaces of the eye for normal or abnormal structures. It is particularly useful to view the cornea, conjunctiva, sclera, and iris. Using a slit lamp can assist in guiding the removal of a foreign body in the eye if one is present. Fluorescein (a yellow dye) is added to the eye as a drop to examine the cornea and tear layer with the slit lamp (see Corneal abrasion with fluorescein staining). Contact lenses should be removed prior to staining. The patient is instructed to blink a few Multilinear corneal abrasion This image shows a multilinear corneal abrasion in a 12-year-old boy who was hit in the eye with a tennis ball. The triangle-shaped corneal abrasion is evident superiorly with the cobalt blue light after fluorescein staining.
Source: Rapuano CJ. Color Atlas and Synopsis of Clinical Ophthalmology Wills Eye Institute – Cornea. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
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times to distribute the stain into the tear film after the stain is administered. A topical anesthetic can be used prior to staining if the patient is in pain. The stain makes it easier to detect a foreign body as well as injured or infected areas of the cornea. The fluorescein staining with cobalt light illumination can reveal epithelial damage in a corneal abrasion or scratches sustained to the epithelium from a foreign body. (See Multilinear corneal abrasion.) Corneal abrasion may not necessarily appear linear with fluorescein but may rather appear as swaths of scratches, punctuate markings, or large, circular/rectangular, irregularlyshaped areas consistent with the injury.4,21 Once the defect is identified, it can be measured, and the defect can be diagramed for location. Areas where corneal abrasions are present will be fluorescent green. Some of the disadvantages of using fluorescein stain include the following: fluorescein can stain mucus; in rare instances, patients may have an allergic reaction; the introduction of infection if proper technique is not used; and instilling too much dye can mask the results.4,21 Pupil dilation may be necessary if damage to the posterior eye is suspected. Bacterial and viral cultures should be sent if infection is suspected, since there is a disruption to the integrity of the cornea, which increases infection risk. Cultures of any lesions should be obtained to rule out suspected herpes infection. ■ Common differential diagnosis Acute narrow angle glaucoma. Acute narrow angle glaucoma is an acute rise in eye pressure due to the blockage of the drainage angle. Patients typically present with blurry vision, eye pain accompanied with headache and nausea, and vomiting. Patients may report a history of halos, and the cornea (normally clear and transparent) may appear hazy. The eye may be hard and tender with the pupil fixed and dilated, and decreased central vision may be noted.17,22 Acute iritis. Patients with acute iritis or inflammation of the iris typically present with symptoms of eye pain, tearing, floaters, decreased/blurred vision, and photophobia. Visual acuity can vary from normal to decreased.23 Conjunctivitis. Conjunctivitis is inflammation of the conjunctiva (usually bilateral) with symptoms of itchy, red eyes, grittiness or “foreign body” sensation, discharge, watery or purulent drainage with crusting of the lashes, red eye, and no changes in visual acuity.23 Keratitis. Bacterial or microbial keratitis symptoms include the following: a painful, slightly blurred red eye with foreign body sensation with or without mucopurulent drainage. Keratitis is usually related to Staphylococcus, Streptococcus, or Pseudomonas infection and is most common in
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Management of corneal abrasions
patients who are contact lens wearers, especially with use of extend-wear contact lenses.16,24 Herpes lesions. The patient with herpetic keratitis presents with unilateral watery tearing red eye, decreased vision, photophobia, and a visible dendriform pattern on the cornea. Vesicular skin rash and history of conjunctivitis may be present, and a viral swab may confirm herpes simplex infection.25,26 Recurrent corneal abrasion. The patient with recurrent corneal abrasion is usually a noncontact lens wearer with a history of corneal abrasion. The patient with recurrent corneal abrasion presents with sudden spontaneous symptoms weeks after the abrasion has healed. Patients complain of pain, photophobia, and tearing upon waking in the morning.3,27 ■ Treatment The goals of treatment are to relieve symptoms, resolve the abrasion, prevent infection, remove foreign body if present, prevent loss of function, and instruct the patient on prevention measures. Most corneal abrasions will heal over time, and the main goal of therapy is to prevent infection. The more recent practice is limiting antibiotic eye drop use for patients sustaining injuries from contact lenses.18 Treatment for corneal abrasions also includes eye rest, topical anesthetics, and eye patching. Making the clinical decision to patch should be based on the following guidelines: patching for severe eye pain for 4 to 6 hours post injury; avoiding to patch an eye that has obvious infection, as patching abrasions that have been caused by agents that harbor bacteria (fingernails, contact lens, or organic matter) can further promote bacterial growth; and not using a patch for a corneal ulcer.28 Patching the eye is not without controversy. Patching does not promote healing, and some practitioners may patch the eye for comfort. Furthermore, the patient loses some degree of depth perception with eye patching (especially with driving and ambulating) and has an increased risk of falls. Ibuprofen may be administered to manage pain if not contraindicated. In addition, opioid analgesics are sometimes necessary to control pain.4 A dilute solution of proparacaine an ophthalmic topical local anesthetic, has been shown to significantly reduce pain without affecting healing.29 Eye drops such as diclofenac, a topical nonsteroidal antiinflammatory ophthalmic solution, can be an alternative to patching because vision is maintained.4 Patient teaching should include the patient’s current treatment plan, instructions for proper medication administration, signs and symptoms of infection (pain after 72 hours of injury, sticky 5 The Nurse Practitioner
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discharge from the eye), follow-up appointments, and general information about the duration of the injury and what to expect over the next 48 to 72 hours. Antibiotic ophthalmic solutions and ointments such as fluoroquinolones (ciprofloxacin, norfloxacin, ofloxacin), macrolides (erythromycin), or aminoglycosides (tobramycin, gentamicin) are used to cover most bacterial infections, such as streptococcus, pseudomonas, and chlamydia. The fluoroquinolones are often given as first-line or first choice, as they cover a broad spectrum of bacteria and have low toxicity.4 The fluoroquinolones are indicated for the prevention and treatment of ocular infection. Fluoroquinolones are administered initially every 2 to 4 hours, decreasing to every 4 hours on or about day 3.30 Patients should be instructed not to allow the applicator to come in contact with the eye or fingers to prevent contamination. Fluoroquinolones are contraindicated in patients with hypersensitivity reactions. Common adverse reactions include burning, discomfort, sensations of foreign body in eye, itching, and blurry vision.4,30 Macrolides, primarily erythromycin ointment, are indicated as well for the treatment and prevention of ocular infection. Macrolides are administered as a topical ointment and are applied to the affected eye for 3 to 5 days.30 Adverse reactions to erythromycin are rare and may include redness or hypersensitivity reactions.4 Aminoglycocides, such as gentamicin, should be avoided, as they can cause damage to the corneal epithelium.3,17 Treatment with aminoglycosides may be considered when the abrasions are large and dirty.4 Antipseudomonal antibiotic therapy should be prescribed for corneal abrasions caused by contact lenses. However, patients should be instructed not to use contact lenses unless instructed to do so by the practitioner. Premature use of contact lenses can prolong healing time and further aggravate the corneal abrasion.31 Evidence does not support the use of mydriatics and cycloplegics for routine treatment of corneal abrasions.18 It was previously thought that mydriatics brought relief from the ciliary spasms in corneal abrasions.18 Some practitioners may administer long-acting cycloplegic agents for large corneal abrasions with associated blepharospasm and photophobia.18 Cycloplegic agents are associated with slower wound healing and can cause an acute glaucoma attack, so the patient should be assessed for history of glaucoma.3,14 Cycloplegic agents, such as tropicamide, may be used during the physical exam for the patient’s comfort. In addition, corneal abrasions should never be treated with topical corticosteroids; topical corticosteroids slow healing and increase the risk of superinfection.17
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Management of corneal abrasions
Healing usually takes 2 to 3 days; patients should be reevaluated 24 hours after diagnosis, and then again approximately 1 week later if there is no evidence of healing. Patients who are not healing or who have severe injuries should be referred to an ophthalmologist for further workup and additional treatment when the injuries or symptoms are complex.13 ■ Prevention Patients should be instructed on the prevention of corneal abrasion. Corneal abrasion prevention implies avoiding injury and protecting the cornea. The following steps can help prevent corneal trauma1,3,4: • Wearing protective eye wear in high-risk occupations and when using machinery that can send dust and other particles into the air. • Trimming fingernails of small children and infants. • Contact lenses should be cleaned as directed and removed as directed. • Using caution when applying contact lenses. • Using clean hands when handling contact lenses. • Wearing protective eye gear during contact sports. • Wearing protective eye gear outdoors for recreational activities, such as hiking or working outdoors when farming; this helps avoid wind-blown objects. • Wearing safety goggles when performing routine outdoor care to lawns and trees. • Trimming low-hanging tree branches in the yard. ■ Moving forward A focused history and physical exam can identify patients with corneal abrasions and improve intervention time. Minor corneal abrasions usually heal within 48 hours without complication or eye damage. There are few risks or adverse reactions in the treatment of corneal abrasions; however, there is always risk of infection until the abrasion is fully healed. Complications can result in permanent or partial vision loss. Patients should wear protective eyewear when required and adhere to proper guidelines for use and care of contact lenses to minimize the possibility of complications. REFERENCES 1. Bowling E, Sonsino J, Shovlin J, Sindt C. Corneal atlas. Review of Optometry; 2012:1-22. 2. Naidu K. Common eye emergencies. African Journals Online. 2007;25(10): 470-474. 3. Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. 2007;75(7):1017-1022. 4. Verma A. Corneal abrasion. The Medscape References Website. 2011. http:// emedicine.medscape.com/article/1195402-overview.
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5. Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010;125(3):e565-e569. 6. Listman DA. Paintball injuries in children: more than meets the eye. Pediatrics. 2004;113(1 Pt 1):e15-e18. 7. Krader C, McDonald M. Ointment fulfills dry eye need. Ophthalmology Times. 2011. 8. Ruberti JW, Roy AS, Roberts CJ. Corneal biomechanics and biomaterials. Annu Rev Biomed Eng. 2011;13:269-295. 9. Alexander L. Disorders and injuries of the eye and eyelid. CME Resource Course # 8049; 2011:1-74. 10. Sowka J, Gurwood A, Kabat A. The handbook of ocular disease management. Supplement to Review of Optometry; 2010:1-63. 11. DelMonte DW, Kim T. Anatomy and physiology of the cornea. J Cataract Refract Surg. 2011;37(3):588-598. 12. Aaronson A. Corneal laceration. The Medscape Referenced Website. 2011. http://emedicine.medscape.com/article/798005-overview. 13. Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199-216. 14. Khare GD, Symons RC, Do DV. Common ophthalmic emergencies. Int J Clin Prac. 2008;62(11):1776-1784. 15. Moore D. How to identify and treat eye injuries. Hospital Doctor; 2007:24-27. 16. Smit D. Complications of contact lens wear: what pharmacists should know. S Afr Pharm J. 2011;78(8):31-34. 17. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137-144. 18. Kahn F. Emergency care of corneal abrasion. The Medscape Reference Website. 2011. http://emedicine.medscape.com/article/799316-overview. 19. Sharma NS, Ooi JL, Li MZ. A painful red eye. Aust Fam Physician. 2009; 38(10):805-807. 20. Robinett DA, Kahn JH. The physical examination of the eye. Emerg Med Clin North Am. 2008;26(1):1-16. 21. Slitlamp American Academy of Ophthalmology Preferred Practice Patterns Committee: Preferred Practice Pattern Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; 2010. 22. Galor A, Jeng BH. Red eye for the internist: when to treat, when to refer. Cleve Clin J Med. 2008;75(2):137-144. 23. Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008;26(1):35-55. 24. Green M, Apel A, Stapleton F. Risk factors and causative organisms in microbial keratitis. Cornea. 2008;27(1):22-27. 25. Wang J. Ophthalmologic manifestations of herpes simples keratitis. The Medscape Referenced Website. 2010. http://emedicine.medscape.com/ article/1194268-overview. 26. Noble J, Lloyd J. Five things to know about ...the red eye. CMAJ. 2011;183(1):81. 27. Heath G. Medical management of common corneal conditions. Optometry in Practice. 2010;11(4):151-160. 28. Thyagarajan SK, Sharma V, Austin S, Lasoye T, Hunter P. An audit of corneal abrasion management following the introduction of local guidelines in an accident and emergency department. Emerg Med J. 2006;23(7):526-529. 29. Dullert C, Lewin M. Treating patients in the emergency department with dilute proparacaine for management of acute corneal injury. The Medscape Referenced Website. 2012. http://www.medscape.com/viewarticle/768476_2. 30. Roy H. Corneal abrasions empiric therapy. The Medscape Referenced Website. 2011. http://emedicine.medscape.com/article/2016881-overview. 31. Gibson A, Sommerkamp S. HEENT pitfalls. In: Goyle D, Mattu A, eds. Urgent Care Emergencies: Avoiding the Pitfalls and Improving Outcomes. Hoboken, NJ: Wiley Blackwell; 2012:1-10. Scott J. Saccomano is an assistant professor at Herbert H. Lehman College, Department of Nursing, Bronx, N.Y. Lucille R. Ferrara is an assistant professor and director at Pace University College of Health Professions, Family Nurse Practitioner Program, Pleasantville, N.Y. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000452977.99676.cf
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