EM@3AM – Corneal Abrasion

Author: Wells Weymouth, MD (Resident Physician, SAUSHEC, USA) and Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 43-year-old male, with no significant medical history, presents to the ED for right eye pain. The patient notes his pain as constant and sharp (8/10); associated with light-sensitivity and blurred vision. He reports the onset of his symptoms two hours prior to arrival, while mowing his lawn. The man denies a requirement for glasses/contact lenses. He denies known ocular trauma, and he denies an ocular surgical history.

Triage VS: BP 136/86, HR 110, T 99.6 F oral, RR 14, SpO2 98% on room air.

OD: 20/30
OS: 20/20
OU: 20/20

Pertinent physical examination findings:
HEENT: PERRLA, 3 mm bilaterally; EOMI, visual fields intact. OD: Mild conjunctival injection. No FB on lid eversion.

Examination with Fluorescein:

What are the next steps in your evaluation and treatment?

Answer: Corneal Abrasion^1-8

• Clinical Presentation: Patients often report pain, foreign body sensation, tearing, and light-sensitivity.
• Evaluation, Treatment, and Disposition:
  • Treat pain and facilitate the exam: instill a topical anesthetic (e.g. tetracaine).
  • Utilize Seidel’s test to rule out open globe.
  • Evert the lid(s) to assess for foreign body (FB):
    • Maintain high suspicion in a patient whose cornea is marred by numerous vertical, linear, abrasions.²
  • Patients with corneal abrasions commonly display reactive miosis:
    • Large, non-reactive pupil => findings indicative of injury to the pupillary sphincter => investigate for intra-ocular FB .³
  • Treatment of corneal abrasions (< 50% of corneal involvement):^4,5
    • Consider a cycloplegic (e.g. cyclopenolate or homatropine) to decrease ciliary spasm and reduce pain.
    • Provide outpatient analgesia (oral or topical NSAIDs advised).
    • Prescribe a topical antibiotic ointment (recommendation based in clinical practice; ointment preferred = lubricating; limited data suggests reduced time to epithelial healing):⁴
      • Non-contact lens wearers: erythromycin ointment.
      • Contact lens wearers: cover for Pseudomonas species (ophthalmic ciprofloxacin, ofloxacin, etc.)
    • Ophthalmology follow-up in 24-48 hours recommended. (Exception: Follow-up within 24 hours if vision loss is > one line on a Snellen chart.)⁶
    • Patching no longer recommended for abrasions involving < 50% of the cornea.⁵
  • Consult ophthalmology:^7,8
    • Large abrasions (involving > 50% of the cornea).
      • Consider patching for improved pain control (no evidence of improved healing).⁵
    • Findings suggestive of corneal ulceration.
    • Inability to remove retained FB.
    • Hypopion
•  Pearls:
  • Pediatric patients: consider corneal abrasion in the inconsolable infant.
  • Ophthalmic anesthetics (e.g. tetracaine) not advised for home use – risk of corneal toxicity and epithelial growth retardation.³

References:

1. Calhoun, J. S. (2013, July 08). Corneal Abrasion With Foreign Body Present. Retrieved July 22, 2017, from http://imagebank.asrs.org/file/7362/corneal-abrasion-with-foreign-body-present
2. Wipperman, J. L., & Dorsch, J. N. (2013). Evaluation and management of corneal abrasions. American Family Physician, 87(2).
3. Wilson, S. A., & Last, A. (2004). Management of corneal abrasions. American Family Physician, 70, 123-132.
4. Fraser, S. (2010). Corneal abrasion. Clinical ophthalmology (Auckland, NZ), 4, 387.
5. Weaver, C. S., & Terrell, K. M. (2003). Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing?. Annals of Emergency Medicine, 41(1), 134-140.
6. Khaw, P. T., Shah, P., & Elkington, A. R. (2004). ABC of eyes: Injury to the eye. British Medical Journal, 328(7430), 36.
7. Flynn, C. A., D’amico, F., & Smith, G. (1998). Should we patch corneal abrasions? A meta-analysis. Journal of Family Practice, 47(4), 264-271.
8. Whitcher, J. P., Srinivasan, M., & Upadhyay, M. P. (2002). Prevention of corneal ulceration in the developing world. International Ophthalmology Clinics, 42(1), 71-77.

 For Additional Reading:

Ophthalmologic Medications: Pearls & Pitfalls in the ED:

Ophthalmologic Medications: Pearls & Pitfalls for the ED