WHAT YOU'LL LEARN
Proper assessment of the post-trauma patient
Assessment and management of traumatic corneal abrasion
Indications for infection prophylaxis, bandage contact lenses, cycloplegics, and corticosteroids
Introduction
Introduction
This course will review common etiologies of corneal abrasion, as well as the typical presentation, evaluation, and management of a patient with corneal abrasion secondary to trauma.
Etiology and Differential Diagnosis
Most patients suffering from corneal abrasion present with recent history of trauma to the affected eye. Such trauma may be caused by fingernails, contact lens wear, plant matter, or foreign body in the eye. In the absence of acute trauma, consider other etiologies such as recurrent corneal erosion, ultraviolet keratopathy, contact lens complications, or superficial punctate keratitis secondary to another ocular surface disease. If the epithelial defect is associated with an infiltrate, an inflammatory or infectious etiology must be ruled out.
Evaluation of Traumatic Corneal Abrasion
Comprehensive Examination and Assessment of Ocular Trauma
Any case of ocular trauma can result in tissue damage and sequelae which may lead to vision loss if not properly evaluated and treated in a timely manner. Therefore such patients require extensive and through examination. The assessment begins with a detailed history with respect to the mechanism of trauma to assist in determining the types of injuries which may be present. It is important to inquire about possible chemical exposure, non-penetrating foreign body, blunt force, penetrating trauma, or intraocular foreign body secondary to high speed projectile. Additional important information includes when the injury occurred, and if any type of safety eyewear was worn. A detailed medical history is also necessary, including current medical conditions, prescription and over the counter medications, and any known drug allergies.
Examination of the patient nearly always begins with determination of the visual acuity. Acuities may first be taken without anesthesia, then again with anesthesia if indicated to determine the best level of acuity. Evaluation of pupillary function is also crucial, as the presence or absence of an afferent pupillary defect may give clues to future visual potential.1 Gross visual fields should be assessed by confrontation fields, as any abnormalities may signal retinal, optic nerve, or visual cortex compromise.2 Abnormalities in ocular motility or globe position may indicate orbital injury, including possible blow out fracture, orbital compartment syndrome, or cranial nerve injury.2 However, it is important to note that depending on the etiology of the injury, evaluation of EOMs, as well as applanation tonometry, may need to be deferred until open globe injury is ruled out. Anterior segment assessment may reveal iridonesis or iris sphincter tear, traumatic cataract, or damage to the trabecular meshwork or zonules.1 Posterior segment and fundus examination should be performed as early as is appropriate to rule out optic nerve and retinal complications, including macular hole, commotio retinae, retinal tear or detachment, choroidal hemorrhage or rupture, and disc edema.2 When not contraindicated, scleral depression may be performed to rule out peripheral retinal tears or retinal dialysis. Otherwise, thorough peripheral retinal examination may be performed through a traditional dilated retinal examination, or b-scan may be employed if no view is possible otherwise. Depending on the type of trauma, plain radiography (x-ray) or computed tomography (CT) may be employed to rule out intraocular foreign body, orbital fracture, or head trauma especially if any loss of consciousness occurred.1 Magnetic resonance imaging (MRI) of orbital soft tissues may be used to evaluate optic nerve compromise, choroidal detachment, and non-metallic penetrating foreign body.2
Signs and Symptoms of Corneal Abrasion
A patient with a corneal abrasion often presents with complaints of blurred vision, photophobia, tearing, foreign body sensation, or sharp pain which may be exacerbated by blinking or eye movements. Most abrasion patients present with recent history of trauma to the affected eye. The cornea will show an epithelial defect, and possibly an associated conjunctival defect. These defects in the ocular surface will stain with fluorescein. A foreign body may be located in the nearby ocular tissue. The injury may also be associated with conjunctival injection, eyelid edema, or a mild anterior chamber reaction.
Evaluation of the Injury
Initial evaluation of the injured tissue must include documentation of the extent of the epithelial defect using fluorescein dye during a slit lamp examination. The height, width, and location of the epithelial lesion must be carefully measured so that healing may be closely monitored. Furthermore, penetrating trauma and corneal laceration must be ruled out. A distorted or peaked pupil, or shallow anterior chamber, may indicate an open globe. The presence of vertical or linear abrasions indicates a likely foreign body, and the eyelids must be everted to ensure all foreign bodies are located and removed. Additionally, because loose epithelium can inhibit healing, it is necessary to evaluate the cornea for tissue that may need to be debrided to form a clean leading edge for healing. Traumatic iritis may occur in conjunction with the abrasion, so it is important to monitor for an anterior chamber reaction which can develop 24 to 72 hours post-trauma.
Management of Traumatic Corneal Abrasion
Medical Management
Management of a traumatic corneal abrasion includes use of an antibiotic for infection prophylaxis, especially if the abrasion is large or deep, or the offending agent was a fingernail or vegetative in nature. Though the decision to use topical drops or ointment may be considered controversial, the Wills Eye Manual states “ointments offer better barrier and lubricating function between eyelid and abrasion but tend to blur vision temporarily.”3 For patients who are unable to tolerate the associated blur, ointment may be used only at bedtime, while drops may used during the day when clear vision may be crucial for work or other activities. In these cases, a broad spectrum drop may be instilled four times per day, and a broad spectrum ointment may be instilled at bedtime.4 Contact lens wearers must have anti-pseudomonas coverage, and this can also be accomplished using a topical fluoroquinolone at least four times per day.3 See Table 1 for additional medication recommendations. Once the epithelial defect resolves, non-contact lens wearers can discontinue antibiotic use; however, contact lens wearers should continue treatment for an additional one to two days, and may resume contact lens wear approximately one week after discontinuing topical antibiotics, as long as the eye feels normal.
Table 1: Ophthalmic Antibiotic Recommendations for Corneal Abrasion Management
While the use of cycloplegics for pain control after uncomplicated corneal abrasion is generally discouraged,5,4,7 cycloplegics should always be employed if concurrent iritis is present. Iritis treatment is designed to resolve inflammation and pain while minimizing complications, and often includes the use of a cycloplegic agent to decrease pain by immobilizing the iris and preventing ciliary spasm, to prevent posterior synechia, and to stabilize the blood-aqueous barrier.8 It is best to avoid long acting agents for small abrasions in order to allow for faster visual recovery.3 It is important to note that phenylephrine has no cycloplegic or anti-inflammatory effect, and is generally not recommended for management of uveitis.8 One or two percent cyclopentolate can be used two to three times per day for mild cases.3 It is important to note that for all cycloplegics, the duration of action can be greatly decreased in an inflamed eye, warranting multiple doses per day in more severe cases.4 Cycloplegics can be discontinued once the cell and flare reaction has begun to resolve.8
Corticosteroid agents should be avoided for iritis with epithelial defects because it may slow epithelial healing and increase the risk of secondary infection.3 This is especially true if the injury is secondary to plant matter, as the risk of fungal keratitis is higher.9 Once the epithelial defect is resolved, a topical steroid may be considered based on the level of any lingering inflammation. Corticosteroids help to suppress the migration and circulation of leukocytes, inhibit the release of lysozyme by granulocytes, and reverse the increased capillary permeability by stabilizing cell membranes.4,10 Prednisolone acetate 1% is often employed due to its high effectivity and good corneal penetration.4 Durezol (difluprednate ophthalmic emulsion 0.05%) also offers high effectivity and corneal penetration, often with a decreased dosing schedule. Caution should be taken with known steroid responders: while some suggest avoiding steroids and substituting NSAIDs whenever possible,8 the patient may be better served with a soft steroid if the severity allows for it. A gradual taper of corticosteroid therapy may begin when there are fewer than five cells per high power field visible in the anterior chamber, or once the inflammation is completely resolved.8,11
In the case of a severe abrasion, pressure patching may be carefully considered, but is rarely necessary as it does not improve pain levels or healing time.3,12 In fact, patching can cause worsening or new abrasion if not properly applied,3 and slow healing even when properly applied.5 Alternately, a bandage contact lens may be used for pain control or to assist in cases of poor epithelial healing. If applied, broad spectrum topical antibiotic drops should be used concurrently.3 Both a pressure patch and bandage lens may be contraindicated in patients with trauma related to contact lens wear, fingernails, or vegetation as they may increase the risk of infectious keratitis.3
For pain associated with corneal abrasion and ocular trauma, a topical NSAID may be considered for patients with no other ocular surface disease. One review found “NSAIDs provide greater pain relief and improvement of other subjective symptoms when compared with placebo” and may be a good option for patients “who must return to work immediately, particularly where potential opioid-induced sedation is intolerable.”13 In these cases a drug such as ketorolac 0.4 to 0.5% may be used up to four times per day for three days.3 Oral NSAIDs or narcotics may also be considered for more severe cases; however, the use of aspirin and other NSAIDs increases the risk of hyphema rebleed and should be avoided in cases with an associated traumatic hyphema.1 Topical anesthetics should be avoided after the initial examination because they can slow healing and cause further corneal damage,5 including worsening epithelial defect and dense infiltrates.4
Follow-up Protocols
Most small abrasions heal in two to three days, while larger abrasions that involve more than one half of the surface area of the cornea may take four to five days.14 If patched or given a bandage contact lens, or if the abrasion is central or especially large, the patient should return in 24 hours for close monitoring and to ensure the defect is healing. Once the patient shows improvement, or in the case of peripheral or small wounds, the patient may return every two to five days until healed. If the need for ongoing management of inflammation is present, the individual follow-up schedule is determined by the severity of the inflammation, but is usually recommended within five to seven days,3 then biweekly once taper has begun.11 As always, the patient should also be instructed to return sooner if any symptoms worsen.
Prevention and Patient Education
Many eye injuries are preventable; the primary method of prevention includes the use of eye protection, including safety goggles and full face masks, as indicated by the activity in which the patient is engaging. Those who participate in certain high risk occupations, hobbies, or sports should wear such eye protection. A discussion should be had with each patient regarding their individual risks and protective needs. For example, if during a comprehensive eye exam, the social history reveals a patient works construction or enjoys metal working, the risks of ocular injury and methods of eye protection should be addressed. Additionally, this should be addressed for any patient entering the office for care after an eye injury.
Once ocular trauma has occurred, proper patient education regarding after-care of the injury is crucial to optimize the patient’s final outcome. The patient must understand that treatment compliance is essential and that even small details must be attended to. For example, the patient may be advised to wait 10 minutes between all eye drops to allow each time to penetrate and perform their function. Patients must also be knowledgeable of possible complications, how to prevent further damage, and signs to immediately seek care. Lastly, the patient must be advised of the importance of future follow up, evaluation and management in case of possible late sequelae.
References
References
- Bansal S, Gunasekeran DV, Ang B, et al. Controversies in the pathophysiology and management of hyphema. Surv Ophthalmol. 2016 May;61(3):297-308.
- Mahadevan SV, Savitsky E. Emergency Management of Traumatic Eye Injuries: 2001. Available at: https://www.reliasmedia.com/articles/71714-emergency-management- of-traumatic-eye-injuries. Accessed December 1, 2019.
- Bagheri N, Wajda AK. Chapter 3: Trauma. In The Wills Eye Manual, 7th edition. Philadelphia: Wolters Kluwer; 2017; 12-51.
- Lonsberry BB, Wyles L, Goodwin D, et al. Chapter 26: Diseases of the Cornea. In Bartlett JD, Jaanus SD, eds. Clinical Ocular Pharmacology, 5th edition. St. Louis: Butterworth-Heinemann; 2008;483-547.
- Wilson SA, Last A. Management of Corneal Abrasions. Am Fam Physician. 2004 May;70(1):123-8.
- Melton R, Thomas R, Vollmer P. 2019 Clinical Guide to Ophthalmic Drugs. Rev Optom. 2019:23(1-51).
- Brahma AK, Shah S, Hillier VF, et al. Topical analgesia for superficial corneal injuries. J Accid Emerg Med. 1996;13(3):186–188.
- Agrawal RV, Murthy S, Sangwan V, et al. Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmol. 2010 Jan-Feb;58(1):11-9.
- Bharathi MJ, Ramakrishan R, Vasu S, et al. Epidemiological Characteristics and Laboratory Diagnosis of Fungal Keratitis. Indian J Ophthalmol 2003;51:315-21.
- Mahabadi N, Kim J, Edens MA. Iritis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019.
- Harthan JS, Opitz DL, Fromstein SR, Morettin CE. Diagnosis and treatment of anterior uveitis: optometric management. Clin Optom (Auckl). 2016; 8: 23–35.
- Kaiser PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology. 1995 Dec;102(12):1936-42.
- Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med. 2003 Jan;41(1):134-40.
- Dua HS, Forrester JV. Clinical patterns of corneal epithelial wound healing. Am J Ophthalmol. 1987 Nov 15;104(5):481-9.
