Overview
Corneal Abrasion
Quick Reference
Critical Alerts
- Rule out globe rupture: Do NOT apply pressure if suspected
- Fluorescein staining under cobalt blue light: Diagnostic
- Remove contact lenses: Risk of Pseudomonas keratitis
- Never patch contact lens-related injuries: Increases infection risk
- Refer ophthalmology for large, central, or complex injuries
- Tetanus prophylaxis if needed
Key Diagnostics
| Test | Finding |
|---|---|
| Visual acuity | Baseline, may be decreased |
| Fluorescein + cobalt blue light | Epithelial defect stains green |
| Slit lamp exam | Visualize defect, rule out infiltrate/ulcer |
| Eversion of eyelids | Remove retained foreign body |
Emergency Treatments
| Intervention | Details |
|---|---|
| Topical antibiotics | Erythromycin ointment or fluoroquinolone drops |
| Cycloplegics | Cyclopentolate for pain relief (optional) |
| Oral analgesics | NSAIDs, acetaminophen |
| Avoid patching | No benefit, may delay healing |
| Ophthalmology referral | Large, central, contact lens, or no improvement |
Definition
Overview
A corneal abrasion is a superficial defect of the corneal epithelium, commonly caused by trauma, foreign bodies, or contact lens wear. It is one of the most common eye complaints in the ED. While most heal spontaneously within 24-72 hours, proper treatment prevents infection and promotes comfort.
Classification
By Etiology:
| Type | Examples |
|---|---|
| Traumatic | Fingernails, branches, paper, makeup brushes |
| Foreign body-related | Metal, wood, glass, dirt |
| Contact lens-related | Overwear, poor hygiene, sleeping in lenses |
| Spontaneous (recurrent erosion) | Prior corneal injury, epithelial basement membrane dystrophy |
By Size/Location:
- Small (<1 mm) vs Large (>5 mm)
- Peripheral vs Central (affects vision more)
Epidemiology
- Very common: ~2% of ED visits are for eye complaints; corneal abrasion is leading cause
- Occupational: Grinding, welding, construction
- Contact lens wearers: Higher risk
Etiology
Common Causes:
| Category | Examples |
|---|---|
| Traumatic | Fingernail, infant scratches, sports |
| Foreign body | Metal fragment, wood chip, sand |
| Contact lens | Overwear, poor fit, sleeping in lenses |
| Chemical | Splash injuries (separate entity) |
| UV keratitis | Welding flash (photokeratitis) |
Pathophysiology
Mechanism
- Mechanical trauma: Disrupts corneal epithelium
- Epithelial defect: Exposes nerve endings (pain, tearing)
- Inflammatory response: Edema, photophobia
- Healing: Epithelial cells migrate and proliferate (24-72 hours)
Corneal Anatomy
- Epithelium: Outermost layer (affected in abrasion)
- Bowman's layer: Acellular layer beneath epithelium
- Stroma: Thick middle layer
- Descemet's membrane: Basement membrane
- Endothelium: Innermost layer
Cornea is highly innervated → Small injuries cause significant pain
Clinical Presentation
Symptoms
| Symptom | Description |
|---|---|
| Eye pain | Moderate to severe, foreign body sensation |
| Tearing | Lacrimation |
| Photophobia | Light sensitivity |
| Blurred vision | If central cornea involved |
| Eye redness | Conjunctival injection |
History
Key Questions:
Physical Examination
Visual Acuity:
External Exam:
| Finding | Significance |
|---|---|
| Lid edema | Trauma |
| Conjunctival injection | Inflammation |
| Evert lids | Retained foreign body |
Slit Lamp with Fluorescein:
| Finding | Significance |
|---|---|
| Epithelial defect (green stain) | Abrasion |
| Linear vertical scratches | Retained subtarsal FB |
| White infiltrate | Corneal ulcer (refer urgently) |
| Seidel test positive (streaming fluorescein) | Globe rupture |
Pupil Exam:
Mechanism of injury (what hit the eye?)
Common presentation.
Contact lens use (type, duration of wear, sleeping in lenses)
Common presentation.
Time of injury
Common presentation.
Prior corneal injuries or surgery
Common presentation.
Tetanus status
Common presentation.
Occupational risk (grinding, welding)
Common presentation.
Using eye protection?
Common presentation.
Red Flags
Must Exclude Serious Injury
| Finding | Concern | Action |
|---|---|---|
| Mechanism: High-velocity projectile | Globe rupture, IOFB | CT orbits, ophthalmology |
| Teardrop pupil | Penetrating injury | Shield eye, do NOT pressure |
| Seidel test positive | Globe rupture | Emergent ophthalmology |
| White infiltrate | Corneal ulcer | Urgent ophthalmology |
| Hypopyon | Infectious keratitis | Urgent ophthalmology |
| Decreased visual acuity (significant) | Deeper injury | Ophthalmology |
| Contact lens + infiltrate | Pseudomonas keratitis | Urgent referral |
Differential Diagnosis
Other Causes of Red, Painful Eye
| Diagnosis | Features |
|---|---|
| Corneal ulcer | White infiltrate, hypopyon |
| Foreign body | Visible FB, linear scratches |
| Acute angle-closure glaucoma | Fixed mid-dilated pupil, halos, rock-hard eye |
| Iritis/Uveitis | Photophobia, ciliary flush, cells/flare |
| Herpes simplex keratitis | Dendritic pattern on fluorescein |
| Conjunctivitis | Discharge, no photophobia, no fluorescein uptake |
| Chemical injury | History of splash, may have severe damage |
| UV keratitis (photokeratitis) | Welding or tanning bed without protection |
Diagnostic Approach
Visual Acuity
- Essential: Document with and without correction
- Use Snellen chart or near card
Slit Lamp Examination
Technique:
- Instill topical anesthetic (proparacaine)
- Apply fluorescein strip to inferior fornix
- Examine under cobalt blue light
- Look for staining (green = epithelial defect)
Key Findings:
| Pattern | Interpretation |
|---|---|
| Focal defect | Simple abrasion |
| Linear vertical scratches | Subtarsal foreign body |
| Dendritic pattern | Herpes simplex keratitis |
| Large geographic defect | Severe abrasion or neurotrophic keratopathy |
| Infiltrate | Ulcer (refer urgently) |
Evert Eyelids
- Upper lid eversion essential: Remove retained foreign body
- Technique: Have patient look down, grasp lashes, flip lid over cotton swab
Seidel Test
- Apply fluorescein, look for streaming (aqueous leak)
- Positive = Globe rupture → Shield eye, call ophthalmology
Treatment
Principles
- Rule out serious injury: Globe rupture, penetrating injury, ulcer
- Remove foreign body: If present
- Topical antibiotics: Prevent secondary infection
- Pain control: Topical cycloplegics (optional), oral analgesics
- No patching: No benefit, may delay healing
- Ophthalmology referral: For complicated cases
Topical Antibiotics
First-Line Options:
| Agent | Dose | Duration |
|---|---|---|
| Erythromycin 0.5% ointment | Apply TID-QID | 5-7 days |
| Polymyxin B/Trimethoprim drops | 1 drop QID | 5-7 days |
| Ciprofloxacin 0.3% drops | 1 drop QID | 5-7 days |
| Ofloxacin 0.3% drops | 1 drop QID | 5-7 days |
Contact Lens Wearers:
- Use fluoroquinolone drops (cover Pseudomonas)
- Ciprofloxacin or ofloxacin preferred
- Do NOT use ointment (blurs vision, foreign body sensation)
Pain Management
Cycloplegics (Optional):
| Agent | Dose | Notes |
|---|---|---|
| Cyclopentolate 1% | 1 drop | Relieves ciliary spasm; lasts 24h |
Oral Analgesics:
| Agent | Dose |
|---|---|
| Ibuprofen | 400-600 mg q6-8h |
| Acetaminophen | 650-1000 mg q6h |
| Opioids (short-term) | If severe |
Topical NSAIDs (Controversial):
- May reduce pain but concern for delayed healing
- Not routinely recommended
Topical Anesthetics:
- Do NOT prescribe for home use: Delays healing, may cause ulcer
- Used only for exam
Eye Patching
NOT Recommended:
- Studies show no benefit
- May delay healing
- Increases risk of infection in contact lens wearers
Tetanus Prophylaxis
- Update if needed (especially if soil/organic material involved)
Foreign Body Removal
- Irrigate with saline
- Use cotton swab or needle (under slit lamp) if embedded
- If metallic FB, remove rust ring with burr (ophthalmology if inexperienced)
Disposition
Discharge Criteria
- Simple corneal abrasion
- Pain controlled
- No signs of ulcer or penetrating injury
- Reliable follow-up
Ophthalmology Referral (Urgent/Emergent)
| Indication | Urgency |
|---|---|
| Globe rupture | Emergent |
| Corneal ulcer/infiltrate | Same day |
| Large or central abrasion | 24-48 hours |
| Contact lens-related (high risk) | 24-48 hours |
| No improvement in 24-48 hours | Urgent |
| Herpes simplex keratitis | Same day |
| Retained intraocular FB | Emergent |
Follow-Up
| Situation | Follow-Up |
|---|---|
| Simple abrasion | PCP or optometry in 24-48h if not improving |
| Contact lens abrasion | Ophthalmology in 24 hours |
| Large/central abrasion | Ophthalmology in 24 hours |
Patient Education
Condition Explanation
- "You have a scratch on the surface of your eye."
- "This will heal on its own within 1-3 days."
- "Use the antibiotic drops to prevent infection."
Home Care
- Use drops/ointment as prescribed
- Avoid rubbing eye
- Stay out of contact lenses until healed (usually 1 week after symptom resolution)
- Wear sunglasses if photophobic
- Avoid dusty/dirty environments
Warning Signs to Return
- Worsening pain or vision
- White spot on cornea
- Increasing redness or discharge
- No improvement in 24-48 hours
Special Populations
Contact Lens Wearers
- Higher risk of Pseudomonas keratitis
- Use fluoroquinolone drops
- Do NOT patch
- Stay out of lenses until healed and asymptomatic × 1 week
- Ophthalmology follow-up recommended
Recurrent Corneal Erosion
- Prior corneal injury or epithelial basement membrane dystrophy
- Presents with sudden pain, often upon waking
- Treat like abrasion; ophthalmology follow-up for prophylaxis (lubricants, hypertonic saline)
Children
- Common (fingernails, toys)
- Use ointment (easier than drops)
- Minimize eye rubbing
Welders (UV Keratitis / Photokeratitis)
- "Flash burn" from UV exposure
- Bilateral punctate staining
- Usually occurs hours after exposure
- Treatment: Supportive, cycloplegics, antibiotics
- Heals in 24-48 hours
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Visual acuity documented | 100% | Baseline assessment |
| Fluorescein exam performed | 100% | Confirm diagnosis |
| Lid eversion for FB | >0% | Remove retained FB |
| Topical antibiotics prescribed | 100% | Prevent infection |
| Ophthalmology referral for high-risk | 100% | Prevent complications |
Documentation Requirements
- Mechanism of injury
- Visual acuity (before treatment)
- Slit lamp findings
- Size and location of abrasion
- Treatment given
- Follow-up plan
Key Clinical Pearls
Diagnostic Pearls
- Fluorescein + cobalt blue = diagnostic: Green staining is epithelial defect
- Linear vertical scratches = subtarsal FB: Evert lid, remove FB
- Dendritic pattern = herpes: Refer ophthalmology
- White infiltrate = ulcer: Refer urgently
- Seidel positive = globe rupture: Shield eye, do not pressure
- Check visual acuity ALWAYS: Baseline and medicolegal
Treatment Pearls
- No patching: Studies show no benefit
- Topical anesthetics NOT for home: Delays healing, causes ulcers
- Fluoroquinolone for contact lens wearers: Cover Pseudomonas
- Erythromycin ointment for most others: Lubricates, protects
- Cycloplegics for pain: Optional but helpful
- Tetanus if needed: Especially organic material
Disposition Pearls
- Most abrasions heal in 24-72 hours: Reassure patients
- Follow-up if not improving: May have ulcer or retained FB
- Stay out of contacts until healed: At least 1 week after symptoms resolve
- Ophthalmology for complicated cases: Large, central, contact lens, ulcer
References
- Verma A, et al. Corneal abrasion. StatPearls. 2024.
- Wipperman JL, et al. Evaluation and treatment of corneal abrasions. Am Fam Physician. 2013;87(2):114-120.
- Carley F, et al. Corneal abrasion and recurrent corneal erosion syndrome. Community Eye Health. 2015;28(89):13-14.
- Turner A, et al. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;(2):CD004764.
- Calder LA, et al. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions. Ann Emerg Med. 2016;68(1):148-152.
- Lim CH, et al. Contact lens-related corneal ulcers: risk factors and clinical outcomes. Graefes Arch Clin Exp Ophthalmol. 2017;255(4):859-864.
- American Academy of Ophthalmology. Corneal Abrasion Guidelines. 2020.
- UpToDate. Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis. 2024.