What is the diagnosis and treatment for a male with eye pain after sanding wood, with fluorescein (fluorescein) testing showing a linear pattern, and is it a corneal abrasion or corneal ulcer?

Diagnosis and Treatment of Wood-Sanding Eye Injury with Linear Fluorescein Pattern

Diagnosis

This is a corneal abrasion (Option A). A linear fluorescein staining pattern following wood-sanding trauma is pathognomonic for a traumatic corneal abrasion, not a corneal ulcer 1. The linear pattern indicates mechanical disruption of the corneal epithelium where fluorescein dye permeates through disrupted intercellular junctions 1.

Key Distinguishing Features

• Corneal abrasion presents with acute onset following trauma, with fluorescein showing epithelial defects that appear yellow under normal light and green under cobalt blue light 2, 3
• Corneal ulcer would show stromal involvement, infiltrate, suppuration, and typically develops over time rather than immediately post-trauma 1
• The linear pattern specifically indicates a scratch or scrape mechanism consistent with foreign body or direct trauma 1

Treatment Protocol

Immediate Management

Initiate broad-spectrum topical antibiotic prophylaxis immediately, ideally within 24 hours of injury 1, 4. This is critical because:

• Prophylactic antibiotics following traumatic corneal abrasion prevent progression to bacterial keratitis and corneal ulceration 1
• Wood particles carry risk of both bacterial and fungal contamination 1
• Treatment started within 24 hours has been shown to prevent ulceration 1

Antibiotic Selection

Use fluoroquinolone drops (moxifloxacin or gatifloxacin) 4 times daily as first-line therapy 4. These are preferred because:

• Broad-spectrum coverage against common pathogens 4
• FDA-approved for bacterial keratitis treatment 4
• Superior penetration compared to ointments 1

Alternative regimen: Apply antibiotic ointment at bedtime for additional protection and lubrication 4, 2

Pain Management

• Oral analgesics (acetaminophen or NSAIDs) for pain control 4, 3
• Topical NSAIDs may be considered for symptomatic relief 2, 3
• Avoid topical cycloplegics - evidence does not support their use for uncomplicated corneal abrasions 3

Critical Management Principles

Do NOT patch the eye 1, 4. Patching:

• Does not improve pain 4, 3
• May delay healing 4, 3
• Increases risk of secondary bacterial keratitis 1

Do NOT use topical steroids initially 4. They:

• Delay epithelial healing 4
• Increase infection risk 4

Foreign Body Examination

• Carefully examine for retained wood particles under slit lamp with eversion of upper lid 3, 5
• Remove any foreign bodies present before initiating treatment 3
• Wood foreign bodies carry particular risk for fungal infection 1

Follow-Up Strategy

Re-evaluate in 24 hours for all patients except those with 3:

• Small abrasions (≤4 mm)
• Normal vision
• Rapidly resolving symptoms

Warning Signs Requiring Urgent Ophthalmology Referral

Immediate referral is indicated for 3, 5:

• Increasing pain despite treatment
• Purulent discharge
• Corneal infiltrate or ulcer development
• Significant vision loss
• Symptoms worsening or not improving within 24-48 hours

Common Pitfalls to Avoid

• Failure to prescribe antibiotics for traumatic abrasions - this is a critical error as wood contamination carries high infection risk 1
• Using eye patches - contraindicated and potentially harmful 1, 4
• Inadequate foreign body search - retained particles will prevent healing 3
• Allowing patient to rub the eye - worsens injury and delays healing 4
• Missing penetrating injury - always exclude globe rupture with careful examination 3, 5

Expected Healing Timeline

Most uncomplicated corneal abrasions heal within 24-72 hours with appropriate treatment 2, 6. If healing is delayed beyond this timeframe, consider retained foreign body, infection, or recurrent erosion syndrome 6.