What is the management for a patient with a corneal abrasion from an eye prick by a foreign object?

Management of Eye Prick from Object (Corneal Abrasion)

For a corneal abrasion from an eye prick, immediately irrigate the eye with sterile saline, apply broad-spectrum topical antibiotic prophylaxis (moxifloxacin four times daily), use topical NSAIDs for pain control, and avoid eye patching. 1, 2

Immediate Assessment and Red Flags

Test visual acuity immediately to establish baseline function and identify acute vision loss requiring urgent ophthalmology referral. 2

Critical Red Flags Requiring Emergency Ophthalmology Referral:

• High-velocity mechanisms (grinding, metal work, nailing) suggest possible globe penetration 3, 2
• Irregular pupil after trauma indicates penetrating injury 2
• Eye bleeding or vision loss after trauma 3, 2
• Embedded foreign body that cannot be easily removed 1
• Contact lens-related injuries require immediate lens removal and discontinuation 3, 2

Initial Management Steps

Do NOT:

• Never rub the eye - this embeds foreign bodies deeper and worsens corneal abrasion 3
• Do not patch the eye - multiple studies show patching does not help healing and may hinder it 4, 5

DO:

1. Irrigate with sterile saline or commercial eye wash to flush loose foreign material 1, 2
2. Shield the eye with hard plastic eye shield, paper cup, or plastic cup to prevent unintentional touching 3, 2
3. Remove visible superficial foreign body if easily accessible; if embedded or difficult, refer to ophthalmology 1
4. Apply fluorescein staining under cobalt-blue light to confirm diagnosis and assess extent 4

Pharmacologic Treatment

Antibiotic Prophylaxis (Required):

Apply broad-spectrum topical antibiotic to prevent infection, particularly with corneal fluorescein staining or frank ulceration 6, 1, 2:

• Moxifloxacin drops four times daily (preferred) 1, 2
• Alternative: Gatifloxacin 2

Note: Recent Cochrane review shows very low certainty evidence for antibiotics preventing infection, but guidelines universally recommend prophylaxis given low risk and potential severity of infection. 7

Pain Management (Highly Effective):

Topical NSAIDs provide superior pain control with strong evidence:

• Ketorolac tromethamine ophthalmic solution significantly decreases pain, photophobia, and foreign body sensation at 24 and 48 hours 1, 8
• Reduces oral analgesia use by 53% compared to control 8
• No healing delays or increased complications with topical NSAIDs 8

Oral analgesics as adjunct:

• Acetaminophen or oral NSAIDs for additional pain relief 1, 2

Cycloplegic agents (optional for severe pain):

• Cyclopentolate to decrease pain from ciliary spasm and anterior segment inflammation 1, 2

What NOT to Use:

• Eye patching is contraindicated - delays healing, increases pain, and worsens compliance 4, 5
• Topical mydriatics alone are not beneficial for pain control 4

Follow-Up Requirements

Mandatory ophthalmology follow-up within 24-48 hours to monitor for infection development, particularly for metallic foreign bodies (assess for rust ring formation). 2

Warning Signs to Return Immediately:

• Worsening pain or vision 2
• Increasing redness 2
• Discharge or purulent material 2
• Persistent foreign body sensation despite treatment 3, 2

Expected Healing Timeline

Most corneal abrasions heal within 24-72 hours without progression to corneal erosion or infection. 4 Patients without patches heal significantly faster than those with patches. 5

Special Considerations

For metallic foreign bodies: Ensure complete removal and assess for rust ring formation at follow-up, as incomplete removal can cause ongoing inflammation. 2

For contact lens wearers: Higher risk of infection; immediate lens removal, discontinuation of use, and closer monitoring required. 3, 2