What is the appropriate examination and treatment for a suspected corneal abrasion in an 8-year-old patient?

Examination and Treatment of Suspected Corneal Abrasion in an 8-Year-Old

For a suspected corneal abrasion in an 8-year-old, perform fluorescein staining with cobalt-blue light examination to confirm the diagnosis, then immediately start topical broad-spectrum antibiotic drops (fluoroquinolone four times daily) within 24 hours of injury to prevent bacterial keratitis, provide oral pain relief, and schedule 24-hour follow-up—never patch the eye. 1, 2

Examination Protocol

History Taking

• Mechanism of injury: Determine if trauma involved contact lenses, vegetable matter (fungal risk), or high-velocity projectiles (penetrating injury risk) 1, 3
• Timing: Document when injury occurred—antibiotic efficacy decreases significantly after 24 hours 1, 4
• Symptoms: Ask specifically about eye pain, foreign body sensation, tearing, photophobia, and vision changes 5, 3

Physical Examination Steps

Visual acuity testing should be performed first under standard lighting with and without correction—this is one of the most sensitive techniques for detecting eye abnormalities in children 2

External inspection includes:

• Eyelid position and function (check for lagophthalmos or incomplete closure) 2
• Facial symmetry and head positioning (abnormal head tilt may indicate compensatory mechanism) 2
• Penlight evaluation of lids, conjunctiva, sclera, cornea, and iris 2

Pupillary examination:

• Assess size, shape, symmetry, and reactivity to light 2
• Perform swinging-light test to detect relative afferent pupillary defect (suggests optic nerve pathology) 2
• Red flag: Irregular pupil after trauma requires immediate ophthalmology referral 1

Fluorescein staining with cobalt-blue light:

• This confirms the diagnosis—abrasion appears yellow under normal light and bright green under cobalt-blue filtered light 5, 3
• Carefully examine for retained foreign bodies under the upper eyelid by everting it 3, 2
• Document size and location of the defect 3

Slit-lamp biomicroscopy (if available):

• Evaluate depth of involvement—superficial epithelial vs. stromal 2
• Look for infiltrates, suppuration, or signs of infection 1, 2

Treatment Protocol

Antibiotic Prophylaxis (CRITICAL)

Start topical broad-spectrum antibiotics within 24 hours of injury—this timing is essential as prophylactic antibiotics prevent ulceration specifically when initiated in this timeframe 1, 2, 4

For simple (non-contact lens) abrasions:

• First-line: Moxifloxacin 0.5% or gatifloxacin 0.5% four times daily until complete healing 1, 2
• Cost-effective alternative (if cost is a barrier): Chloramphenicol ointment 1% three times daily for 3 days (96% success rate in preventing ulceration) 4

For contact lens-related abrasions (if applicable):

• Mandatory antipseudomonal coverage: Fluoroquinolones (moxifloxacin 0.5% or gatifloxacin 0.5%) with more aggressive dosing 1, 2
• Never patch the eye in contact lens wearers—this dramatically increases bacterial keratitis risk 1, 2
• Advise complete contact lens avoidance until healing confirmed 1

Pain Management

Oral analgesics are preferred:

• Over-the-counter ibuprofen or acetaminophen provide adequate pain relief 1, 4, 3
• Topical NSAIDs may be used but can delay corneal epithelialization 4, 5

Avoid topical anesthetics for home use—while they provide immediate relief, evidence does not support their safety for outpatient use beyond 72 hours 6

Critical Management Principles: What NOT to Do

• Do NOT patch the eye: Multiple studies show patching does not improve pain, may delay healing, and increases infection risk 1, 5, 3
• Do NOT use topical corticosteroids initially: They delay healing and increase infection risk 1, 2
• Do NOT use combination steroid-antibiotic drops as initial therapy 1
• Do NOT use cycloplegics routinely: Evidence does not support their use for uncomplicated abrasions 3, 5

Follow-Up Protocol

24-hour re-evaluation is mandatory for all patients except those with very small (<4mm), uncomplicated abrasions with normal vision and resolving symptoms 1, 3

At follow-up, assess:

• Epithelial healing with repeat fluorescein staining 1
• Early signs of infection (infiltrate, suppuration, worsening pain) 1, 2
• Visual acuity improvement 3

Red Flags Requiring Immediate Ophthalmology Referral

Refer emergently if any of the following are present:

• Central infiltrate >2mm with stromal involvement 1, 2
• Corneal infiltrate with suppuration, necrosis, or feathery margins (bacterial keratitis) 1, 7
• Irregular pupil or hyphema after trauma 1
• High-velocity injury or suspected penetrating trauma 1, 3
• Vision loss or eye bleeding 1
• Increasing pain, purulent discharge, or worsening symptoms despite treatment 1, 3

Common Pitfalls to Avoid

Delayed antibiotic initiation: The 24-hour window is critical—efficacy decreases significantly after this timeframe 1, 4

Missing foreign bodies: Always evert the upper eyelid to check for retained material 3, 2

Inadequate follow-up: Children may not reliably report worsening symptoms—ensure caregiver understands warning signs 1, 2

Vegetable matter injuries: These require consideration of antifungal coverage in addition to antibiotics due to fungal contamination risk 4

Misdiagnosing penetrating injury as simple abrasion: High-velocity mechanisms, irregular pupils, or deep anterior chamber involvement require immediate specialist evaluation 1, 3