What is the appropriate management and differential diagnosis for a patient who poked their eye with a makeup brush and now has pain and blurry vision?

Eye Pain and Blurry Vision from Makeup Brush Injury: Management and Differential Diagnosis

A patient with eye pain and blurry vision after poking their eye with a makeup brush requires immediate evaluation for corneal abrasion, foreign body, or penetrating injury, with topical antibiotics mandatory to prevent bacterial keratitis given the trauma history. 1

Immediate Assessment

Critical Red Flags to Exclude First

• Penetrating globe injury: Look for irregular pupil, shallow anterior chamber, hyphema, or visible corneal/scleral laceration—these require immediate ophthalmology referral and eye shield placement without any pressure on the globe 2, 3
• Retained foreign body: Examine carefully under slit lamp or direct visualization for makeup brush fibers or debris embedded in cornea or conjunctiva 4
• Corneal infiltrate or ulcer: Any white/gray opacity in the cornea suggests infection requiring urgent treatment 1

Essential Examination Components

• Visual acuity testing: Reduced vision indicates significant ocular damage requiring more aggressive management 2, 4
• Fluorescein staining: Corneal abrasion appears yellow under normal light and bright green under cobalt blue light 4
• Pupillary examination: Irregular pupil suggests penetrating injury; reactive pupil with photophobia suggests traumatic iritis 5, 3
• Foreign body search: Evert upper lid to check for retained makeup brush fibers in superior fornix 4

Differential Diagnosis

Most Likely Diagnoses

• Corneal abrasion: Most common after blunt trauma, presents with foreign body sensation, tearing, photophobia, and pain 4, 3
• Traumatic iritis: Develops from blunt trauma, causes photophobia, pain, and blurred vision with cells/flare in anterior chamber 5
• Retained foreign body: Makeup brush fibers can embed in cornea or hide under upper lid 4

Serious Diagnoses to Rule Out

• Bacterial keratitis: Trauma is a major risk factor; presents with pain, redness, blurred vision, and corneal infiltrate 1
• Corneal laceration/penetrating injury: Irregular pupil, shallow anterior chamber, or visible full-thickness defect 2, 3
• Hyphema: Blood in anterior chamber from blunt trauma 5, 6

Management Algorithm

For Simple Corneal Abrasion (No Complications)

• Topical antibiotics are mandatory: Despite trauma mechanism, prophylactic antibiotics prevent bacterial superinfection, particularly important given makeup brushes harbor bacteria 1, 4
• Pain control: Topical NSAIDs (ketorolac) or oral analgesics—evidence does not support routine cycloplegics for uncomplicated abrasions 4
• No patching: Patching does not improve pain and may delay healing 4
• Follow-up: Small abrasions (≤4mm) with normal vision and improving symptoms may not need follow-up; all others require re-evaluation in 24 hours 4

For Trauma-Related Abrasions (Makeup Brush Injury)

Critical guideline: Topical antibiotics should be prescribed to prevent acute bacterial keratitis in patients presenting with trauma-related corneal abrasion 1

• Broad-spectrum topical antibiotic: Fluoroquinolone (moxifloxacin or gatafloxacin) or polymyxin B/trimethoprim applied 4 times daily 1, 4
• Remove any foreign bodies: Use topical anesthesia and foreign body spud or cotton swab under magnification 5, 4
• Avoid patching: Patching increases risk of bacterial keratitis in trauma cases 1

If Traumatic Iritis Present

• Cycloplegic agent: Homatropine 2% or cyclopentolate 1% reduces pain and prevents posterior synechiae formation when substantial anterior chamber inflammation present 1, 5
• Topical corticosteroids: Consider prednisolone acetate 1% four times daily for significant inflammation, but only after ruling out infection 5

Immediate Ophthalmology Referral Required For:

• Any penetrating injury signs: Irregular pupil, shallow anterior chamber, visible laceration 2, 3
• Corneal infiltrate or ulcer: White/gray opacity suggests infection 1
• Large or central abrasion (>4mm): Higher risk of complications 1
• Vision loss that doesn't improve: Suggests deeper injury 4, 3
• Symptoms worsening or not improving in 24 hours: May indicate developing infection 4

Common Pitfalls to Avoid

Critical Errors

• Not prescribing antibiotics for trauma: Trauma is a major risk factor for bacterial keratitis—antibiotics are not optional 1
• Patching traumatic abrasions: Increases bacterial keratitis risk and delays healing 1
• Missing retained foreign body: Always evert upper lid to check superior fornix where makeup brush fibers commonly lodge 4
• Dismissing as "minor" without fluorescein exam: Cannot assess extent of injury without staining 4

Antibiotic Selection Considerations

• Standard trauma abrasions: Any broad-spectrum topical antibiotic acceptable 4
• Contact lens wearers (if applicable): Must use antipseudomonal coverage (fluoroquinolone) due to Pseudomonas risk 1, 4
• Awareness of resistance: Increasing MRSA and Pseudomonas resistance to fluoroquinolones noted, but they remain first-line 1

When to Escalate Care

• Corneal infiltrate develops: Requires smears/cultures and fortified antibiotics if central, large (>2mm), or significant stromal involvement 1
• No improvement in 24-48 hours: Re-examine for missed foreign body, developing infection, or deeper injury 4
• Progressive vision loss: Suggests serious pathology requiring specialist evaluation 3