A patient presents after a small wooden object entered his eye, with severe eye pain, photophobia, inability to open the eye, and fluorescein staining demonstrating an epithelial defect. What is the most likely diagnosis?

Corneal Abrasion

The most likely diagnosis is B. Corneal abrasion. This patient presents with the classic triad of acute traumatic eye injury (wooden foreign body), severe pain with photophobia and inability to open the eye, and a fluorescein-positive epithelial defect—all hallmark features of corneal abrasion rather than ulcer, hemorrhage, or conjunctivitis 1.

Diagnostic Reasoning

Corneal abrasion is confirmed by:

• Acute traumatic mechanism (wooden object entering the eye) 1
• Severe eye pain, photophobia, and foreign body sensation 2, 3
• Fluorescein-positive epithelial defect visible on examination 1, 2
• Immediate symptom onset following trauma 3

Why not the other diagnoses:

Corneal Ulcer (Option A)

• Develops over days, not immediately after trauma 1
• Requires stromal infiltrates >1 mm with indistinct margins, stromal edema, and leukocyte infiltration 1
• Shows suppuration, necrosis, or feathery margins on examination 4
• This patient has an acute epithelial defect without these features

Subconjunctival Hemorrhage (Option C)

• Presents as painless blood-red area beneath the conjunctiva 1
• No epithelial defects, photophobia, or inability to open the eye 1
• Does not cause severe pain or fluorescein uptake
• Completely inconsistent with this presentation

Acute Conjunctivitis (Option D)

• Causes discharge, conjunctival injection, and mild discomfort 1
• Lacks severe pain, marked photophobia, or fluorescein-positive epithelial defects 1
• Does not present with inability to open the eye
• Wrong clinical picture entirely

Critical Management for Wooden Foreign Body

This case requires heightened vigilance because organic material (wood) carries significantly higher infection risk:

Immediate Actions

• Perform meticulous examination under magnification to confirm complete removal of all wooden fragments 1
• Initiate broad-spectrum topical antibiotic drops within 24 hours to prevent bacterial keratitis 5, 4
• Use fluoroquinolones (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily until epithelial healing confirmed 4, 6

Why Fluoroquinolones Are Mandatory

• Achieve high corneal tissue concentrations superior to ointments 4, 6
• Provide broad-spectrum coverage against both bacterial and fungal pathogens following trauma 5, 4
• Prophylactic antibiotics started within 24 hours prevent ulceration 5

Follow-Up Protocol

• Mandatory 24-hour re-evaluation to detect early infection 1, 3
• Wooden foreign bodies increase risk of fungal keratitis 5
• Instruct patient to return immediately for increasing pain, purulent discharge, or worsening vision 1, 4

Pain Management

• Oral acetaminophen or NSAIDs for analgesia 1, 6
• Topical NSAIDs may be added if needed 1
• Never patch the eye—patching does not improve pain and may delay healing 5, 1, 2

Red Flags Requiring Urgent Ophthalmology Referral

• High-velocity mechanism suggesting possible globe penetration 1, 4
• Irregular pupil, intraocular bleeding, or vision loss after trauma 1, 4
• Development of corneal infiltrate (suggests progression to bacterial keratitis) 1, 4
• Central infiltrate >2 mm, hypopyon, or deep stromal involvement 4

Critical Pitfalls to Avoid

• Do not use topical corticosteroids before infection is excluded—steroids exacerbate infectious keratitis and worsen outcomes in fungal infections 1, 4, 6
• Do not use combination steroid-antibiotic drops as initial therapy 4, 6
• Do not place therapeutic contact lenses on traumatic abrasions due to increased infection risk 5
• Do not assume complete foreign body removal without careful slit-lamp examination—retained organic material dramatically increases infection risk 5