A patient with a wooden foreign body to the eye presents with severe pain, photophobia, inability to open the eye, and fluorescein staining shows an epithelial defect. What is the most likely diagnosis? A. Corneal ulcer B. Corneal abrasion C. Subconjunctival hemorrhage D. Acute conjunctivitis

Corneal Abrasion

The most likely diagnosis is B. Corneal abrasion. A patient presenting with acute traumatic injury from a wooden foreign body, severe eye pain, photophobia, inability to open the eye, and a fluorescein-positive epithelial defect is diagnostic of corneal abrasion. 1

Clinical Reasoning

The clinical presentation clearly distinguishes corneal abrasion from the other options:

• Corneal abrasion presents with acute traumatic injury, severe pain, photophobia, foreign body sensation, and a fluorescein-positive epithelial defect appearing immediately after trauma. 1, 2, 3

• Corneal ulcer (Option A) develops over days rather than immediately after trauma, presents with stromal infiltrates larger than 1 mm, indistinct margins, stromal edema, and leukocyte infiltration—none of which are described in this case. 1

• Subconjunctival hemorrhage (Option C) appears as a painless, blood-red area beneath the conjunctiva without epithelial defects, photophobia, or inability to open the eye—the opposite of this patient's presentation. 1

• Acute conjunctivitis (Option D) causes discharge, conjunctival injection, and mild discomfort but lacks severe pain, marked photophobia, or fluorescein-positive epithelial defects. 1, 4

Critical Management Considerations for Wooden Foreign Bodies

Wooden (organic) foreign bodies dramatically increase the risk of fungal keratitis and require heightened vigilance. 1

Immediate Treatment Steps

• Confirm complete removal of the wooden fragment through meticulous slit-lamp examination, as retained organic material dramatically raises infection risk. 1

• Initiate broad-spectrum topical antibiotics within 24 hours to prevent both bacterial and fungal infection; fluoroquinolone drops (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily provide high corneal tissue concentrations and coverage against both bacterial and fungal pathogens. 1, 5

• Provide pain control with oral acetaminophen or NSAIDs; topical NSAIDs may be added if needed. 1

• Avoid eye patching, as it does not improve pain and may delay epithelial healing. 1, 2, 3

Mandatory Follow-Up

• Arrange close follow-up within 24 hours to detect early signs of infection, especially given the elevated fungal risk with organic material. 1

• Instruct patients to return urgently for increasing pain, purulent discharge, or worsening vision, which may indicate progression to keratitis. 1

Red-Flag Findings Requiring Urgent Ophthalmology Referral

• High-velocity mechanism suggesting possible globe penetration, irregular pupil, intra-ocular bleeding, or loss of vision after trauma. 1

• Development of a corneal infiltrate or ulcer. 1, 3

• Presence of hypopyon (layered white cells in the anterior chamber), which signals severe infection. 5

Critical Pitfalls to Avoid

• Do not prescribe topical corticosteroids before infection has been excluded, as steroids can exacerbate infectious keratitis and worsen outcomes in fungal or Acanthamoeba infections. 1, 5

• Do not place therapeutic contact lenses on traumatic corneal abrasions, as they increase infection risk. 1

• Do not assume complete removal of wooden fragments without thorough examination; retained organic material dramatically raises infection risk. 1