When should a corneal abrasion be referred to an ophthalmologist?

When to Refer Corneal Abrasions to Ophthalmology

Refer immediately to ophthalmology if there is any suspicion for penetrating eye injury, corneal ulcer, bacterial keratitis, or ophthalmic zoster, as these are sight-threatening conditions requiring emergent specialist evaluation. 1

Immediate/Emergent Referral Criteria

Refer urgently for same-day ophthalmology evaluation if any of the following are present:

• Suspected penetrating eye injury (irregular pupil, deep laceration, or mechanism suggesting perforation) 1, 2
• Corneal infiltrate or ulcer visible on examination 2
• Signs of bacterial keratitis (purulent discharge, progressive pain, white/yellow infiltrate) 3, 1
• Significant vision loss that does not improve with refraction 2, 4
• Severe pain unrelieved by topical anesthetics 4
• Contact lens-related abrasion with infiltrate (high risk for Pseudomonas infection) 3
• Large central abrasions (>4mm or involving visual axis) 2
• Recurrent corneal erosions despite appropriate treatment 4

Next-Day Ophthalmology Follow-Up Required

Schedule ophthalmology evaluation within 24 hours for:

• All contact lens-related abrasions (even without infiltrate, due to increased infection risk) 3, 5
• Abrasions larger than 4mm 2
• Any abrasion with abnormal vision 2
• Symptoms not improving or worsening after initial treatment 2, 4
• Contaminated injuries (organic matter, soil, vegetable matter) requiring fungal coverage consideration 3
• Patients with chronic epithelial defects or ocular surface disease 3

Cases That Can Be Managed in Primary Care

Small, uncomplicated abrasions (≤4mm) may be managed without ophthalmology referral if ALL of the following criteria are met:

• Non-contact lens wearer 2
• Normal vision (or vision correctable to baseline) 2
• Clean mechanism of injury (no contamination) 3
• No corneal infiltrate on fluorescein examination 2
• Resolving symptoms within 24-48 hours 6, 2
• Reliable patient who can return for urgent evaluation if symptoms worsen 3

Primary Care Management Protocol

For appropriate cases managed without immediate referral:

• Prescribe broad-spectrum topical antibiotics (Polytrim drops 4 times daily or erythromycin ointment) to prevent bacterial keratitis 3, 6
• Provide oral analgesics (acetaminophen or NSAIDs) rather than topical NSAIDs which may delay healing 6
• Avoid eye patching as it does not improve pain and may increase infection risk 3, 6
• Ensure 24-48 hour follow-up to confirm healing 6, 2
• Educate patients to return immediately for worsening pain, discharge, or vision changes 3

Critical Pitfalls to Avoid

• Never assume contact lens-related abrasions are simple - these require antipseudomonal coverage (fluoroquinolone, not Polytrim) and ophthalmology follow-up due to high Pseudomonas risk 3, 5
• Do not patch contact lens-related abrasions as this significantly increases bacterial keratitis risk 3
• Avoid topical steroids unless directed by ophthalmology, as they can worsen infection and delay healing 4
• Do not use therapeutic bandage contact lenses in primary care for traumatic abrasions, especially in contact lens wearers, due to infection risk 3
• Recognize that prophylactic antibiotics do not eliminate infection risk - patient vigilance and appropriate follow-up remain essential 3