What is the workup for corneal abrasion?

From the Guidelines

The workup for a corneal abrasion should begin with a thorough history and comprehensive eye examination, including the use of topical anesthetic drops and fluorescein staining to identify the abrasion, as well as assessment for foreign bodies and evaluation of the size, depth, and location of the abrasion. This approach is supported by the most recent guidelines on bacterial keratitis preferred practice pattern 1. The examination should include visual acuity testing in both eyes as a baseline, and a slit lamp examination to assess the cornea and rule out any other ocular conditions.

When treating a corneal abrasion, it is essential to consider the risk of infection, particularly in patients who wear contact lenses or have a history of trauma. Topical antibiotics, such as erythromycin ointment or moxifloxacin drops, should be prescribed 4 times daily for 5-7 days to prevent infection 1. Pain management is also crucial and may include oral NSAIDs and cycloplegic drops like cyclopentolate 1% to reduce ciliary spasm if pain is severe.

It is also important to note that eye patching is no longer recommended as it may delay healing, especially in patients who wear contact lenses 1. Instead, patients should be advised to avoid contact lens wear until the abrasion is fully healed and to follow up within 24-48 hours to ensure proper healing. If the abrasion is large, central, or associated with significant vision loss, consideration should be given to referral to an ophthalmologist. The corneal epithelium typically heals within 24-72 hours with appropriate treatment, as epithelial cells rapidly migrate and proliferate to cover the defect.

Key considerations in the management of corneal abrasions include:

• Avoiding contact lens wear until the abrasion is fully healed
• Following up within 24-48 hours to ensure proper healing
• Referring to an ophthalmologist if the abrasion is large, central, or associated with significant vision loss
• Being aware of the increased risk of infection in patients who wear contact lenses or have a history of trauma
• Using topical antibiotics to prevent infection
• Avoiding eye patching due to the risk of delayed healing.

From the Research

Corneal Abrasion Workup

• Corneal abrasions result from cutting, scratching, or abrading the thin, protective, clear coat of the exposed anterior portion of the ocular epithelium, causing pain, tearing, photophobia, foreign body sensation, and a gritty feeling 2.
• Symptoms can be worsened by exposure to light, blinking, and rubbing the injured surface against the inside of the eyelid 2.
• Visualizing the cornea under cobalt-blue filtered light after the application of fluorescein can confirm the diagnosis 2, 3.

Diagnosis and Examination

• History and physical examination should exclude serious causes of eye pain, including penetrating injury, infective keratitis, and corneal ulcers 3.
• Physicians should carefully examine for foreign bodies and remove them, if present 3.
• After fluorescein staining of the cornea, an abrasion will appear yellow under normal light and green in cobalt blue light 3.

Treatment and Management

• Initial treatment should be symptomatic, consisting of foreign body removal and analgesia with topical nonsteroidal anti-inflammatory drugs or oral analgesics; topical antibiotics also may be used 2.
• Pain relief may be achieved with topical nonsteroidal anti-inflammatory drugs or oral analgesics 3.
• Evidence does not support the use of topical cycloplegics for uncomplicated corneal abrasions 3.
• Patching is not recommended because it does not improve pain and has the potential to delay healing 2, 3, 4.
• Topical antibiotics are commonly prescribed to prevent bacterial superinfection, although evidence is lacking 3.
• Contact lens-related abrasions should be treated with antipseudomonal topical antibiotics 3.

Follow-up and Referral

• Follow-up may not be necessary for patients with small (4 mm or less), uncomplicated abrasions; normal vision; and resolving symptoms 3.
• All other patients should be reevaluated in 24 hours 3.
• Referral is indicated for any patient with symptoms that do not improve or that worsen, a corneal infiltrate or ulcer, significant vision loss, or a penetrating eye injury 3.
• Persistent, worsening, or new symptoms warrant immediate specialist consultation 5.

Antibiotic Prophylaxis

• The current evidence is insufficient to support any antibiotic regimen being superior to another in preventing ocular infection or accelerating epithelial healing following a corneal abrasion 6.
• Given the low to very low certainty of the available evidence, any beneficial effects of antibiotic prophylaxis in preventing ocular infection or accelerating epithelial healing following a corneal abrasion remain unclear 6.