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Corneal abrasions and corneal foreign bodies: Management

Corneal abrasions and corneal foreign bodies: Management
Literature review current through: Sep 2023.
This topic last updated: Mar 09, 2022.

INTRODUCTION — This topic will review the management of corneal abrasions. The clinical manifestations and diagnosis of corneal abrasions, the evaluation of the red eye, and the assessment and management of other ocular injuries are discussed separately:

(See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)

(See "The red eye: Evaluation and management".)

(See "Approach to diagnosis and initial treatment of eye injuries in the emergency department".)

(See "Overview of eye injuries in the emergency department".)

TERMINOLOGY — Corneal abrasion is often used to refer to any defect in the corneal surface epithelium (figure 1). However, this is an inexact use of the term, because it also implies etiology. Many corneal abnormalities are more appropriately called "corneal epithelial defects," while corneal abrasion more strictly refers to a defect in the epithelial surface of the cornea that is caused by mechanical trauma to the surface of the eye. Nevertheless, since "corneal epithelial defect" is not a term in general usage by patients and providers, we will use both terms interchangeably to refer to corneal epithelial defects of all etiologies.

Corneal abrasions can be classified as traumatic, including foreign body related and contact lens related, or spontaneous. Spontaneous defects in the corneal epithelium may occur with no immediate antecedent injury or foreign body. Eyes that have suffered a previous traumatic abrasion or eyes that have an underlying defect in the corneal epithelium are prone to this problem. Spontaneous corneal abrasions are also known as recurrent erosions. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Terminology'.)

DIAGNOSIS — Any patient who complains of severe eye pain with photophobia and/or foreign body sensation preventing opening of the eye generally can be presumed to have a corneal epithelial defect. The provider must then first rule out penetrating trauma, and second an infectious infiltrate, especially herpes simplex virus infection (picture 1). The rapid overviews provide key diagnostic findings and initial management for patients with open globes and traumatic hyphemas (table 1 and table 2). (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Diagnosis' and "Open globe injuries: Emergency evaluation and initial management" and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)

The clinician should confirm the diagnosis of corneal abrasions with fluorescein staining only after completing a complete eye examination and excluding an open globe. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Fluorescein examination'.)

A history of contact lens wear should be specifically ascertained because this information will influence choice of antibiotic.

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Patients with signs of an open globe warrant emergent consultation with an ophthalmologist. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Excluding penetrating trauma' and "Open globe injuries: Emergency evaluation and initial management", section on 'Primary evaluation and management'.)

Prompt involvement of an ophthalmologist for patients with hyphema is also typically necessary to perform a comprehensive eye examination, including intraocular pressure measurement, especially in younger children. (See "Traumatic hyphema: Clinical features and diagnosis".)

Patients with isolated corneal abrasions and the following findings should undergo prompt evaluation by an ophthalmologist on the day of presentation:

Corneal infiltrate, white spot, or opacity suggestion ulceration (picture 2A)

Foreign body that cannot be removed

Hypopyon (pus in the anterior chamber) (picture 3)

Urgent referral to an ophthalmologist is indicated in patients with the following physical findings at follow-up:

A larger epithelial defect

Purulent discharge

A drop in vision of more than one to two lines on a Snellen chart (eg, drop from 20/20 [6/6] to 20/80 [6/24])

An infant or child with persistent discharge or unwillingness to keep the eye open (see 'Pediatric considerations' below)

Corneal abrasion that has not healed after three to four days

These findings suggest a retained foreign body, poor healing, superinfection, or infectious keratitis.

MANAGEMENT — The approach to treatment of corneal abrasions is summarized in the algorithm (algorithm 1). Treatment options vary based upon the subtype of corneal abrasion. Children with corneal abrasions are treated similarly to adults with some age-specific modifications. (See 'Pediatric considerations' below.)

Traumatic and foreign body abrasions — Administration of topical antibiotics and, for large abrasions, cycloplegics have been the mainstay of therapy for decades, along with daily follow-up until the eye is healed. Patching was previously routine but is no longer recommended for most patients. (See 'Patching' below.)

Animal studies suggest that tetanus prophylaxis is warranted for penetrating eye injuries but is not necessary for corneal abrasions or foreign bodies [1].

Patients who have a corneal abrasion with contaminated material (farm instruments, vegetable matter) are at risk for developing bacterial keratitis; this is the most common cause of bacterial keratitis among rural agricultural laborers in undeveloped countries [2]. These patients warrant daily monitoring for corneal infiltrate or ulceration. (See 'Follow-up' below.)

Foreign body removal — If a corneal foreign body is detected, an attempt can be made to remove it by irrigation after the instillation of topical anesthetic. This is particularly helpful in the case of multiple superficial foreign bodies (eg, sand). An attempt can then be made to remove the foreign body with a swab, using direct visualization [3].

Foreign bodies under the lid should be removed after flipping the lid. If the foreign body cannot be dislodged by irrigation or with a swab, the patient should be treated by an individual trained and supervised in the use of instruments to dislodge foreign bodies off the ocular surface [3]. This procedure is performed using magnification (usually a slit lamp, sometimes loupes) and a metal instrument. Topical anesthetic is instilled in the eye. The instrument used can be a 25G needle or a foreign body spud. Appropriate technique, including patient instruction, tangential approach to the cornea, and stabilization of the hand on the zygoma, is required to ensure patient cooperation and to avoid further injury to the cornea.

Typically, ophthalmology residents and residents in emergency medicine and in family practice receive formal training in the removal of corneal foreign bodies. Those without formal training should not approach the globe with sharp instruments; an appropriately trained clinician should be consulted if removal with a swab is unsuccessful [3]. The foreign body should be removed within 24 hours. The patient should be treated in the meantime with a topical antibiotic ointment (eg, erythromycin) four times a day and no patch.

It is not possible to clinically distinguish infected from non-infected corneal bodies. In one study, 14 percent of 63 removed foreign bodies (the majority of which were metallic) cultured positive; the major pathogen was coagulase negative Staphylococcus [4]. Neither the mechanism of injury, the presence of a rust ring, nor the time present in the cornea allowed prediction of the presence or absence of infection. Nevertheless, foreign bodies need not be sent for culture; all patients with foreign body associated abrasions are treated with empiric broad spectrum antibiotics. (See 'Topical antibiotics' below.)

Rust ring — After removal of a foreign body containing iron there is often a residual rust ring and reactive infiltrate. Patients with rust ring should be treated as patients with corneal abrasions. The rust ring itself is not harmful and will usually resorb gradually. If there is failure of the epithelium to heal after two to three days, debridement of rust ring can be considered by clinicians trained in the use of instruments at the slit lamp [3]. Removal of rust ring on a routine basis at time of foreign body removal is not recommended because of potential damage to Bowman’s membrane and resultant scarring.

Topical antibiotics — We suggest that patients with corneal abrasions receive topical antibiotics to prevent superinfection rather than no treatment (table 3). For adults with low-risk abrasions (eg, not associated with contact lens wearing, not caused by a foreign body, and not located over the central cornea), close observation without prescribing topical antibiotics is a reasonable option. Such patients may still benefit from a topical ophthalmologic lubricant to reduce pain. Use of topic antibiotics for corneal abrasions is primarily based upon clinical experience. Evidence is lacking to indicate whether topical antibiotics prevent infection or shorten the time to healing [5]. In one small trial comparing topical antibiotic drops to sterile saline in 94 patients, there was no difference in time to healing based upon symptoms, visual acuity, and corneal defect between treatment and control groups. However, the ability of this trial to detect a true difference was limited because of the small sample size [6]. In another observational study of over 350 patients with corneal abrasions who were not treated with topical antibiotics, the rate of infection was <1 percent. It is important to note that patients with corneal injury associated with the use of contact lens, a known risk factor for pseudomonas keratitis, were excluded from the study [7]. It is also worth considering that the report arose from a high-resource nation with a temperate climate, and that a very small fraction of patients had trauma likely to involve organic matter [8,9].

Considerations for selection of topical antibiotics include:

An ointment is theoretically better than drops because it functions as a lubricant and may reduce disruption of the remaining and newly generated epithelium.

For patients who wear contact lenses, select an ointment or drop that covers for Pseudomonas species (eg, ciprofloxacin, ofloxacin, or, if fluoroquinolones are not available, tobramycin or gentamicin).

For patients who are not contact lens wearers, erythromycin ointment (Ilotycin, Diomycin, Erocin) is a good choice, used four times daily for three to five days.

For patients who are not contact lens wearers and who insist on a drop rather than an ointment, sulfacetamide 10 percent, polymyxin/trimethoprim (Polytrim, PMS-Polytrimethoprim), ciprofloxacin (Ciloxan, Ciprodar, Sophixin Ofteno), or ofloxacin (Ocuflox, Apo-Ofloxacin, Exocin) are reasonable choices (table 3). Aminoglycosides should be avoided in these patients because aminoglycosides can be toxic to the epithelium. (See 'Treatments to avoid' below.)

Antibiotic preparations containing steroids are contraindicated because they reduce host resistance to superinfection and may make a missed diagnosis of herpes simplex virus epithelial keratitis or microbial keratitis worse.

The optimal duration and frequency of antibiotic therapy have never been subjected to outcome analysis. It is reasonable to decrease the frequency to twice daily once the foreign body sensation has resolved and to discontinue therapy entirely if the eye is symptom free for 24 hours. Continued symptoms beyond three days warrants evaluation by an ophthalmologist. (See 'Indications for subspecialty consultation or referral' above.)

Pain control — The approach to pain control for corneal abrasions varies according to the size of the abrasion:

Small corneal abrasions – Most small abrasions (less than one-fourth of corneal surface area [eg, a round abrasion that is 4 mm across]) will heal overnight if the lid is closed and there is no rubbing or squeezing.

Mild to moderate pain can typically be controlled with oral nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen) or topical use of ophthalmic NSAID solutions (eg, diclofenac, ketorolac). Ophthalmic topical NSAID solutions provide some pain relief and may limit the need for rescue medications, without apparent adverse effects upon healing [10,11]. Some experts note that topical NSAID solutions are painful to apply and expensive, which limits adherence and efficacy. Long-term use is associated with surface keratopathy and corneal melting. In addition, the trials of topical NSAIDs for corneal abrasions have not always used a measure of pain reduction that may be clinically relevant and a meta-analysis of these trials judged the evidence for their use as weak [11].

In the few patients with small abrasions that fail to heal despite these treatments, an oral opioid prescription (eg, oxycodone-acetaminophen combination medications) that provides analgesia coverage for 24 hours is typically sufficient to permit healing and resolution of pain.

Large corneal abrasions – A large abrasion will not heal overnight and additional measures may be required for pain control and to allow for healing. Oral opioids (eg, acetaminophen-oxycodone combination medications) may be required for 48 hours to provide adequate pain control.

Cycloplegic (parasympatholytic drops) and patching may also be necessary in some patients, especially those with abrasions that cover >50 percent of the corneal surface as follows:

Cycloplegic drops – Cycloplegics are parasympatholytic drops that inhibit the miotic (pupil-constricting) response to light; it is this response to light that causes the ache and photophobia of corneal abrasion. These drops do not relieve foreign-body sensation.

Patients with large abrasions who are particularly photophobic can be treated for up to 48 hours with cyclopentolate (0.5 to 1 percent) one drop twice daily or homatropine (2.5 to 5 percent) one drop daily (table 3). Longer acting drugs such as topical atropine are used by ophthalmologist for iritis and severe cases of ocular disease; these drugs can interfere with accommodation for weeks and should not be used to treat abrasions.

Cycloplegics make the pupil large, causing glare, and also block accommodation, thereby interfering with near work such as reading. Cyclopentolate (Cyclogyl) 0.5 or 1 percent has the shortest duration of action, but still lasts for 24 to 36 hours. Thus, patients with small abrasions that heal overnight typically find that the side effects of cycloplegic drops outweigh the benefit of pain control.

Patching – Although data are limited, patching may decrease the pain of large corneal abrasions. Patching is not recommended for small abrasions. (See 'Patching' below.)

Repeated topical anesthesia – Because of the possibility of overuse (ie, use beyond 24 hours) and the risk of inappropriate administration to patients with conditions other than simple corneal abrasions, we recommend that clinicians not dispense or prescribe topical anesthetics for the treatment of corneal abrasions, although they may be used during the initial examination. We favor other means of pain control as described above. According to animal studies, commonly available topical anesthetics (eg, proparacaine 0.5 percent) can delay corneal epithelial healing, particularly with repeated applications [12]. In addition to delayed wound healing, anesthetic overuse in which the patient persists in use of the drops, sometimes surreptitiously, for a painful, non-healing surface can ultimately lead to keratopathy, ulceration, perforation, scarring, or blindness [13,14].

Limited evidence does not support the safety of brief use (eg, <24 hours) of dilute solutions of proparacaine (0.05%, versus standardly available 0.5%) or preservative-free tetracaine 1% when prescribed by physicians other than ophthalmologists [15-19]. For example, in a retrospective observational study of 444 patients with corneal abrasions given a 24-hour supply of topical tetracaine at the initial emergency department visit, no patient had serious complications or uncommon adverse events (95% CI, 0 to 0.8 percent) [19]. However, definitive outcomes were only known for 120 patients who returned for rechecks. Patients receiving topical tetracaine were more likely to return for emergency department reevaluation and topical tetracaine was prescribed inappropriately, according to the investigator’s a priori definition, in 151 patients, including those with large corneal abrasions, retained rust rings, herpes keratitis, anterior uveitis, and corneal erosions. Thus, high-quality studies are needed to establish the safety of this practice for simple corneal abrasions and avoid overuse or prevent administration to high-risk eye conditions.

Patching — We recommend that patients with uncomplicated, small, traumatic or foreign body corneal abrasions not undergo patching. Patching is also contraindicated for patients with corneal abrasions in patients with recent contact lens wear. (See 'Abrasions and recent contact lens wear' below.)

Although data is limited, patching may decrease the pain of large corneal abrasions that cover >50 percent of the corneal surface.

In theory, a pressure patch promotes epithelial proliferation and migration by keeping the lid lowered and stationary over the epithelial defect; a pressure patch is also thought to relieve pain. However, a meta-analysis has shown that, in patients with uncomplicated traumatic or foreign body corneal abrasions, the rate of healing is not improved by a patch (seven trials) and that patching does not decrease pain (ten trials) when compared with not patching [20]. As an example, in one trial of patching versus not patching in 201 patients with uncomplicated traumatic or foreign body-related corneal abrasions, patients with traumatic corneal abrasions (n = 120) healed significantly faster, had less pain, and fewer reports of blurred vision when they were not wearing a patch [21]. The amount of photophobia, tearing, and foreign body sensation were similar between the patch and no patch groups. In patients with corneal abrasions due to removal of foreign bodies (n = 81), healing also occurred significantly faster and was associated with less pain in those not wearing a patch. There was no difference in the amount of photophobia, tearing, foreign body sensation, or blurred vision.

In addition to the lack of benefit, patched patients may experience significant discomfort as follows:

The patch is frequently irritating and cannot be tolerated for the prescribed amount of wear.

Patching results in loss of depth perception and restriction of visual fields that can interfere with ambulation, particularly negotiating stairs and curbs.

Patients should not drive with a patch.

Patients who are monocular or amblyopic and have an abrasion in their "good" eye will be incapacitated by patching.

Nausea or bradycardia from the oculocardiac reflex should inadvertent and excessive ocular pressure occur during patch placement.

Technique — If the decision is made to apply a pressure patch for pain control caused by a large corneal abrasion, proper application is critical. A properly applied patch precludes blinking. Improper application may allow the patient to blink under the patch or worse, abrade the cornea further. Patching should not be performed in patients with recent contact lens wear. (See 'Abrasions and recent contact lens wear' below.)

Patching is performed as follows:

Assemble two gauze eye pads and three strips of tape.

Apply antibiotic ointment (eg, erythromycin ophthalmic ointment) to the eye by instilling a small amount (0.5 to 1 inch ribbon) in the inferior cul-de-sac.

Fold one pad in half.

Ask the patient to gently close both eyes. There should be no squeezing of the orbicularis muscles.

Use the folded patch to occupy the space over the globe in the orbit and apply pressure to the globe.

Place the second pad over the folded pad.

Ask the patient or an assistant to apply firm pressure to the second pad, while it is being taped firmly with the three strips of tape. These strips are most effective if place obliquely from the midline over the nose toward the cheekbone.

Ask the patient to open the eyes and report if the lid under the patch can be raised. If it can, then the patch has not been applied successfully and must be redone.

Leave the patch in place overnight, and no more than 24 hours. A patch that is worn too long may interfere with the diagnosis of infection because the patient cannot monitor vision and discharge.

Abrasions and recent contact lens wear — Contact lens wearers who present with a corneal epithelial defect should be examined with a penlight or slit lamp to look for a corneal infiltrate, which is a white spot or opacity, or an ulcer (picture 2A-B), representing a surface breakdown, thinning, or necrosis that occurs in an area of infiltration. Any patient with such a finding should be seen by an ophthalmologist that day. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Indications for subspecialty consultation or referral'.)

If a corneal abrasion is present and no infiltrate is seen, patients with recent contact lens wear require timely topical antibiotics that are effective against Pseudomonas species (eg, ciprofloxacin, ofloxacin, or, if fluoroquinolones are not available or cannot be used in an individual patient, then tobramycin, or gentamicin (table 3)). Sulfacetamide and erythromycin are not satisfactory antibiotic choices because they do not provide adequate Pseudomonas coverage [22]. This recommendation addresses increased risk of sight-threatening pseudomonas keratitis associated with contact lens wear. (See "Complications of contact lenses", section on 'Infectious keratitis'.)

Because of the risk of infection, patients with abrasions in the setting of recent contact lens wear should not be patched. Patching of what appeared to be sterile abrasions can lead to sight-threatening infection [23]. Increased temperature under the patch is theorized to be a contributing factor, as well as the presence of the patch itself, which interferes with the patient's ability to monitor for clinical deterioration. (See 'Treatments to avoid' below.)

Cycloplegia, NSAIDs, and/or opioids for pain relief can be used as needed as for traumatic abrasions. (See 'Pain control' above.)

The patient should be checked in 24 hours by an ophthalmologist or optometrist to confirm the absence of a corneal infiltrate or ulcer (picture 2A-B). Patients should refrain from wearing contacts until the eye is fully healed as determined by an ophthalmologist or optometrist.

Infectious keratitis risk — Contact lens wear is the most common cause of infectious keratitis in industrialized nations. Extended wear increases the risk of infection. The increased risk is thought to be multifactorial and related to the following factors (see "Complications of contact lenses", section on 'Incidence and risk factors'):

Alterations in pathogen adhesion to the ocular surface due to the mechanical presence of the contact lens

Adhesion of pathogens to the lens itself

Colonization of solutions and lens cases with pathogens

The warmer and more humid environment at the ocular surface created by the presence of a lens, particularly when the eye is closed, as when patients sleep with their lenses in

Improper lens cleaning and storage are also significant contributing factors. Guidelines for the safe use of contact lens are discussed separately. (See "Overview of contact lenses", section on 'Guidelines for prevention of infectious keratitis'.)

Infectious pseudomonas keratitis is a fulminant, necrotizing, ulcerative process that can result in corneal melting and perforation within 24 hours. Even if perforation and vision loss on that basis is averted, there is often permanent corneal scarring that requires corneal transplantation. (See "Complications of contact lenses", section on 'Infectious keratitis'.)

Recurrent erosion — Patients with recurrent (or spontaneous) corneal erosions are treated the same as patients with traumatic abrasions. However, these individuals are often exquisitely symptomatic to even the smallest epithelial disruption. Our clinical experience is that they do better with frequent application (every one to two hours) of ointment at the first suggestion of symptoms (either an antibiotic such as Ilotycin or over-the-counter lubricant such as Refresh PM or Lacri-Lube), and limited duration of opioid analgesia if needed, rather than patching. Lubricant ointment therapy should be continued at bedtime for months after acute symptoms have resolved as a prophylactic regimen.

Recurrent erosions that are particularly large or show no signs of healing in 24 hours should be referred to an ophthalmologist who may debride flaps of epithelium and may choose to use an extended wear contact lens as a bandage [24]. Cases that do not respond to these measures can be treated with any of a number of minor surgical procedures including stromal micropuncture, epithelial debridement, polishing of Bowman’s layer, and phototherapeutic keratectomy.

Treatments to avoid — The following treatments are not appropriate for patients with corneal abrasions:

Topical corticosteroids – Corneal abrasions should never be treated with a topical corticosteroid because of the increased potential for secondary infection or exacerbation of missed herpes simplex virus or microbial keratitis.

Black fabric patches – There is no role for a "pirate's patch" in the treatment of corneal abrasions. These are black fabric patches on an elastic band sold at pharmacies. These patches are designed to cover an unsightly or light sensitive eye with no useful vision; they should not be used in cases of corneal abrasion. They do not keep the lid down as a properly applied pressure patch does and increase the risk of further abrading the cornea.

PEDIATRIC CONSIDERATIONS — Treatment in children is similar to that in adults with the following differences in approach:

Antibiotic ointment is preferred over drops both for the persistent lubricating effect and because drops sting. If the child does not tolerate the visual blurring caused by ointment, the ointment can be applied at nap time or before bed. (See 'Traumatic and foreign body abrasions' above.)

Children generally pull off pressure patches, which are of no proven benefit in any case, and so a pressure patch should not be attempted.

As in adults, cycloplegia can improve comfort in children with large (eg, >50 percent corneal surface) abrasions. However, cyclopentolate, the shortest acting of the cycloplegic agents, stings the most. For this reason, in children receiving cycloplegic drops, it may be preferable for the treating clinician to apply a single drop of homatropine 2.5 to 5 percent in the affected eye at the time of diagnosis. This will produce a sustained effect for a couple of days and thus minimize any further need for drops to be applied by the child's caregivers.

As in adults, a corneal abrasion in a child typically heals overnight as the child sleeps. Sleep can be aided with analgesia (eg, acetaminophen, ibuprofen) and/or a sedating antihistamine (eg, diphenhydramine). Oxycodone can be used in young children.

There may be some mucous crusting of the lids on the first morning, but if the child is happy to keep the eye open once this is wiped away, the abrasion can be considered healed.

An infant or child with persistent discharge or unwillingness to keep the eye open beyond 24 hours after the injury should be evaluated by an ophthalmologist, because these findings suggest a retained foreign body, poor healing, superinfection, or infectious keratitis. (See 'Indications for subspecialty consultation or referral' above.)

FOLLOW-UP — Most small corneal abrasions (less than one-fourth of corneal surface area [eg, a round abrasion that is 4 mm across]) heal within 24 to 48 hours. Follow-up may not be necessary in reliable older children, adolescents, and adults as long as symptoms resolve [3]. Such patients should be instructed to return if eye drainage or decreased vision occurs or if symptoms persist beyond 48 hours.

Larger abrasions, abrasions from contact lens, abrasions that are associated with decreased vision, and abrasions in young children warrant daily follow-up until healing has occurred.

Indications for referral to an ophthalmologist are discussed separately. (See 'Indications for subspecialty consultation or referral' above.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Corneal abrasion (The Basics)" and "Patient education: Chemical eye injury (The Basics)")

SUMMARY AND RECOMMENDATIONS

Management – The treatment of corneal abrasions is summarized in the algorithm (algorithm 1). Management options vary based upon the subtype of corneal abrasion; children with corneal abrasions are treated similarly to adults with some age-specific modifications. Important considerations include recent contact lens wear, the presence of a foreign body, and the size of the abrasion. (See 'Management' above and 'Pediatric considerations' above.)

Recent contact lens wear – Contact lens wearers who present with a corneal epithelial defect should be examined with a penlight or slit lamp to look for a corneal infiltrate (white spot or opacity) or an ulcer (picture 2A-B), representing a surface breakdown in an area of infiltration. Patients with an infiltrate or ulcer require evaluation by an ophthalmologist that day.

Patients with corneal abrasions but no corneal infiltrate and a history of recent contact lens wear require timely topical antibiotics that are effective against Pseudomonas species (eg, ciprofloxacin, ofloxacin, gentamicin, or tobramycin (table 3)). Because of the risk of sight-threatening infection, contact lens wearers should never undergo patching, and they warrant timely referral to an ophthalmologist or optometrist for daily follow-up care. (See 'Abrasions and recent contact lens wear' above.)

No contact lens wear – For patients with corneal abrasions who don't wear contact lenses, we suggest topical antibiotics to prevent superinfection rather than no treatment (table 3) (Grade 2C). An ointment (eg, erythromycin ophthalmic ointment) is theoretically better than drops because it functions as a lubricant and may reduce disruption of the remaining and newly generated epithelium. Ointments are preferred to drops in children because they do not sting during application. For adults with low-risk abrasions (eg, not associated with contact lens wearing, not caused by a foreign body, and not located over the central cornea), close observation without prescribing topical antibiotics is a reasonable option. Such patients may still benefit from a topical ophthalmologic lubricant to reduce pain. (See 'Topical antibiotics' above.)

We recommend that patients with uncomplicated, small, traumatic or foreign body corneal abrasions not undergo patching (Grade 1A). Patching may provide pain control in selected patients with large corneal abrasions. No patch should be left in place for more than 24 hours. (See 'Patching' above and 'Abrasions and recent contact lens wear' above.)

Pain control – The approach to pain control for corneal abrasions varies according to the size of the abrasion (see 'Pain control' above):

Small corneal abrasions (less than or equal to one-fourth of corneal surface area (eg, circular abrasion 4 mm in diameter) – Oral analgesia (eg, ibuprofen) with or without topical nonsteroidal anti-inflammatory ophthalmic drops (eg, ketorolac, diclofenac) is typically sufficient for small corneal abrasions.

Large abrasions – Cycloplegic drops, oral opioid analgesia, and, in patients without retained corneal foreign bodies or recent contact lens wear and with abrasions covering >50 percent corneal surface, eye patching.

Because of the possibility of overuse (ie, use beyond 24 hours) and the risk of inappropriate administration to patients with conditions other than simple corneal abrasions, we recommend that clinicians not routinely dispense or prescribe topical anesthetics for the treatment of corneal abrasions (Grade 1C). Topical anesthetics may be used to facilitate the initial examination. (See 'Pain control' above.)

Follow-up – Most small corneal abrasions heal within 24 to 48 hours. Vision should return to normal in that time, although the presence of ointment on the ocular surface may reduce vision by one or two lines. Follow-up may not be necessary in reliable older children, adolescents, and adults as long as symptoms resolve and anticipatory guidance is provided. (See 'Follow-up' above.)

The following abrasions warrant daily follow-up until healing has occurred (see 'Follow-up' above):

Larger abrasions

Abrasions from contact lens

Abrasions associated with decreased vision

Abrasions in young children

Specialty referral – After initial treatment, urgent referral to an ophthalmologist is indicated for patients with the following (see 'Indications for subspecialty consultation or referral' above):

Larger epithelial defects at 24 hours

Purulent discharge

Decrease in vision of more than one to two lines (eg, 20/20 to 20/60 [6/6 to 6/18])

Corneal abrasions that have not healed after three to four days

Children who are unwilling to open the affected eye after 24 hours

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Topic 90922 Version 29.0

References

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