Management of Corneal Abrasions

STEPHEN A. WILSON, M.D., and ALLEN LAST, M.D., University of Pittsburgh Medical Center
St. Margaret Family Practice Residency Program, Pittsburgh, Pennsylvania

Corneal abrasions result from cutting, scratching, or abrading the thin, protective, clear coat
of the exposed anterior portion of the ocular epithelium. These injuries cause pain, tearing,
photophobia, foreign body sensation, and a gritty feeling. Symptoms can be worsened by
exposure to light, blinking, and rubbing the injured surface against the inside of the eyelid.
Visualizing the cornea under cobalt-blue filtered light after the application of fluorescein can
confirm the diagnosis. Most corneal abrasions heal in 24 to 72 hours and rarely progress to
corneal erosion or infection. Although eye patching traditionally has been recommended in
the treatment of corneal abrasions, multiple well-designed studies show that patching does
not help and may hinder healing. Topical mydriatics also are not beneficial. Initial treatment
should be symptomatic, consisting of foreign body removal and analgesia with topical non-
steroidal anti-inflammatory drugs or oral analgesics; topical antibiotics also may be used.
Corneal abrasions can be avoided through the use of protective eyewear. (Am Fam Physician
2004;70:123-8,129-30. Copyright© 2004 American Academy of Family Physicians.)

M
Patient information ost of the human eye lies Function and Structure of the Cornea
�

handout: A patient within a protective bony The cornea (Figure 1) is a highly organized
information handout
on corneal abrasions, orbit. The exposed anterior group of cells and proteins with three func-
adapted from a handout portion has other anatomic tions: barrier protection, filtration of some of
previously published in and functional protections. The eyebrow the ultraviolet wavelengths in sunlight, and
AFP, is provided on page
and eyelashes partially shield the eye from refraction (the cornea is responsible for 65 to
129.
small particles. Eyelids close rapidly and 75 percent of the eye’s capacity to focus light
See page 13 for definitions reflexively when ocular danger is sensed. A on the retina). The cornea must be totally
of strength-of-recommen-
dation labels. tear response attempts to wash away any- transparent to refract light properly. Therefore,
thing that reaches the ocular surface. Tears it has no blood vessels and instead is nourished
also lubricate the eye and prevent tissue by tears, environmental oxygen, and the aque-
dehydration. ous humor of the anterior chamber.
Despite built-in protections, eye injuries
still occur. One such injury is abrasion of
the outermost layer of the eye. Although Pupil
damage to the white part of the eye usually Cornea Iris
is of little significance, corneal abrasion can
Conjunctiva
be serious. When minor abrasions occur,
Lens
healthy cells quickly fill the defect to prevent Sclera
vision-diminishing infection or irregular-
ity in refraction. If the abrasion penetrates
the cornea more deeply, the healing pro-
cess takes longer—24 to 72 hours.1,2 Deeper
ILLUSTRATIONS BY DAVID KLEMM

scratches can cause corneal scarring that

can impair vision to the point where cor- Retina
neal transplant is needed. Specific incidence
and prevalence data are not available, but
corneal abrasion is the most common eye
injury in children presenting to emergency Figure 1. Cornea in relationship to the rest of
departments.3 the eye.

July 1, 2004 � Volume 70, Number 1 www.aafp.org/afp American Family Physician 123
 Epithelium

Bowman’s
layer

Stroma

Descemet’s
membrane Figure 3. Corneal abrasion stained with fluo-
rescein.
Cornea Endothelium

Figure 2. Anatomy of the cornea.

Within its thin dimensions—about 11.6 mm

vertically, 10.5 mm horizontally, 1 mm thick
peripherally, and 0.55 mm thick centrally—
the cornea has five distinct, transparent layers;
from anterior to posterior they are epithelium, Figure 4. Corneal abrasion stained with fluo-
Bowman’s layer, stroma, Descemet’s mem- rescein and highlighted by cobalt blue light.
brane, and endothelium (Figure 2).

Diagnosing Corneal Abrasion

A history of recent ocular trauma and subse-
quent acute pain suggests corneal abrasion.
Other symptoms include photophobia, pain
with extraocular muscle movement, exces-
sive tearing, blepharospasm, foreign body
sensation, gritty feeling, blurred vision, and
headache. Symptoms can be present without
the patient’s recollection of trauma and with
as little trauma as aggressive eye rubbing. Figure 5. Rust ring remaining after removal of
The diagnosis of corneal abrasion can be a small, metallic foreign body.
confirmed by visualizing the cornea under
cobalt-blue filtered light after the applica- bia, blepharospasm, decreased vision, and
tion of fluorescein, which will cause the lacrimation on awakening or after rubbing
abrasion to appear green (Figures 3 and 4). If or opening the eyes. These symptoms are
examination is limited by pain, instillation annoying to the patient but typically are not
of a topical anesthetic (e.g., proparacaine severe enough to interfere with activities.4
[Ophthetic], tetracaine [Pontocaine]) may Lesions usually are found near the original
be needed. During the examination it is abrasion; they may recur only rarely or
important to assess for and remove any for- as often as daily. True idiopathic or bilat-
eign bodies, some of which may leave a rust eral lesions suggest a basement membrane
residue (Figure 5). dystrophy, characterized by poor adhesion
Rarely, simple corneal abrasions become between the epithelial basement membrane
complicated. Recurrent corneal erosion and Bowman’s layer.
(RCE)—repeated, spontaneous disruption
of corneal epithelium—can occur in corneal Treatment Options
tissue weakened by abrasion months or years Although eye patches, topical antibiotics,
earlier. Symptoms of RCE include ocular and mydriatic agents traditionally have been
pain, foreign body sensation, photopho- used in patients with corneal abrasions,

124 American Family Physician www.aafp.org/afp Volume 70, Number 1 � July 1, 2004
 Corneal Abrasions

treatment recommendations recently have similar results.2,3 In the past, Eye patching can result in
evolved. Current recommendations stress patching was thought to reduce decreased oxygen delivery,
the use of topical or oral analgesics and topi- pain by reducing blinking increased moisture, and a
cal antibiotics (Table 1). Most corneal abra- and decreasing eyelid-induced higher chance of infection.
sions heal with this approach. trauma to the damaged cornea.
However, the patch itself was the
EYE PATCHING
main cause of pain in 48 percent of patients.6
Eye patching is no longer recommended for Children with patches had greater difficulty
corneal abrasions.2,3,5 A meta-analysis of five walking than those without patches.3 Fur-
randomized controlled trials (RCTs) failed to thermore, patching can result in decreased
reveal an increase in healing rate or improve- oxygen delivery, increased moisture, and a
ment on a pain scale.5 Two subsequent RCTs higher chance of infection. Thus, patching
(one in children, one in adults) reported may actually retard the healing process.7,8

TABLE 1
Topical NSAIDs and Antibiotics

Drug Dosage Price (generic)* Comments

Topical NSAIDs
Diclofenac (Voltaren), 0.1% One drop four times daily $52 for 5 mL May delay wound healing.
solution Use caution in patients with
bleeding tendencies.
Ketorolac (Acular), 0.5% One drop four times daily $56 for 5 mL Avoid use in patients who
solution wear contact lenses.
Discontinue use if epithelium
breakdown occurs.
Topical antibiotics
Bacitracin (AK-Tracin), 500 1/2-inch ribbon two to four times daily $5 for 3.5 g
units per g ointment
Chloramphenicol (Chloroptic), Two drops every three hours $22 for 3.5 g Discontinue use if no
1% ointment improvement after one week.
Ciprofloxacin (Ciloxan), Day 1: two drops every 15 minutes for
0.3% solution six hours, then two drops every 30
minutes for rest of day
Day 2: Two drops per hour
Days 3 to 14: Two drops $45 for 5 mL Anti-pseudomonal activity
every four hours
Erythromycin 0.5% ointment 1/2-inch ribbon two to four times daily $3 to $6 for
3.5 g
Gentamycin (Garamycin), One to two drops every four hours or $10 ($5 to $10) Anti-pseudomonal activity
0.3% ointment or solution 1/2-inch ribbon two to three times for 5 mL
daily
Ofloxacin (Ocuflox), Days 1 and 2: One to two drops every
0.3% solution 30 minutes
Days 3 to 7: One to two drops per hour
Day 8 to treatment completion: One to $40 for 5 mL Anti-pseudomonal activity
two drops four times daily.

NSAID = nonsteroidal anti-inflammatory drug

*—Estimated cost to the pharmacist based on average wholesale prices in Red book. Montvale, N.J.: Medical Economics Data, 2004. Cost to the patient
will be higher, depending on prescription filling fee.

July 1, 2004 � Volume 70, Number 1 www.aafp.org/afp American Family Physician 125
 TOPICAL ANALGESICS this use. A two-year, non–placebo-controlled,
Topical nonsteroidal anti-inflammatory prospective cohort study11 of topical antibi-
drugs (NSAIDs) such as diclofenac (Voltaren) otic prophylaxis for corneal abrasion showed
and ketorolac (Acular) are modestly useful that the use of 1 percent chloramphenicol
in reducing pain from corneal abrasions.9 ointment was associated with lower risk of
In a systematic review of five RCTs, topical subsequent ulcer, especially if prophylaxis
NSAID use decreased pain by an average began within 18 hours after the injury. A
of 1.3 cm on a standard 10-cm pain scale.9 single-blind, non–placebo-controlled ran-
Qualitatively, patients using topical NSAIDs domized trial12 showed that corneal abrasions
indicated greater relief from pain and other in patients treated with fusidic acid eye drops
symptoms.9 Patients using topical NSAIDs did not heal significantly faster than patients
may take fewer oral analgesics (two of three treated with chloramphenicol ointment.
studies), return to work earlier (one study), If antibiotics are used, ointment (e.g., baci-
and require fewer narcotics.9 tracin [AK-Tracin], erythromycin, gentamy-
Topical anesthetics should be avoided after cin [Garamycin]) is more lubricating than
the initial examination. They can retard drops and is considered first-line treatment.
healing and cause corneal damage. In patients who wear contact lenses, an anti-
pseudomonal antibiotic (e.g., ciprofloxacin
MYDRIATICS
[Ciloxan], gentamycin, ofloxacin [Ocuflox])
Mydriatics are no longer recommended for should be used, and contact lens use should
the treatment of pain in patients with cor- be discontinued. Clinical trial data are lack-
neal abrasions.10 Mydriatics formerly were ing, but it is recommended that contact lenses
prescribed to relieve ciliary muscle spasm be avoided until the abrasion is healed and
that was thought to occur in patients with the antibiotic course completed.13
corneal abrasions. However, in one RCT
ORAL ANALGESICS
with limited follow-up, pain was similar in
patients using an eye lubricant or mydriatic No direct evidence is available from clinical
(2 percent homatropine [Homapin]), alone trials for the efficacy of oral analgesics in
or combined with a topical NSAID.10 the treatment of corneal abrasions. However,
because most abrasions heal without signifi-
TOPICAL ANTIBIOTICS
cant long-term complications, pain relief is
Because a concomitant infection can cause the primary concern and the basis for rou-
slower healing of corneal abrasions, some tine use of oral analgesics. Oral analgesics
clinicians use prophylactic antibiotic treat- are less expensive than topical preparations.
ment, although there is no strong evidence for No studies directly address the role, if any, of
opioid analgesia. Individual patient charac-
The Authors teristics (e.g., age, concomitant illness, drug
allergy, ability to tolerate NSAIDs, potential
STEPHEN A. WILSON, M.D., is assistant director for predoctoral education
for opioid abuse, employment conditions
and faculty research at the University of Pittsburgh Medical Center (UPMC)
St. Margaret Family Practice Residency Program and clinical instructor of family such as driving and machine operation)
medicine at the University of Pittsburgh School of Medicine, where he received should guide therapy.
his medical degree. He completed a family practice residency and a fellowship in
faculty development at UPMC St. Margaret. Follow-up and Referral Guidelines
ALLEN LAST, M.D., is a first-year fellow in the UPMC St. Margaret Faculty
Most patients should be re-evaluated in
Development Fellowship Program and is matriculating through the University 24 hours; if the abrasion has not fully healed,
of Pittsburgh Graduate School of Public Health. He received his medical degree they should be evaluated again three to four
from the University of Wisconsin Medical School, Madison, and completed a days later. Patients who wear contact lenses
family practice residency at UPMC St. Margaret. should be re-evaluated in 24 hours and again
Address correspondence to Stephen A. Wilson, M.D., UPMC St. Margaret three to four days later even if they feel well.
Family Practice Residency, 815 Freeport Rd., Pittsburgh, PA 15215 (e-mail: Any worsening of symptoms should prompt
wilsons2@upmc.edu). Reprints are not available from the authors. a thorough re-evaluation for foreign bodies

126 American Family Physician www.aafp.org/afp Volume 70, Number 1 � July 1, 2004
 Corneal Abrasions

Figure 6. Corneal ulcer in a patient who wears contact lenses. (Left) View without fluorescein
stain. (Right) View with fluorescein stain.

or full-thickness injuries. Immunocompro- Corneal abrasion, the most common peri-

mised or monocular patients also warrant operative ocular injury, results from lag-
closer attention and may require earlier ophthalmos during general anesthesia. It
ophthalmologic referral. can be prevented by taping the patient’s
Referral to an ophthalmologist is indicated eyelids closed or instilling soft contact lenses
for patients with deep eye injuries, foreign or aqueous gels; paraffin-based ointments
bodies that cannot be removed, and sus- (e.g., Lacrilube, Duratears) appear to be less
pected RCE. Patients with persistent symp- effective.14
toms after three days, worsening symptoms, Screening is important in three popula-
and symptoms that do not improve daily tions: neonates on mask ventilation, sedated
also should be referred. Patients who wear or paralyzed patients on a ventilator, and
contact lenses should be referred if there is persons who wear contact lenses. Corneal
no improvement in symptoms within a few abrasion, with subsequent Pseudomonas
hours of lens removal. panophthalmitis, can occur in patients in
neonatal intensive care units who are receiv-
Primary Prevention and Screening ing continuous positive airway pressure ven-
Most corneal abrasions are preventable. tilation. It is attributed to the pressure of the
Persons in high-risk occupations (e.g., min- masks on the orbit.15 Eye discharge in mask-
ers, woodworkers, metal workers, landscap- ventilated neonates should prompt evalua-
ers) and those who participate in certain tion for corneal abrasion and infection.
sports (e.g., hockey, lacrosse, racquetball) A similar problem can occur in adults who
should wear eye protection. Levels of pro- are deeply sedated or receiving neuromus-
tection include plastic safety glasses, poly- cular blocking agents while on a ventilator,
carbonate lenses of varying thickness, because their protective corneal reflex is sup-
industrial safety goggles with polycarbon- pressed. The incidence of corneal abrasion in
ate, and helmets with facemasks. All pro- this population decreased from 18 to 4 per-
vide barrier protection from airborne debris cent when prophylactic lubricating ointment
(e.g., sand, sawdust, metal) and other was administered every four hours.16 Persons
objects that could cause ocular trauma who wear contact lenses are at higher risk of
(e.g., fingernails, tree branches, sports developing abrasions that become infected
balls). Eye guards without lenses are not and ulcerate (Figure 6). Soft, extended-wear
sufficient. Other preventive measures lenses have been associated with a 10-fold to
include careful fitting and placement of 15-fold increase in ulcerative keratitis.17 Case
contact lenses, keeping the fingernails of reports and a nonsystematic review suggest
infants and young children clipped short, that screening for corneal abrasions also may
and removing low-hanging tree branches or be needed after airbag deployment in auto-
objects from the home environment. mobile crashes.18,19

July 1, 2004 � Volume 70, Number 1 www.aafp.org/afp American Family Physician 127
 Strength of Recommendation (SOR) Labels

Key clinical recommendations SOR labels References

Patching is not effective for treatment of corneal abrasions and is not A 2,3,6
recommended.
Consider topical nonsteroidal anti-inflammatory drugs in patients with A 9
corneal abrasions.
Topical mydriatics are not effective for treatment of corneal abrasions B 10
and are not recommended.
Consider use of topical antibiotics in patients with corneal abrasions. C 11,12
Discontinue contact lens use in patients with corneal abrasions. C 13

Prognosis body removal. Corneal Abrasion Patching Study Group.

Ophthalmology 1995;102:1936-42.
Healing time depends on the size of the
9. Weaver CS, Terrell KM. Evidence-based emergency
corneal abrasion. Most abrasions heal in medicine. Update: do ophthalmic nonsteroidal anti-
two to three days, while larger abrasions inflammatory drugs reduce the pain associated with
simple corneal abrasion without delaying healing? Ann
that involve more than one half of the sur-
Emerg Med 2003;41:134-40.
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Waxman, M.D. viscous eye drops and Chloramphenicol eye ointment
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128 American Family Physician www.aafp.org/afp Volume 70, Number 1 � July 1, 2004