S05.01XA-02XS Superficial Injury of Cornea

Corneal abrasions are defined as injuries to the most superficial layer of the cornea, the epithelium.

Structural Damage to the Eye 

• Damage of the cornea at a superficial level — break does not involve Bowman’s membrane
• Damage of the corneal at a deeper level — break penetrates Bowman’s membrane, but does not rupture Descemet’s membrane

Functional Damage to the Eye 

• Blurred vision as a result of the compromised cornea 
• Corneal edema can result from the insult to the cornea depending on the level of damage

The main goal of the diagnostic evaluation of a patient with corneal abrasion is to accomplish the following:

• Assess the amount of structural damage to the cornea
• Reduce patients symptoms
• Manage pain accordingly
• Prevent further damage to the cornea
• Reduce re-occurrence of damage to the cornea during the healing process

Patient History

Patients with corneal abrasion may present with any of the following clinical symptoms:

• Acute pain
• Tearing
• Photophobia
• Blurred vision
• Foreign body sensation
• Blepharospasm
• Pain with eye movements

External Ocular Examination with Biomicroscopy

• Measure the size of the abrasion by using fluorescein dye
• Evaluate the anterior chamber for signs of ocular inflammation (e.g., cells and flare)
• Rule out penetrating trauma

DIAGNOSTIC TESTS

External Ocular Photography 

• Used to document degree of corneal damage

Two categories of corneal abrasions can occur:  superficial or deep abrasions.

Superficial abrasions do not involve Bowman’s membrane.

Deep abrasions penetrate Bowman’s membrane, but do not rupture Descemet’s membrane.

Recurrent Corneal Erosions

• The symptoms of pain, discomfort and photophobia are the same; however the etiology of the corneal damage is very different (the case history is very important in differentiating the two)
• Corneal abrasions are usually caused by foreign bodies, contact lenses, chemicals, or some form of trauma
• Recurrent corneal erosion happen from rubbing their eyes or opening their eyes or upon awakening from sleep — usually months after a history of a corneal abrasion from some mechanical trauma

Corneal Ulcers 

• The symptoms of pain, discomfort and photophobia are similar, but patients with ulcers also report redness, watery eyes or mucopurelent discharge as well
• Usually there is a history of contact lens wear or some form of trauma left untreated to develop into a corneal ulcer

Herpes Simplex Keratitis

• The symptoms of pain, discomfort and photophobia are the same; however the etiology of the corneal damage is very different (the case history is very important in differentiating the two)
• Patients with Herpes simplex will not report an initiating insult that caused the corneal damage

Treatment options vary depending on the cause of the corneal abrasion.  Patients with contact lens-induced abrasions must have anti-pseudomonas coverage.  

Phamacologic Therapy — Cycloplegia 

Traumatic iritis may develop one-to-three days after the initial injury.  Use cycloplegics only because steroids may delay epithelial healing and increase the risk of corneal infection.  

• Atropine 1% for severe abrasions 
• Homatropine 5% for moderate abrasions 
• Cyclopentolate 1% for mild abrasions

Pharmacologic Therapy — Topical Antibiotic

• Fourth generation fluoroquinolones (Vigamox, Zymar, Ocuflox, Quixin, Besivance) for large abrasions 
• Polytrim, Gentamycin, Tobramycin for small abrasions
• Ointments or drops may be used, but ointments offer better barrier function and lubrication between the eyelid and the cornea

Pharmacologic Therapy — Topical NSAID (for pain) 

• Acular LS, Nevanac or Prolensa if necessary

Pharmacologic Therapy — Oral Medication

• Oral acetaminophen
• Oral narcotics in severe cases

Surgical Therapy — Amniotic Membrane Placement 

Surgical Therapy — Epithelial Debridement

		Abrasion Associated with Loose/Hanging Corneal Epithelium Loose tissue may delay corneal healing Remove loose epithelium with cotton-tipped applicator, surgical sponge or Alger brush

Mechanical Therapy — Pressure Patching

• Patching is usually not necessary
• Consider patching if the abrasion is large, if the patient’s discomfort is severe, and/or if the abrasion is healing poorly in the absence of infection

1-day examination

• Assess cornea, determine if patient needs to be patched for a second day
• Consider bandage contact lens

Mechanical Therapy — Bandage Contact Lens

• Low water content bandage contact lens for moderate-to-severe abrasion to relieve pain
• Bed rest, inactivity and OTC analgesics
• Prophylactic topical antibiotics should be used while bandage contact lenses are worn

1-day examination

• Assess cornea, alter topical regimen as appropriate, determine if bandage contact can be removed
• Determine if a hypertonic therapy (sodium chloride 2% or 5% drops/ointment) needs to be added to treat any secondary corneal edema

1.  Shah C, Ehlers J.  The Wills Eye Manual (fifth edition):  Corneal Abrasion. 2008; 15-16.