> Table of Contents > Corneal Abrasion and Ulceration
Corneal Abrasion and Ulceration
Caroline A. Coicou, MD
Christine S. Persaud, MD
image BASICS
DESCRIPTION
  • Corneal abrasions result from scratching, denuding, abrading, or cutting of the epithelial layer of the cornea. They are usually traumatic and accidental but can occur spontaneously as well.
  • Corneal ulcers usually represent an infection deeper in the cornea by bacteria, viruses, or fungi as a result of breakdown in the protective epithelial barrier.
  • Both corneal abrasions and ulcerations can result in scarring, which may impair vision.
  • Both lesions can occur centrally or marginally.
EPIDEMIOLOGY
Incidence
  • Corneal abrasion is the most common ophthalmologic visit to the emergency department and is a commonly seen problem in urgent care:
    • 64% of cases are caused by direct minor trauma to eye.
    • 12% of cases are due to contact lens-related problems.
  • Ulceration is also common in the United States.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Corneal abrasions most commonly result from accidental trauma (e.g., fingernail scratch, makeup brush):
    • Dirt, sand, sawdust, or other foreign body gets caught under eyelid.
  • Corneal ulcers result from presence of an entryway to the external eye through dry eye; burns; abrasion; contact lenses; inappropriate use of topical anesthetics, antibiotics, or antiviral drops; immunosuppressant drugs; diabetes; or immunodeficiency. Causes of ulcerations include the following:
    • Infection with gram-positive organisms ˜29-53% (Staphylococcus aureus and coagulase-negative Streptococcus are common ones)
    • Infection with gram-negative organisms ˜47-50% (Pseudomonas being most common, followed by Serratia marcescens, Proteus mirabilis, and gram-negative enteric bacilli)
  • Viral infections, especially herpes
  • Fungal infections (Candida, Aspergillus, Fusarium, Acanthamoeba) in agricultural workers or associated with ocular corticosteroid use
  • Autoimmune disorders, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and scleroderma, are the usual cause of peripheral ulcerative keratitis.
  • Vitamin A deficiency may cause corneal necrosis or keratomalacia.
RISK FACTORS
  • Any abrasive injury
  • Foreign body in eye
  • Contact lenses (especially soft lenses and extended-wear lenses)
  • Blepharitis
  • Dry eye syndrome
  • Entropion (with lashes scratching cornea)
  • Chronic topical steroid use
  • Abuse of topical anesthetics
  • Autoimmune disorders
  • Vitamin A deficiency
  • Chronic corneal exposure (e.g., Bell palsy, exophthalmos)
  • Recent eye surgery: Trendelenburg position is newly identified as a risk factor for corneal abrasion (2).
  • Immunosuppression and trigeminal nerve abnormalities
  • Flash burn (welding burn or prolonged gazing directly at bright sunlight; symptoms often begin several hours after exposure)
GENERAL PREVENTION
  • Eye protection to avoid injury during work, crafts, and sports
  • Proper contact lens handling
    • Do not sleep while wearing contact lens.
  • Artificial tears for those with inability to blink or known dry eyes
  • Lenses to block UV rays (e.g., welding helmets)
COMMONLY ASSOCIATED CONDITIONS
  • Chronic ulcerations may be associated with neurotrophic keratitis due to lack of 5th nerve innervation of the cornea. Individuals with thyroid disease, diabetes, or immunosuppressive conditions are particularly at risk.
  • Any cause of fat malabsorption may be associated with vitamin A deficiency.
image DIAGNOSIS
PHYSICAL EXAM
  • Visual acuity may be decreased if abrasion or ulcer is centrally located.
  • Conjunctival injection
  • Increased lacrimation on affected side
  • Photophobia
  • Blepharospasm
  • Lesion seen on slit-lamp exam and area of damage shows fluorescein uptake; staining seen using Wood lamp or cobalt blue slit lamp:
    • “Dendritic” staining pattern with fluorescein indicative of viral keratitis
  • Examine for foreign body under eyelids or in cornea (“rust ring”)
DIFFERENTIAL DIAGNOSIS
  • Foreign body in eye
  • Unilateral iritis
  • Acute or chronic glaucoma
  • Keratitis
  • Scleritis with corneal melting
  • Herpes simplex or zoster
  • Bilateral or true idiopathic lesions may suggest basement membrane dystrophy.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Culture ulcer and contact lens, if applicable.
  • Pretreatment with topical antibiotics may alter culture results.
Diagnostic Procedures/Other
Scrapings of the corneal ulcer for culture and sensitivity ideally should be obtained before beginning local antibiotics. The sample should be plated directly onto the culture medium.
Test Interpretation
Scrapings for Gram and Giemsa stain may demonstrate bacteria, yeast, or intranuclear inclusions that may aid in the diagnosis.
image TREATMENT
GENERAL MEASURES
  • Simple corneal abrasions can be managed by primary care physicians, but consider referral for lesions larger than 4 mm. See indications for referral in the following text.
  • All patients with corneal ulceration should be referred immediately to an ophthalmologist. Corneal cultures should be obtained before starting antibiotics. If immediate referral is not possible, it is reasonable to start antibiotics without delay.
  • Flash burns from welding or prolonged exposure to sunlight may be treated like corneal abrasions (3)[C].
  • Topical ophthalmic steroids should be avoided: may delay healing of corneal abrasions (4)[C]. Use of topical anesthetics outside of clinical settings should be avoided: may develop corneal toxicity with prolonged use (5)[A]
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MEDICATION
First Line
  • Eye patching does not reduce pain or speed the healing process (6)[A].
  • Topical NSAIDs have been proven to reduce eye pain (6)[A].
    • Ophthalmic NSAIDs: Diclofenac 0.1% QID helps relieve moderate pain:
      • Alternatives include ketorolac 0.5% and bromfenac 0.09%
      • Caution: Ophthalmic NSAIDs may rarely cause corneal melting and perforation.
  • Ophthalmic antibiotics may help prevent further infection and ulceration of corneal abrasions (3)[C].
  • Some ophthalmic antibiotics include ciprofloxacin 0.3%, ofloxacin 0.3%, gentamicin 0.3%, erythromycin 0.5%, polymyxin B/trimethoprim (Polytrim), and tobramycin 0.3%:
    • Ointment preparations may be more soothing to the eye than solutions.
    • Topical antibiotics should be continued until eye pain is resolved.
    • Chloramphenicol should be avoided due to high risk of toxicity and Stevens-Johnson syndrome.
  • Large corneal abrasions (>4 mm) or very painful abrasions should be treated with a combination of topical antibiotic and topical NSAID.
  • Reevaluate in 24 hours. If improving, no need for further follow-up (3)[C].
  • Fungal keratitis is treated with a protracted course of topical antifungal agents (by ophthalmologist).
  • A combination of cryotherapy and antifungal agents for treatment of fungal corneal ulcer could help facilitate the practice of fungal keratitis treatment in the future (7).
  • Herpetic keratitis should be referred promptly to ophthalmologist and treated initially with trifluridine:
    • Vidarabine and acyclovir are alternatives.
Second Line
  • Oral analgesic medication (hydrocodone and other opioids) if topical analgesia not adequate
  • Supplemental topical cycloplegics (i.e., homatropine 5% and cyclopentolate 1%) have not been found to be beneficial in relieving pain in corneal abrasion (8)[B].
  • Topical 0.3% HA provided a promising treatment for superficial corneal abrasion caused by mechanical damage (9).
  • Sodium hyaluronate reduces reepithelialization time when used after mechanical abrasions of the cornea (10).
  • In the management of traumatic corneal abrasions, the administration of an eye gel containing sodium hyaluronate and xanthan gum is able to reduce the length of occlusive patching (11).
ISSUES FOR REFERRAL
  • Consultation with an ophthalmologist is recommended for all ulcers to help determine appropriate therapy. Moreover, ulcers need corneal cultures to be taken directly onto culture media.
  • Also refer to ophthalmologist if there is history of the following:
    • Significant ocular trauma
    • Corneal infection is suspected (including viral keratitis).
    • Recurrent or nonhealing abrasion is encountered despite standard treatment.
    • Severe ocular pain not explained by apparent pathology (e.g., traumatic iritis)
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Contact lens wearer should be monitored daily with slit lamp for signs of secondary infection.
  • Minor abrasion should be reevaluated only if it becomes more painful (3)[C].
  • Large abrasion (>4 mm) should be reevaluated in 24 hours, and if improving, no need to follow further unless symptoms worsen again (3)[C].
PATIENT EDUCATION
  • Prevention of abrasions and proper handling of contact lenses can prevent recurrence of corneal ulcers.
PROGNOSIS
  • Corneal abrasions and ulcerations should improve daily and heal with appropriate therapy.
  • If healing does not occur within 24 to 48 hours or the lesion extends, obtain an ophthalmology consultation.
REFERENCES
1. Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199-216, viii.
2. Segal KL, Fleischut PM, Kim C, et al. Evaluation and treatment of perioperative corneal abrasions. J Ophthalmol. 2014;2014:901901.
3. Fraser S. Corneal abrasion. Clin Ophthalmol. 2010;4:387-390.
4. Tomas-Barberan S, Fagerholm P. Influence of topical treatment on epithelial wound healing and pain in the early postoperative period following photorefractive keratectomy. Acta Ophthalmol Scand. 1999;77(2):135-138.
5. Duffin RM, Olson RJ. Tetracaine toxicity. Ann Ophthalmol. 1984;16(9):836, 838.
6. Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;(2):CD004764.
7. Chen Y, Yang W, Gao M, et al. Experimental study on cryotherapy for fungal corneal ulcer. BMC Ophthalmol. 2015;15:29.
8. Carley F, Carley S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Mydriatics in corneal abrasion. Emerg Med J. 2001;18(4):273.
9. Lin T, Gong L. Sodium hyaluronate eye drops treatment for superficial corneal abrasion caused by mechanical damage: a randomized clinical trial in the People's Republic of China. Drug Des Devel Ther. 2015;9:687-694.
10. Moreira LB, Scalco R, Hara S. Corneal reepithelialization time with instillation of eye drops containing sodium hyaluronate and carboxymethylcellulose [in Portuguese]. Arq Bras Oftalmol. 2013;76(5):292-295.
11. Faraldi F, Papa V, Santoro D, et al. A new eye gel containing sodium hyaluronate and xanthan gum for the management of post-traumatic corneal abrasions. Clin Ophthalmol. 2012;6:727-731.
Additional Reading
&NA;
  • Ehlers JP, Shah CP, Fenton GL. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Baltimore, MA: Lippincott Williams & Wilkins; 2008.
  • Watson SL, Barker NH. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2007;(4):CD001861, revised in Cochrane Database Syst Rev. 2012;(9):CD001861.
  • Wilhelmus KR. Therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev. 2008;(1):CD002898.
  • Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114-120.
Codes
&NA;
ICD10
  • S05.00XA Inj conjunctiva and corneal abrasion w/o fb, unsp eye, init
  • H16.009 Unspecified corneal ulcer, unspecified eye
  • H16.049 Marginal corneal ulcer, unspecified eye
Clinical Pearls
&NA;
  • Contact lens use should be discontinued until corneal abrasion or ulcer is healed and pain is fully resolved.
  • Eye patching is not recommended.
  • Prescribe topical and/or oral analgesic medication for symptom relief and consider ophthalmic antibiotics.
  • Prompt referral to an ophthalmologist should be made with suspicion of an ulcer, recurrence of abrasion, retained foreign body, viral keratitis, significant visual loss, or lack of improvement despite therapy.