Corneal Abrasions: Managing a Commonly Occurring Injury
Corneal Abrasions: Managing a Commonly Occurring Injury
Once a corneal abrasion is diagnosed, there are a variety of treatment options that promote epithelialization, minimize pain, and prevent infection. However, most traumatic corneal abrasions are small and in an otherwise healthy eye will spontaneously heal without such interventions.
Topical treatments, consisting mostly of prophylactic antibiotics, are universally seen as the therapeutic mainstay for these injuries. Because epithelial damage creates a nidus for possible infection, antibiotics are routinely used despite limited studies showing benefit. Antibiotics can include ophthalmic ointments or drops. In patients with associated intraocular inflammation, a topical mydriatic and cycloplegic drop is often used to help with photophobia, though yet again, proof of its effectiveness is limited.
For pain, topical nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in addition to systemic analgesics. Topical ophthalmic anesthetics should be used only in the context of an ocular examination. Overuse and abuse of these agents should be avoided, because they retard corneal healing and can cause irreversible corneal damage.
Antibiotic ointment with a pressure patch had been the traditional treatment for traumatic corneal abrasions unrelated to contact lens use. However, in the past decade, the majority of specialists have treated most corneal abrasions with topical antibiotics or ointment without patching. Patching an eye with a contact-lens–related corneal abrasion is relatively contraindicated owing to the reported complication of Pseudomonas ulcers. Patching the eye was traditionally believed to promote healing of traumatic corneal abrasions by preventing the eyelid from abrading the newly healing epithelialized surface. Despite the theoretical benefit, pressure patching has not been found to be necessary in many studies.
One of the largest randomized studies (223 participants) to evaluate the effectiveness of pressure patching in the treatment of traumatic corneal abrasions was by Kaiser and colleagues. They found that patients with corneal abrasions (traumatic abrasion or foreign-body–related abrasion) treated without a patch healed significantly faster and had less pain than those treated with a patch. All eyes received the same topical antibiotics and mydriatics. Although the results were statistically significant, a potential for bias exists in the fact that corneal abrasions were about 25% larger in the patched eyes than in the unpatched eyes. Patching for large corneal abrasions may still be a viable option, and more data on the best way to manage these cases are warranted. A subgroup analysis of large traumatic corneal abrasions (≥ 10 mm; 16 patients) from Kaiser and colleagues' study found that they healed faster with patching compared with not patching (3.45 days vs 4.20 days, respectively), although the difference did not reach statistical significance. The authors concluded that although simple traumatic corneal abrasions can be treated topically without the need for a pressure patch, continued patching of large corneal abrasions should still be performed until additional studies show otherwise.
Therapeutic contact lenses, also known as "bandage contact lenses," may be used for the treatment of corneal abrasions, given their ability to promote corneal epithelialization while decreasing pain and maximizing vision. This option is mainly available to eye care professionals and requires mandatory follow-up, unlike other treatments for which follow-up could be based on the patient's symptoms. Donnenfeld and colleagues performed a prospective, randomized, controlled trial (47 participants) comparing pressure patching with a bandage contact lens, with and without a topical NSAID, for the treatment of corneal abrasions. They found no significant difference in healing times between the groups, although the patients treated with a bandage contact lens were able to return to normal activities significantly faster and there was a significant decrease in pain associated with NSAID use.
Menghini and colleagues recently performed a prospective randomized study comparing pressure patching with antibiotic ointment (18 patients), antibiotic ointment alone (28 patients), and therapeutic contact lens with antibiotic eye drops (20 patients). The antibiotic used was ofloxacin. Although the therapeutic contact lens group had the greatest area of abrasion reduction at day 1 (4.1 ± 4.0 mm), it did not significantly differ from the pressure patching group (3.4 ± 3.3 mm) or ointment-only group (3.5 ± 3.1 mm). Compared with the ointment-only group, the therapeutic contact lens and pressure patching groups had lower pain scores (1.7 ± 2.7 vs 0.8 ± 1.6 and 0.9 ± 1.3, respectively) and less use of analgesics. Nonetheless, a statistical difference among the groups was not detected, and only the pressure patching group was shown to have statistically significant pain relief at 3 hours compared with baseline.
Pain resulting from a corneal abrasion can be severe and can be addressed with such treatments as NSAID drops; systemic medications; and, in some cases, cool compresses over the eyelid. Topical NSAID have been shown to be very effective for pain without affecting the healing time.
A double-masked, randomized, placebo-controlled study evaluated the effect of ketorolac tromethamine 0.5% on eyes with corneal abrasions < 10 mm that were treated with topical cycloplegic and antibiotic ointment. The authors found that after 1 day, patients treated with the NSAID four times daily (n = 43) had a very significant decrease in levels of pain (P < .002), photophobia (P < .009), and foreign body sensation (P < .003) compared with the placebo group (n = 45).
Patients with corneal abrasions should be evaluated every 24 hours until the epithelium is restored and symptoms have resolved. In certain scenarios, the corneal abrasion and associated symptoms have been documented to improve without complication and almost completely epithelialize. In such instances, the physician can be more flexible with follow-up examinations.
Epithelial abrasions can occasionally have excess denuded epithelium present at their margins that impairs regrowth. In these cases, a forceps or cotton-tipped applicator can be used to debride poorly adherent and loose tissue. Rarely, topical steroids may be required to treat concomitant ocular inflammation. Depending on the healing rate of the corneal abrasion, these agents may need to be used judiciously, because they can retard corneal healing and in some cases raise intraocular pressure via a steroid response.
Most corneal abrasions are small and uncomplicated and can be managed in the primary care setting. Because corneal abrasions can be associated with other ocular injuries, however, first-line responders, such as primary care and emergency care physicians, need to be aware of what other findings or part of the history can be associated with other more complex ocular injuries and require ophthalmic specialty care. The differing treatment approaches to corneal abrasions are noted in the Table.
Table. Recommended Approach for Medical Provider in Treating Corneal Abrasion
Vision and symptoms improving after 24 hours.
Treatment Strategies
Once a corneal abrasion is diagnosed, there are a variety of treatment options that promote epithelialization, minimize pain, and prevent infection. However, most traumatic corneal abrasions are small and in an otherwise healthy eye will spontaneously heal without such interventions.
Topical treatments, consisting mostly of prophylactic antibiotics, are universally seen as the therapeutic mainstay for these injuries. Because epithelial damage creates a nidus for possible infection, antibiotics are routinely used despite limited studies showing benefit. Antibiotics can include ophthalmic ointments or drops. In patients with associated intraocular inflammation, a topical mydriatic and cycloplegic drop is often used to help with photophobia, though yet again, proof of its effectiveness is limited.
For pain, topical nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in addition to systemic analgesics. Topical ophthalmic anesthetics should be used only in the context of an ocular examination. Overuse and abuse of these agents should be avoided, because they retard corneal healing and can cause irreversible corneal damage.
Antibiotic ointment with a pressure patch had been the traditional treatment for traumatic corneal abrasions unrelated to contact lens use. However, in the past decade, the majority of specialists have treated most corneal abrasions with topical antibiotics or ointment without patching. Patching an eye with a contact-lens–related corneal abrasion is relatively contraindicated owing to the reported complication of Pseudomonas ulcers. Patching the eye was traditionally believed to promote healing of traumatic corneal abrasions by preventing the eyelid from abrading the newly healing epithelialized surface. Despite the theoretical benefit, pressure patching has not been found to be necessary in many studies.
One of the largest randomized studies (223 participants) to evaluate the effectiveness of pressure patching in the treatment of traumatic corneal abrasions was by Kaiser and colleagues. They found that patients with corneal abrasions (traumatic abrasion or foreign-body–related abrasion) treated without a patch healed significantly faster and had less pain than those treated with a patch. All eyes received the same topical antibiotics and mydriatics. Although the results were statistically significant, a potential for bias exists in the fact that corneal abrasions were about 25% larger in the patched eyes than in the unpatched eyes. Patching for large corneal abrasions may still be a viable option, and more data on the best way to manage these cases are warranted. A subgroup analysis of large traumatic corneal abrasions (≥ 10 mm; 16 patients) from Kaiser and colleagues' study found that they healed faster with patching compared with not patching (3.45 days vs 4.20 days, respectively), although the difference did not reach statistical significance. The authors concluded that although simple traumatic corneal abrasions can be treated topically without the need for a pressure patch, continued patching of large corneal abrasions should still be performed until additional studies show otherwise.
Therapeutic contact lenses, also known as "bandage contact lenses," may be used for the treatment of corneal abrasions, given their ability to promote corneal epithelialization while decreasing pain and maximizing vision. This option is mainly available to eye care professionals and requires mandatory follow-up, unlike other treatments for which follow-up could be based on the patient's symptoms. Donnenfeld and colleagues performed a prospective, randomized, controlled trial (47 participants) comparing pressure patching with a bandage contact lens, with and without a topical NSAID, for the treatment of corneal abrasions. They found no significant difference in healing times between the groups, although the patients treated with a bandage contact lens were able to return to normal activities significantly faster and there was a significant decrease in pain associated with NSAID use.
Menghini and colleagues recently performed a prospective randomized study comparing pressure patching with antibiotic ointment (18 patients), antibiotic ointment alone (28 patients), and therapeutic contact lens with antibiotic eye drops (20 patients). The antibiotic used was ofloxacin. Although the therapeutic contact lens group had the greatest area of abrasion reduction at day 1 (4.1 ± 4.0 mm), it did not significantly differ from the pressure patching group (3.4 ± 3.3 mm) or ointment-only group (3.5 ± 3.1 mm). Compared with the ointment-only group, the therapeutic contact lens and pressure patching groups had lower pain scores (1.7 ± 2.7 vs 0.8 ± 1.6 and 0.9 ± 1.3, respectively) and less use of analgesics. Nonetheless, a statistical difference among the groups was not detected, and only the pressure patching group was shown to have statistically significant pain relief at 3 hours compared with baseline.
Pain resulting from a corneal abrasion can be severe and can be addressed with such treatments as NSAID drops; systemic medications; and, in some cases, cool compresses over the eyelid. Topical NSAID have been shown to be very effective for pain without affecting the healing time.
A double-masked, randomized, placebo-controlled study evaluated the effect of ketorolac tromethamine 0.5% on eyes with corneal abrasions < 10 mm that were treated with topical cycloplegic and antibiotic ointment. The authors found that after 1 day, patients treated with the NSAID four times daily (n = 43) had a very significant decrease in levels of pain (P < .002), photophobia (P < .009), and foreign body sensation (P < .003) compared with the placebo group (n = 45).
Patients with corneal abrasions should be evaluated every 24 hours until the epithelium is restored and symptoms have resolved. In certain scenarios, the corneal abrasion and associated symptoms have been documented to improve without complication and almost completely epithelialize. In such instances, the physician can be more flexible with follow-up examinations.
Epithelial abrasions can occasionally have excess denuded epithelium present at their margins that impairs regrowth. In these cases, a forceps or cotton-tipped applicator can be used to debride poorly adherent and loose tissue. Rarely, topical steroids may be required to treat concomitant ocular inflammation. Depending on the healing rate of the corneal abrasion, these agents may need to be used judiciously, because they can retard corneal healing and in some cases raise intraocular pressure via a steroid response.
Treatment Approach by the Medical Provider
Most corneal abrasions are small and uncomplicated and can be managed in the primary care setting. Because corneal abrasions can be associated with other ocular injuries, however, first-line responders, such as primary care and emergency care physicians, need to be aware of what other findings or part of the history can be associated with other more complex ocular injuries and require ophthalmic specialty care. The differing treatment approaches to corneal abrasions are noted in the Table.
Table. Recommended Approach for Medical Provider in Treating Corneal Abrasion
| Manage in Primary Care Setting | Refer to Ophthalmologist |
|---|---|
| Uncomplicated abrasion | Contact-lens–related abrasion |
| Perioperative abrasion in a previously normal eye | Corneal ulcer or infiltrate present |
| Superficial foreign body | Inability to remove a foreign body, or presence of rust ring |
| Penetrating injury | |
| History of injury by high-speed projectile | |
| Presence of hyphema or hypopyon | |
| Trauma with organic matter, such as plant or tree branch | |
| Associated chemical or periocular burn | |
| Worsening vision or symptoms after 24 hours | |
| Increased abrasion size after 24 hours | |
| Failure to heal after 3-4 days |
Vision and symptoms improving after 24 hours.
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