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InnovAiT, 6(9), 551–554 DOI: 10.

1177/1755738012467981

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Corneal abrasion:
assessment and
management

C
orneal abrasions result from a superficial lesion to the most anterior aspect
of the eye, the corneal epithelium. Patients can present to the GP with an
array of symptoms including pain, foreign body sensation, decreased visual
acuity/blurring, epiphora (excess watering) and photophobia. Most corneal abra-
sions are self-limiting and appropriate management can be instituted in the GP
surgery. However, some require referral for specialist ophthalmology assessment.
This article looks at the assessment and management of corneal abrasions and
provides evidence-based guidance for ophthalmology referral.

The GP curriculum and corneal abrasions

Clinical example 3.16: Care of people with eye problems lists the management of emergency eye disease
including corneal abrasions. It states that GPs must be able to:
. Recognise and institute primary management of ophthalmic emergencies and refer appropriately: superficial
ocular trauma, including assessment of foreign bodies, abrasions and minor lid lacerations
. Apply the information gathered during the history-taking and examination, generate a differential diagnosis and
formulate a management plan to include assessment of severity and need for referral to secondary care
. Demonstrate a reasoned approach to the diagnosis of eye symptoms using history, examination, incremental
investigations and referral
. Demonstrate complete examination of the eye, assessing both structure and function, including: measurement of
visual acuity, pinhole testing, external examination of the eye, eversion of eyelid, examination of the pupil and
assessment of the red reflex, assessment of ocular movements and cover testing, visual field testing by con-
frontation, direct ophthalmoscopy, colour vision testing, fluorescein staining of the cornea

ophthalmic examination to exclude causes of red eye


Background
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........................................................... that may have similar presentation but warrant urgent


specialist treatment, such as anterior uveitis and acute
The cornea is the anterior-most part of the eye and func- angle closure glaucoma. A more detailed list of other
tions to refract light rays on to the retina in order to obtain causes of red eye can be found in a previous issue of
a focused image of our surroundings. It is usually pro- InnovAiT (Wilson, 2010).
tected by the eyelids yet is susceptible to injury, especially
from trauma. An abrasion of the cornea results from loss of
the epithelial cell surface, which can be superficial or deep, Assessment
...........................................................
and is usually caused by cutting or scraping of the cornea
by a foreign body. Although most abrasions heal within a History
matter of days, others can take longer and are associated A history indicating the occurrence of recent ocular
with complications such as secondary bacterial infection. trauma followed by pain and redness of the involved
eye is suggestive of a corneal abrasion. Enquire about
It is important that GPs are able to diagnose corneal associated symptoms including:
abrasions confidently and perform a comprehensive . foreign body sensation

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. visual acuity/blurring Once this has been done, examine the pupils for size and
. epiphora (excess watering) and reactivity, comparing the two. Visualise the cornea with a
. photophobia cobalt-blue light after staining with fluorescein (see Fig. 2).
This causes any abrasion to appear green in colour and is
Always remember to ask about contact lens wear as this can usually seen over the corneal surface.
complicate the presence of an abrasion and may indicate
that referral for a specialist opinion is required. It is important
to note that the patient may be unable to recollect any his-
tory of trauma and this emphasises the need for a compre-
hensive examination to rule out a corneal abrasion.

Examination
Prior to examining a patient with a corneal abrasion, it is
essential to instill a topical anaesthetic agent such as
tetracaine 0.5%. This not only helps the examiner to
carry out a comprehensive assessment but also puts
the patient at ease, alleviating pain.

The examination should be carried out in a systematic


fashion. Begin by assessing visual acuity, then examine Figure 2. Corneal abrasion with fluorescein stain.
the eyelids and adnexa for signs of ocular inflammation Photo courtesy of Karin Lecuona/Dept. of Ophthalmology
and trauma and evert the upper eyelid to check for the University of Cape Town.
presence of a foreign body (see Fig. 1). Box 1 lists the
steps involved in everting the upper eyelid.
Management
...........................................................
Topical antibiotics
It is routine practice to prescribe topical antibiotic agents in
order to reduce the risk of a secondary microbial infection,
which is increased in the presence of an epithelial defect.
The most commonly used antibiotic is chloramphenicol 1%
ointment or 0.5% drops (four times daily for 5 to 7 days).
Other broad-spectrum antibiotics such as ciprofloxacin
(0.3%) and ofloxacin (0.3%) may also be used. The latter
are more commonly used in contact lens wearers due to
their anti-pseudomonal activity (Wilson and Last, 2004).

Topical anti-inflammatories
Figure 1. Foreign body under eyelid. Although not commonly prescribed in UK primary care,
Photo: Murray McGavin, Published in: Stevens S. Ophthalmic a systematic review of five randomised control trials
practice. Community Eye Health Journal (2005) 18(5). (RCTs) involving use of NSAIDs for treatment of corneal
Reproduced with permission. abrasion (Calder et al., 2005) found that topical NSAIDs
when compared to placebo decrease pain in patients
with corneal abrasions and aid quicker return to normal
activities, with no delay in healing rates or significant side
effects. The topical agents used included diclofenac
Box 1. Tips for eyelid eversion. 0.1%, ketorolac 0.5% and indomethacin 0.1%. Although
oral analgesic agents may play a role in the management
. Ensure patient is sitting comfortably. of pain in corneal abrasions, their overall efficacy is
. Ask the patient to look down. reduced because the cornea is an avascular structure
. Using your thumb and forefinger gently pull on and thus their use is limited.
the eyelashes.
. Use a cotton bud to vertically press down on the
central part of the upper eyelid.
. Gently evert the eyelid. Removal of a foreign body
. Thoroughly examine the area for a foreign body. The presence of a foreign body causes irritation to the
. Using a clean, sterile cotton bud sweep the pal- cornea and can be a major contributing factor to the dis-
pebral conjunctiva to remove any foreign body. comfort faced by the patient. It is therefore essential to
remove any visible foreign body. Foreign bodies are usually

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InnovAiT

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lodged on either the corneal surface or underneath the driving, work and other day-to-day activities. Therefore,
upper eyelid (subtarsal). Linear abrasions over the corneal patching should be avoided for patients with simple cor-
surface are highly suggestive of a subtarsal foreign body. If neal abrasions.
you are unable to remove a foreign body, the patient must
be referred to an ophthalmology service for review.
Contact lens wearers
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Contact lenses may be implicated in the aetiology of cor-
Advice for patients neal abrasions if they fit tightly on the cornea, as they may
Another important aspect of management is providing pull off some epithelium on removal. This is especially true
adequate ‘red flag’ advice about when patients should in individuals with dry eyes, due to the presence of
seek further help. Most corneal abrasions heal within unhealthy corneal epithelium. Also, edges of torn contact
48–72 hours. Therefore, always remember to ‘safety lenses can rub against the cornea precipitating an abrasion.
net’ and advise patients to return to see a GP if their
symptoms do not settle down within that time frame, Patients who wear contact lenses and have a corneal abra-
or worsen in the interim. Persisting symptoms may indi- sion have a high risk of secondary keratitis and ulcer for-
cate the development of a corneal ulcer and warrant mation. Therefore, when treating a corneal abrasion in
referral for specialist review. contact lens wearers, it is extremely important to advise
them to discontinue contact lens use until symptoms have
resolved and they have finished a course of topical anti-
Routine follow-up biotic therapy. Have a low threshold in these patients to
Most patients, if given appropriate safety-netting advice, refer for specialist ophthalmology review if diagnosis is
do not require routine follow-up in the GP surgery. unclear or symptoms are failing to improve as expected.
Routine follow-up is advised for patients with large cor-
neal abrasions as they may take longer to heal and are
therefore at a higher risk of secondary infection.
Ophthalmology referral
...........................................................
The majority of corneal abrasions can be successfully man-
Treatments to avoid aged in the GP surgery. It is important, however, for GPs to
Although topical anaesthetic agents may be used in the
recognise cases that need specialist input in order to pre-
GP surgery to aid examination and relieve the pain of a
vent irreversible damage to a patient’s vision. The follow-
corneal abrasion, they should never be prescribed for
ing list provides guidance about which patients with a
patients to use for pain relief at home. This is because
corneal abrasion should be referred for specialist review:
they delay wound healing and increase the risk of corneal
. foreign body visualised that you are unable or lack
ulcer formation (Wilson and Last, 2004).
confidence to remove
. contact lens wearers with worsening symptoms
Topical mydriatics have traditionally been used for
. persistent symptoms for longer than 48 hours
patients with corneal abrasions. The rationale behind
. recent surgery to the affected eye
their use was that they relieved ciliary muscle spasm
. involvement of patient’s only seeing eye
and therefore helped with the pain associated with cor-
. dry eyes
neal abrasions. However, recent evidence suggests no
. recurrent corneal abrasions
additional benefit with these agents and they should no
. presence of a corneal ulcer on staining
longer be used in the routine management of this con-
. history of previous herpetic keratitis (which may pre-
dition (Carley and Carley, 2001).
sent with reduced visual acuity and a red eye, occa-
sionally in the absence of pain)
In the past it has also been suggested that patients with
a corneal abrasion should wear an eye patch. However,
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Dr Syed M Shahid
Foundation Year 2 Trainee, University Hospital Lewisham
Email: ss4562@doctors.org.uk

Mr Nigel Harrison
Consultant Emergency Medicine, University Hospital Lewisham

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