OVERVIEW: What every practitioner needs to know

Are you sure your patient has a corneal abrasion or foreign body? What are the typical findings for this disease?

Intense eye pain with protective lid closure/spasm

Tearing and photophobia

Foreign body sensation

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Corneal Abrasion/Corneal Foreign Body

Corneal abrasion is an extremely common pediatric ocular injury. Ocular foreign body is less frequent but causes symptoms similar to that of corneal abrasion and can produce a corneal abrasion from disruption of the corneal epithelium.

What other disease/condition shares some of these symptoms?

Herpes simplex keratitis

Recurrent corneal erosion and superficial punctate keratopathy can present with similar symptoms. Superficial punctate keratopathy can result from multiple conditions, including dry eye syndrome, exposure from poor lid closure, thermal or ultraviolet burns, chemical injury, conjunctivitis, contact lens disorders, trichiasis, and structural lid problems.

What caused this condition to develop at this time?

Pediatric corneal abrasion results from scratching the corneal surface. The protective epithelium is disrupted through a traumatic event. The possible causes are expansive, but fortunately are most likely to result in a minor injury and are unlikely to cause permanent vision loss. Conjunctival and corneal foreign bodies result from exposure to direct contact or airborne particles onto the ocular surface.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Laboratory studies are not required for typical corneal abrasion or foreign body.

Would imaging studies be helpful? If so, which ones?

Imaging studies are not necessary unless there is a concern for laceration or perforation of the globe or concern for an intraocular foreign body.

Confirming the diagnosis

Note: Pressure should never be placed on the globe or onto the lids until more serious ocular injury such as laceration, perforation of the globe, or penetrating foreign body have been ruled out.

Note: History of high-velocity injury, extensive subconjunctival hemorrhage, any sign of puncture or laceration of the ocular surface, distortion or peaking of the pupil towards the cornea or sclera, or signs of intraocular bleeding all necessitate an ophthalmologic consultation

The diagnosis of corneal abrasion and/or foreign body is made by examination of the ocular surface and inspection of the eyelids, including the undersurfaces of the eyelids for a foreign body. Installation of a topical anesthetic will relieve the intense pain and lid spasm and permit evaluation of the cornea and lids. Inspection of the cornea, assisted by magnification, will demonstrate a disruption in the smooth homogeneous and glistening epithelial surface. A linear abrasion will show changes in the corneal tear film surface. Loss of surface epithelium will show a superficial geographic depression in the epithelial surface. Installation of fluorescein dye will stain the defect a brilliant lime green when viewed with a cobalt blue light.

A corneal foreign body will be visible when embedded in the corneal surface. Magnification will be necessary for small foreign bodies. Small translucent foreign bodies from vegetable matter (grain husks) and insect parts (wing parts or exoskeleton fragments) may be translucent and firmly suctioned to the cornea with minimal underlying defect.

Vertical linear scratches, especially on the superior half of the cornea, indicate a foreign body under the lid or and offending aberrant eyelash. Eversion of the upper lid will reveal the foreign body.

If you are able to confirm that the patient has a corneal abrasion for foreign body, what treatment should be initiated?

Antibiotics are generally prescribed topically when the corneal epithelial surface has been violated. Ointments and drops are both effective. Ointments tend to blur the vision but provide more of a lubrication barrier for comfort. Antibiotic treatment with a broad spectrum antibiotic is preferred. For general purposes polymyxin B/trimethoprim drops or polysporin, bacitracin, or erythromycin ointment can be applied every 2-4 hours. If the abrasion resulted from a contaminated or foreign body source consider fluoroquinolone drops four times a day or ciprofloxacin ointment every 2-4 hours.

Note: corneal abrasion in a contact lens wearer requires antibiotic coverage for Pseudomonas. Coverage with tobramycin, ciprofloxacin, gatifloxacin or moxifloxacin four times a day or tobramycin or ciprofloxacin ointment every 2-4 hours should be effective.

Children should be seen daily until the abrasion is healed. In general, contact lens–associated abrasions and central cornea or large corneal abrasions are reevaluated after 24 hours.

Corneal foreign body removal can often be accomplished by using topical anesthetic drops and irrigation. If mechanical removal with an instrument is necessary, use of slit lamp magnification in a compliant child or sedation and use of an operating room microscope in a younger or noncompliant child are the main considerations.

Rust ring removal should be performed at the same time with either a spud instrument or ophthalmic drill. The corneal defect is then treated as a corneal abrasion.

Pain control

Nonsteroidal anti-inflammatory drops, ketorolac four times a day for 3 days, may be used in patients who have had no recent ocular surgery or history of ocular surface disease or aspirin allergy.

Oral acetaminophen for mild to moderate and oral narcotics can be given for severe pain.

Pressure patching to keep the lid closed may be useful for comfort. Patching should not be used if the abrasion was caused by a contaminated source or is in a contact lens wear.

A bandage contact lens is used by some clinicians. It is most useful in larger corneal abrasions with no evidence of infection. If patched, the patient should be reevaluated in 24 hours, sooner if the condition worsens with increased discomfort.

Secondary iritis and discomfort from ciliary body spasm may develop over the first 24-48 hours . This may prove more uncomfortable than the abrasion itself, especially for small rapidly healing abrasions.

A cycloplegic agent, such as cyclopentolate 1%, twice a day, can be used along with the topical antibiotic.

What are the possible outcomes of corneal abrasion or foreign body?

Small corneal abrasions will reepithelialize the defect in 24 hours or less. Larger corneal defects or defects in patients with underlying systemic conditions such as diabetes may take days to resolve.

Corneal abrasions and corneal foreign bodies can produce permanent scarring. The scar is most likely to cause visual change if located in the central visual axis. Small and more peripheral scars cause little or no change in vision.

What causes this disease and how frequent is it?

Corneal abrasion is one of the most common ocular injuries seen in childhood. Corneal foreign body is common but is a less frequent occurrence.

What complications might you expect from the disease or treatment of the disease?

Corneal abrasion and corneal foreign body can produce scarring of the cornea. Large central scars can produce vision loss. Fortunately this is a less likely occurrence.

How can corneal abrasion or foreign body be prevented?

Corneal abrasion and corneal/conjunctival foreign body are usually random occurrences, making prevention more difficult. Certain precautions, however, can reduce the risk. Eye protection should always be worn when working with saws, hammers, grinders, and other tools that produce high- and low-speed airborne particles. Similar protection should be considered during high-contact athletic contests.

Contact lens wearers should remove the lens at the first sign of redness or persistent irritation. The offending problem (torn lens, foreign body, infection) should be identified before wearing the lens again.

What is the evidence?

Michael, JG, Hug, D, Dowd, MD. “Management of corneal abrasion in children: a randomized clinical trial”. Ann Emerg Med. vol. 40. 2002. pp. 67-72. (This study looked at 37 patients aged 3 to 17 years with a diagnosis of isolated corneal abrasion. They were randomized to patch versus no patch groups. The study suggested that there was no difference in the rate of healing, level of comfort, or interference with the activities of daily living between the two groups. The patched group noted greater difficulty walking.)

Ongoing controversies regarding etiology, diagnosis, treatment

Patching of corneal abrasions in children is controversial. The patch may be difficult to keep on in toddlers and active children. Ideally a pressure patch will reduce the rubbing and blinking thus promoting faster healing. However, even large corneal abrasions will heal quickly without patching