Corneal Abrasions

Eye pads, mydriatics, lubricants and topical antibiotics have all traditionally been used in the management of corneal abrasions. The evidence for such treatments has been reviewed extensively in recent years.

In actuality, most corneal abrasions will heal effectively with a treatment plan that utilises topical antibiotics and topical/oral analgesics alone.

Eye pads

Eye pads were traditionally advocated for the management of corneal abrasions in order to ‘protect’ the damaged cornea from further damage from eyelid-induced trauma.

Meta-analysis of five randomised controlled trials (RCTs) demonstrated no increase in the healing rate of corneal abrasion or improvement on a pain scale for patients treated with eye pads versus those that were not [15]. Subsequent RCTs have reported similar results [6, 16].
Eye pads themselves have been shown to be the cause of pain in nearly half of all patients [17] and can result in higher rates of infection and impair the healing process [18-19]. The use of patches has also been shown to lead to a loss in binocular vision [20].

Learning bite

Eye pads do not speed up recovery from a corneal abrasion and may worsen the pain and affect vision.

Mydriatics

Mydriatics, such as tropicamide and cyclopentolate, were traditionally advised to relieve ciliary muscle spasm that was thought to occur in patients with corneal abrasions.

One RCT compared the use of a mydriatic and a lubricant, with lubricant alone, in a sample of 400 patients with corneal abrasion. The results of the comparison showed no difference in pain score over a 24-hour period and the use of oral analgesia [21].

Learning bite

Mydriatics are no longer recommended for the treatment of pain in patients with corneal abrasions.

Topical corticosteroids

Topical corticosteroids have been shown to slow corneal epithelial and stromal healing, increase the risk of infection, and cause serious scarring and visual loss if a dendritic ulcer has been missed [22].

Learning bite

Topical corticosteroids should not be used in the management of corneal abrasions.

Topical anaesthetics

Topical anaesthetics do have a place in the initial assessment of the injured eye but should not be used in the management of corneal abrasions. They abolish the corneal reflex, which increases the risk of further corneal damage [23].

Learning bite

Topical anaesthetics are slow healing and aggravate associated keratitis in corneal abrasion.

Lubricants

Complications of simple corneal abrasions are rare. However, poor adhesion of corneal epithelium to the basement membrane following an abrasion may lead to the development of a recurrent corneal erosion (RCE).
Symptoms of RCE include a foreign body sensation, ocular pain, lacrimation on awakening or after rubbing the eye, blepharospasm and photophobia. On examination there is fluorescein uptake at the site of a previous abrasion.

Lubricants have traditionally been advocated to prevent recurrent symptoms and RCE following uncomplicated traumatic corneal abrasion. There is however a paucity of good evidence to support this. The image below shows an ocular lubricant.

One small non-blinded study actually demonstrated a higher prevalence of symptoms post corneal abrasion in the cohort treated with lubricants as well as standard therapies [24].

Learning bite

There is no evidence to support the use of lubricants in the treatment of corneal abrasions.

Topical analgesics

Topical non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac and ketorolac have been shown to be modestly useful analgesics in corneal abrasion [25].

A systematic review of five RCTs showed that topical NSAIDs decreased pain by an average of only 1.3 cm on a standard 10 cm scale [18]. Patients using topical NSAIDs may take fewer oral analgesics (two of three studies) and return to work earlier (one study).

Diclofenac eye drops are licensed to treat pain after a corneal abrasion in the UK [26] but there is a lack of evidence to compare the efficacy of topical NSAIDs with oral preparations [27].

Tetanus prophylaxis

There are no case reports in the literature of clinical tetanus developing from a simple corneal abrasion.

Unlike skin, corneal epithelium does not have an underlying blood supply (receiving nutrients from the aqueous humour) and often shows substantial healing within six hours of injury.

A study using an animal model failed to induce tetanus following inoculation of a corneal abrasion [28].

Learning bite

Routine tetanus prophylaxis is not recommended for corneal abrasion.

Topical antibiotics

There is no strong evidence to support the use of prophylactic antibiotics to reduce the risk of concomitant infection in corneal abrasion. One cohort study of topical antibiotic prophylaxis for corneal abrasion showed a lower risk of ulceration if 1% chloramphenicol eye ointment was used, especially if the treatment was started within 18 hours of the initial injury [29]. Fusidic acid eye drops have not been shown to be more efficacious than chloramphenicol eye ointment in the management of corneal abrasion [30].
There is no good published evidence that eye ointment is better than eye drops for preventing infection following corneal abrasion. However, expert consensus is that eye ointments are preferred because they are thought to be more lubricating [31].

In patients who wear contact lenses an anti-pseudomonal antibiotic (e.g. gentamicin/ofloxacin/ciprofloxacin) should be used and contact lens use discontinued. It is recommended that contact lenses are avoided until the antibiotic course is completed and the abrasion is healed [32].

Learning bite

Topical antibiotics may reduce the risk of infective complications in patients with a corneal abrasion. In contact lens wearers an anti-pseudomonal antibiotic must be used.

Follow-up and referral

There is no clear consensus in the literature regarding the most appropriate arrangements for review and follow-up of patients with corneal abrasion.
Expert opinion advocates follow-up for all cases of corneal abrasion, with examination using fluorescein stain, after 24 hours [31, 33].

General practitioners (GPs) and emergency nurse practitioners (ENPs) have been identified as suitable professionals to manage follow-up in uncomplicated cases of corneal abrasion.

Specialist referral and re-examination is required if:

• The corneal abrasion has not healed after 72 hours, or is not reducing in size
• The patient experiences increased pain
• There is reduction in visual acuity

Learning bite

There are no clear nationally agreed guidelines for the follow-up of corneal abrasions. Ensure that you know your own department’s protocols.

Full thickness corneal abrasions needs ophthalmology review for surgical management.

Summary of management for Corneal Injuries