CKS Clinical Solutions - Superficial corneal injury

The case: A 30-year-old man presents with a two-day history of the sensation of something in his left eye, which is continuing to water. How should I assess possible corneal injury?

Fluorescein will show abrasions
Fluorescein will show abrasions

Ask about the cause, especially if chemicals or a high-velocity foreign body is suspected. Ask about activities such as chiselling or hammering.

Assess visual acuity, eye movements and eyelid function, and examine pupils. Look for subconjunctival haemorrhage and hyphaema.

Use fluorescein stain to assess the size, shape and position of the corneal abrasion and document carefully. If available, use a slit lamp to reveal further injury.

Evert the upper lid to exclude a foreign body. Consider using a topical anaesthetic if examination is difficult.1,2

Who should I refer?

  • All high-velocity injuries or injury caused by glass, knives, thorns, darts or pencils. These should be treated as penetrating injuries until proved otherwise.
  • All chemical injuries.
  • If there is a foreign body that cannot be removed.
  • Symptoms lasting more than 72 hours, worsening symptoms or a corneal abrasion that shows no improvement.
  • Pain not relieved by local anaesthetic; reduced visual acuity; large abrasions (more than 60 per cent of the cornea); corneal opacities; rust rings that remain after removal of a metallic foreign body; hyphaema; distorted pupil; suspected damage to the retina; deep laceration of the orbit; subconjunctival haemorrhage tracking posteriorly with a history consistent with possible orbital fracture; or marginal lacerations (as the lacrimal ducts may be damaged).
  • Recurrent abrasions may be referred non-urgently. These usually occur at night when there is little secretion of tears, and the epithelium may be torn off.

How do I manage this?
Remove any foreign body if you are confident to do this. Offer paracetamol or ibuprofen and consider a one-off dose of a cycloplegic (e.g. cyclopentolate 0.5%).

To prevent secondary infection prescribe a topical antibiotic.

Advise the patient not to wear contact lenses until the corneal abrasion has completely healed and for 24 hours after finishing treatment with topical antibiotics.

Advise that most corneal abrasions heal in 24-72 hours.3

What follow up do I offer?
Re-examine using fluorescein stain after 24 hours. If the abrasion is reducing in size, re-examine daily to confirm healing.

Refer urgently any abrasion that has not healed in 72 hours. Any worsening symptoms such as increased pain or reduced visual acuity should prompt a thorough re-examination and an urgent referral.1,2

Evidence
Referral,1,3-5 management and follow up1,2 recommendations are based on published expert opinion. CKS found no published evidence that antibiotic eye drops or ointment are effective for preventing infection after corneal injury. However, expert consensus is that they should be used to prevent secondary infection.1

There are no controlled studies to support the claim that cycloplegics reduce ocular pain and inflammation by alleviating ciliary spasm. However, some experts recommend a one-off dose to reduce headache.6

References
1. Khaw PT, Shah P, Elkington AR. BMJ 2004; 328(7430): 36-8.
2. Aslam SA, Sheth HG, Vaughan AJ. Injury 2007; 38(5): 594-7.
3. Wilson SA, Last A. Am Fam Physician 2004; 70(1): 123-8.
4. McGuinness R. Modern Medicine of Australia 1998; 41(4): 82-9.
5. Shields SR. Postgrad Med 2000; 108(5): 99-106.
6. Carley F, Carley S. Emerg Med J 2001; 18(4): 273.

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.

See www.cks.nhs.uk

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