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Corneal Abrasion and Ulceration

Basics

  • Cornea: anterior eye structure for protection, light refraction, and nutrient transmission.
  • Injury types: foreign body abrasion, UV burns (photokeratitis), chemical burns.
  • Corneal abrasion: disruption of corneal epithelium.
  • Corneal ulcer: epithelial loss exposing stromal layer; may progress to infectious keratitis.
  • Peripheral ulcerative keratitis (PUK): autoimmune-related ulceration.

Epidemiology

  • Corneal abrasions: 8% of ER eye traumas; 12% related to contact lenses.
  • Infectious keratitis: 5th leading cause of blindness globally.
  • Chemical injuries: mostly males 20-30 years, occupational or assault-related.
  • 1 million keratitis-related US visits/year.

Etiology and Pathophysiology

  • Abrasions from mechanical trauma, chemicals, UV exposure.
  • Ulcers can be infectious (bacterial, viral, fungal, parasitic) or autoimmune.
  • Common pathogens:
  • Gram-positive: Staph aureus, coagulase-negative strep.
  • Gram-negative: Pseudomonas (contact lens users).
  • Viral: Herpes simplex, herpes zoster.
  • Fungal: Fusarium, Aspergillus, Candida.
  • Parasites: Acanthamoeba (rare, contact lens users).
  • Ulcers more common with immunosuppression or ocular surface disease.

Risk Factors

  • Eye trauma, UV exposure, chemical burns.
  • Contact lens use, especially improper hygiene or extended wear.
  • Immunosuppression (HIV, diabetes).
  • Occupational exposures (construction, manufacturing, agriculture).

Prevention

  • Use protective eyewear in high-risk settings.
  • Proper contact lens hygiene and usage.

Diagnosis

History

  • Recent ocular trauma or exposure.
  • Contact lens use or misuse.
  • Symptoms: foreign body sensation, pain, photophobia, tearing, vision changes.

Physical Exam

  • Visual acuity (document baseline and changes).
  • Inspect eyelids, globe, conjunctiva.
  • Fluorescein stain with Wood’s lamp or slit lamp to identify abrasions or ulcers.
  • Evert lids to inspect for foreign bodies.

Differential Diagnosis

  • Acute angle-closure glaucoma, conjunctivitis, blepharitis, keratitis, uveitis, iritis, entropion.
  • Infectious vs autoimmune ulcers.
  • Herpetic keratitis (dendritic lesions).

Diagnostic Tests

  • Fluorescein staining and slit lamp exam.
  • Culture corneal scrapings for ulcers (avoid antibiotics before culture).
  • Imaging (CT/MRI) if penetrating injury suspected.
  • Tonometry if glaucoma suspected.

Treatment

Goals

  • Control pain, prevent infection, educate on monitoring symptoms.

General Measures

  • Irrigate ocular surface.
  • Remove foreign bodies if possible.
  • Tetanus booster as indicated.
  • Avoid eye patching.

Medications

  • Oral analgesics (NSAIDs, narcotics) for pain.
  • Topical anesthetics for exam only; avoid prolonged use.
  • Cycloplegics (e.g., cyclopentolate) for pain with photophobia.
  • Topical NSAIDs (diclofenac) short term (1-2 days) for pain relief.
  • Topical antibiotics for infection prophylaxis:
  • Low-risk: polymyxin B/trimethoprim drops or erythromycin ointment.
  • High-risk (contact lens users, plant matter injury): antipseudomonal agents (ofloxacin, ciprofloxacin).
  • Antifungals or antivirals if suspected fungal or herpetic keratitis (refer urgently).

Issues for Referral

  • No improvement or worsening within 24 hours.
  • Chemical burns.
  • Corneal ulcer/infiltrate.
  • Penetrating injury.
  • Hyphema or hypopyon.
  • Vision loss >2 lines or abrupt severe decline.
  • Persistent symptoms >3-4 days.

Additional Therapies

  • Experimental: amniotic membrane, autologous blood tears, topical insulin, substance P.

Ongoing Care

  • Follow-up within 24 hours for large or contact lens-related abrasions or decreased vision.
  • Educate on symptom monitoring and prompt reporting.

Prognosis

  • Minor abrasions <4 mm heal in 1-3 days; larger abrasions up to 5 days.
  • Contact lens use increases risk of microbial keratitis significantly.
  • Prompt treatment reduces risk of scarring and vision loss.

Complications

  • Recurrence.
  • Progression to keratitis or ulcer.
  • Corneal scarring and vision impairment.
  • Endophthalmitis.

ICD10: - S05.00XA Inj conjunctiva and corneal abrasion w/o foreign body, unspecified eye, initial encounter - H16.009 Unspecified corneal ulcer, unspecified eye - H16.049 Marginal corneal ulcer, unspecified eye

Clinical Pearls: - Visual acuity is the key vital sign in eye exams. - Avoid patching corneal abrasions. - Topical NSAIDs limited to 3 days max. - Early referral for ulcers and penetrating injuries is critical.