Management of Corneal Abrasion

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Management of Corneal Abrasion
A Review of the Literature
October 27, 2004 Reuben J. Strayer McGill
Emergency Medicine
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Raison detre
Common
Controvercial
Its the eye, stupid
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Survey
I think that a presssure patch is obsolete. A
soft bandage contact lens is more tolerant and
the epithelium will heal under this lens in 24
hours
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Objectives
The background
The noncontrovercial
The controvercial
The evidence
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Background
Corneal abrasion vs. corneal epithelial defect
Five Layers
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Background
Corneal abrasion vs. corneal epithelial defect
Five Layers
Etiologies
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Background
corneal abrasion
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Background
Differential Diagnosis
Blepharitis
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Background
Differential Diagnosis
Blepharitis
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Background
Differential Diagnosis
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Background
Differential Diagnosis
Blepharitis
Recurrent erosion syndrome
(DDx crying baby)
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Background
Differential Diagnosis
Penetrating eye injury
Seidel Test
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Background
Differential Diagnosis
Penetrating eye injury
Seidel Test
Infectious infiltrate / ulcer
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Background
Diagnosis
Positive fluorescein exam
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Background
Fluorescein Exam
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Background
Diagnosis
Pain exacerbated by eye movement
Epiphora
Blepharospasm
Foreign body sensation
Photophobia
Positive fluorescein exam
Response to topical anesthesia
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Background
Diagnosis
Sklar, D.P., et al, Ann Emerg Med 18(11)1209,
November 1989. Topical Anesthesia of the Eye as a
Diagnostic Test
The authors, from the University of New Mexico
School of Medicine, examined the response to a
local anesthetic in patients with eye pain as a
predictor of the nature of the injury.
Seventy-one patients presenting with eye pain
assessed their degree of pain on a visual
analogue scale before and after application of
one drop of 0.5 proparacaine to the affected
eye. Fifty patients had an ultimate slit lamp
diagnosis of simple corneal abrasion or foreign
body, and 21 had other causes of eye pain (e.g.,
conjunctivitis, corneal ulcers or abrasions or
foreign bodies with iritis, hyphema, glaucoma,
subconjunctival hemorrhage). Examination by
direct vision with fluorescein and ultraviolet
light was inaccurate in diagnosing 24 of the
patients with simple corneal abrasions or foreign
bodies, and 29 of the patients with other
diagnoses. Patients with simple corneal
abrasions or foreign bodies had a mean initial
pain score that was significantly higher than
those with other conditions (6.3 vs. 4.8 on a
scale of 1-10), and exhibited a mean change in
pain score after application of topical
anesthesia that was significantly greater than
those with other conditions (5.2 vs. 1.3,
p0.001). A decrease in pain score of more than
five points or a final pain score of less than
one point as an indicator of simple corneal
abrasion or foreign body had a sensitivity and
specificity of 80 and 86, respectively. It is
suggested that pain due to simple corneal lesions
appears to be more responsive to application of
a topical anesthetic than pain due to other
ocular conditions. The response to topical
anesthesia may be useful in the evaluation of
patients presenting with eye pain, particularly
when slit lamp examination is not immediately
available.
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Management
Undebated Approaches
Do not prescribe topical anesthetics for any
reason
Do not patch high risk CA
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Management
Schein, O.D., et al, Am J Emerg Med 11(6)606,
November 1993. Contact Lens Abrasions and the
Nonophthalmologist
About 25 million persons in the U.S. wear contact
lenses. Users of contact lenses who sustain
corneal abrasions often initially present to
primary care physicians. The authors, from the
Johns Hopkins University in Baltimore, discuss
the management of corneal abrasions in these
individuals. Contact lens-associated ulcerative
keratitis, a break in the corneal epithelium with
underlying suppuration of the corneal stroma, is
usually due to bacterial infection and is most
commonly caused by Pseudomonas species. The risk
of contact lens-associated ulcerative keratitis
is increased 10- to 15-fold with overnight use
of extended-wear soft lenses as compared with
daily wear soft lenses. Appropriate management
differs from that of the patient presenting with
a corneal abrasion not associated with contact
lens use. Erythromycin and sulfas that are
frequently employed in patients with other types
of mechanical corneal abrasion are inadequate in
these cases. Aminoglycoside ointments (e.g.,
tobramycin or gentamicin) or combination products
such as Polymyxin B and Bacitracin, which are
effective against Pseudomonas, should be
utilized. Routine patching is discouraged, as
this intervention limits tearing and increases
the temperature and humidity of the ocular
surface, favoring bacterial replication. Topical
steroids also promote bacterial replication.
Since the patient will not experience the pain
relief produced by patching, adequate oral
analgesics should be employed. Early follow-up
should be scheduled (typically within 24 hours),
when reexamination with a slit- lamp
biomicroscope should be performed. Three cases
are discussed in which initial mismanagement
resulted in significant sequelae (and litigation
in two cases).
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Management
Undebated Approaches
Do not prescribe topical anesthetics for any
reason
Do not patch high risk CA
A patch should not be left in place for more than
24 hours
No steroids
Tetanus prophylaxis is indicated for penetrating
eye injuries, not for abrasions.
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Management
Benson, W.H., et al, J Emerg Med 11677, 1993.
Tetanus Prophylaxis Following ocular Injuries
BACKGROUND Tetanus prophylaxis is often
routinely administered to patients with corneal
abrasions. However, development of tetanus
following ocular injuries appears to be extremely
rare. Only 38 cases have been reported between
1847 and 1993 33 of these cases involved
perforation through the cornea or sclera, and
none of the remaining five occurred in patients
with simple corneal abrasions. METHODS This
study, from the Medical College of Virginia and
West Virginia University Health Sciences Center,
assessed the appropriateness of tetanus
prophylaxis following eye injuries. Mice were
passively immunized with tetanus antitoxin 24
hours prior to instrumentation or received no
antitoxin. They were then subjected to three
different types of eye injuries (abrasion,
penetration or perforation) followed by injection
of C. tetani organisms or toxin into the anterior
chamber. RESULTS The frequency of clinical
tetanus or death following perforating injuries
in unimmunized animals was high (29 6/21 and
67 4/6 in mice injected with organisms or
toxin, respectively). There were no cases of
clinical tetanus or death in the 24 immunized
animals subjected to perforating injury, the nine
unimmunized animals or nine immunized animals
subjected to injection of tetanus organisms or
toxin following corneal stroma scarification
(penetrating injury), or in the nine unimmunized
and nine immunized animals subjected to
injection of tetanus organisms or toxin
following corneal abrasion. CONCLUSIONS The
authors suggest that tetanus prophylaxis is
warranted following perforating ocular injuries,
but does not appear to be routinely necessary
following uncomplicated corneal abrasions or
other nonperforating ocular injuries.
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Management
Undebated Approaches
Do not prescribe topical anesthetics for any
reason
Do not patch contact lens-associated CA
A patch should not be left in place for more than
24 hours
No steroids
Tetanus prophylaxis is indicated for penetrating
eye injuries, not for abrasions.
Follow daily
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Where does information for the emergency
physician come from?
Challenge unique to the emergency physician
Relevant information can come from literature in
any specialty
Original studies, review articles,
editorials Literature interpretation
clearinghouses/systematic reviews Cochrane,
BestBETs, infoPOEMs, Clinical
Evidence Opinion clearinghouses EMA, ACP
Journal Club, EM Reports Paper textbooks
(Rosen's Emergency Medicine, Yanoff's
Ophthalmology) Online textbooks (UpToDate,
eMedicine, Jeff Mann's EM Guidemaps,
ReviewOfOptometry.com) Guidelines - local,
national Local practice Personal
experience
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Management
Textbook Approaches
"The decision to patch a corneal injury is made
on a case-by-case evaluation. Patching of the eye
may slow healing and may increase the rate of
infection and is rarely done. However, it still
may be used briefly for patients with significant
ciliary spasm and photophobia."
"The practice of pressure patching eyes with
corneal epithelial defects has no merit."
Tetanus toxoid recommended
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The Search
Cochrane BestBets EMA
Database infoPOEMs - several articles
I already knew about ACP Journal Club,
Clinical Evidence no relevant info National
Guideline Clearinghouse, Ontario Guidelines
Advisory Committee, ACEP Clinical Policies
Policy Statements, CAEP Policies Guidelines,
GuideEM, Primary Care CPG's. no relevant
info EM Reports - Eye emergencies and Eye
trauma reviews Journal Watch EM - two
articles I already knew about PubMed
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Are topical antibiotics indicated for simple
corneal abrasion?
prevents infection
Recommended by most authorities, many of whom
admit data is lacking
Evidence
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Are topical antibiotics indicated for simple
corneal abrasion?
Petroutsos, G., et al, Arch Ophthalmol
101(11)1775, November 1983. Antibiotics and
Corneal Epithelial Wound Healing.
Alfonso E. Effects of gentamicin on healing of
transdifferentiating conjunctival epithelium in
rabbit eyes. Am J Ophthalmol. 1988 Feb
15105(2)198-202.
Petroutsos G. Int Ophthalmol. 1984 Jun7(2)65-9.
The effect of concentrated antibiotics on the
rabbit's corneal epithelium.
Petroutsos G. Arch Ophthalmol. 1983
Nov101(11)1775-8. Antibiotics and corneal
epithelial wound healing.
Stern GA. Arch Ophthalmol. 1983 Apr101(4)644-7.
Effect of topical antibiotic solutions on corneal
epithelial wound healing.
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Are topical antibiotics indicated for simple
corneal abrasion?
Petroutsos, G., et al, Arch Ophthalmol
101(11)1775, November 1983 Antibiotics and
Corneal Epithelial Wound Healing.
The authors of this controlled French study
evaluated the effect of different concentrations
of antibiotic eyedrops on corneal epithelial
wound healing in rabbit eyes subjected to corneal
wounding. Beginning six hours after wounding,
two drops of each test preparation were instilled
into both eyes of groups of five animals six
times daily. A control group was treated with
saline drops. The remaining animals were treated
with bacitracin (500U/ml or 10,000U/ml),
gentamicin sulfate (3mg/ml or 10mg/ml), neomycin
(3.5mg/ml or 8mg/ml), or chloramphenicol
(4mg/ml). Serial evaluation of healing rates,
indicated that the mean healing rates of animals
treated with saline, chloramphenicol, or the
lower concentrations of bacitracin, gentamicin,
and neomycin did not differ significantly.
However when compared to control eyes, corneal
healing in animals treated with the higher
concentrations of bacitracin, gentamicin, and
neomycin was significantly delayed, although the
delay in animals treated with 10mg/ml gentamicin
and 8mg/ml neomycin was most likely clinically
acceptable. Histological examination of four eyes
from each treatment group four days after
wounding demonstrated that epithelial thickness
in eyes treated with saline, 500U/ml bacitracin,
3mg/ml gentamicin, 3.5mg/ml neomycin, and 4mg/ml
chloramphenicol was similar (three to four
layers). Epithelial thickness in eyes treated
with 10mg/ml gentamicin and 8mg/ml neomycin was
two to three layers. In eyes treated with
10,000U/ml bacitracin, maximum epithelial
thickness was two layers. These data confirm the
toxicity of the 10,000U/ml bacitracin preparation
and demonstrate that healing rate may be
influenced by the concentration of antibiotic
eyedrop solutions.
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Are topical antibiotics indicated for simple
corneal abrasion?
Kruger RA, Higgins J, Rashford S, Fitzgerald B,
Land R . Emergency eye injuries. Aust Fam
Physician. 1990 Jun19(6)934-8.
Accident and Emergency Department, Queen
Elizabeth II Jubilee Hospital, Brisbane,
Queensland. This study analyses all patients
presenting with eye complaints to the casualty
section of a Brisbane Hospital during a one month
period. Eye complaints constituted 3.6 per cent
of all patients. A foreign body was involved in
57 per cent of all eye injuries. The patients
were subject to a trial assessing the
effectiveness of antibiotic treatment following
removal of the foreign body. There was no
significant difference between antibiotic and
placebo (sterile saline). PMID 2248588
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Are topical antibiotics indicated for simple
corneal abrasion?
King JW, Brison RJ. Do topical antibiotics help
corneal epithelial trauma? Can Fam Physician.
1993 Nov392349-52.
Topical antibiotics are routinely used in
emergency rooms to treat corneal trauma, although
no published evidence supports this treatment. In
a noncomparative clinical trial, 351 patients
with corneal epithelial injuries were treated
without antibiotics. The infection rate was 0.7,
suggesting that such injuries can be safely and
effectively managed without antibiotics. A
comparative clinical trial is neither warranted
nor feasible. Department of Surgery, Queen's
University's Faculty of Medicine, Kingston. PMID
8268742
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Are topical antibiotics indicated for simple
corneal abrasion?
Upadhyay, PC. The Bhaktapur eye study ocular
trauma and antibiotic prophylaxis for the
prevention of corneal ulceration in Nepal. Br J
Ophthalmol 200185388392.
AimsTo determine the incidence of ocular trauma
and corneal ulceration in the district of
Bhaktapur in Kathmandu Valley, and to determine
whether or not topical antibiotic prophylaxis can
prevent the development of ulceration after
corneal abrasion. MethodsA defined population
of 34 902 individuals was closely followed
prospectively for 2 years by 81 primary eye care
workers who referred all cases of ocular trauma
and/or infection to one of the three local
secondary eye study centres in Bhaktapur for
examination, treatment, and follow up by an
ophthalmologist. All cases of ocular trauma were
documented and treated at the centres.
Individuals with corneal abrasion confirmed by
clinical examination who presented within 48
hours of the injury without signs of corneal
infection were enrolled in the study and treated
with 1 chloramphenicol ophthalmic ointment to
the injured eye three times a day for 3
days. ResultsOver the 2 year period there were
1248 cases of ocular trauma reported in the
population of 34 902 (1788/100 000 annual
incidence) and 551 cases of corneal abrasion
(789/100 000 annual incidence). The number of
clinically documented corneal ulcers was 558
(799/100 000 annual incidence). Of the 442
eligible patients with corneal abrasion enrolled
in the prophylaxis study, 424 (96) healed
without infection, and none of the 284 patients
who were started on treatment within 18 hours
after the injury developed ulcers. Four of the
109 patients (3.7) who presented 1824 hours
after injury developed infections, and 14 (28.6)
of the 49 patients who presented 2448 hours
subsequently developed corneal ulceration. Conclu
sionsOcular trauma and corneal ulceration are
serious public health problems that are occurring
in epidemic proportions in Nepal. This study
conclusively shows that post-traumatic corneal
ulceration can be prevented by topical
application of 1 chloramphenicol ophthalmic
ointment in a timely fashion to the eyes of
individuals who have suffered a corneal abrasion
in a rural setting. Maximum benefit is obtained
if prophylaxis is started within 18 hours after
injury.
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Are topical antibiotics indicated for simple
corneal abrasion?
prevents infection
expense
resistance
inconvenience
may prevent healing
Recommended by most authorities, many of whom
admit data is lacking
Evidence
Bottom line Lemmings
Erythromycin .5 ointment 1/2 inch ribbon to eye
tid x 3 days
Ointments are universally recommended over drops
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Is patching indicated for corneal abrasion?
Patching has been the standard of care for decades
Evidence
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Is patching indicated for corneal abrasion?
Kaiser, PK. A comparison of pressure patching
versus no patching for corneal abrasions due to
trauma or foreign body removal. Corneal Abrasion
Patching Study Group. Ophthalmology 1995
1021936.
PURPOSE To evaluate the effectiveness of
pressure patching in the treatment of
noninfected, noncontact lens-related traumatic
corneal abrasions and abrasions secondary to
removal of corneal foreign bodies. METHODS Two
hundred twenty-three patients with noninfected,
noncontact lens-related traumatic or foreign body
removal-related corneal abrasions were followed
daily after receiving topical antibiotics and
mydriatics and after being randomized to receive
either a pressure patch or no patch. RESULTS
Twenty-two patients were excluded from the study.
For data analysis, the remaining patients were
split into two sections those with traumatic
corneal abrasions (120 patients) and those with
corneal abrasions secondary to removal of corneal
foreign bodies (81 patients). Patients with
traumatic corneal abrasions healed significantly
faster, had less pain, and had fewer reports of
blurred vision" when they were not wearing a
patch. The amount of photophobia, tearing, and
foreign body sensation were similar between the
patch and no-patch groups. Similarly, for corneal
abrasions due to removal of foreign bodies,
patients healed significantly faster and had less
pain when they were not wearing a patch. There
was no difference in the amount of photophobia,
tearing, foreign body sensation, or blurred
vision. Finally, there was better compliance in
the no-patch group. CONCLUSIONS Noninfected,
noncontact lens-related traumatic corneal
abrasions as well as abrasions secondary to
foreign body removal can be treated with
antibiotic ointment and mydriatics alone without
the need for a pressure patch. Massachusetts Eye
and Ear Infirmary, Harvard Medical School, Boston
02114, USA. PMID- 9098299
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Is patching indicated for corneal abrasion?
Flynn, CA, D'Amico, F, Smith, G. Should we patch
corneal abrasions? A meta-analysis. J Fam Pract
1998 47264
BACKGROUND Eye patching is commonly recommended
for treating corneal abrasions. This advice seems
based more on anecdotes or disease-oriented
evidence theorizing that there is faster healing
or less pain when the eye is patched. This
meta-analysis was performed to determine if eye
patching is a useful treatment for corneal
abrasions. METHODS We conducted a comprehensive
search of both MEDLINE (1966 to 1997) and Science
Citation Index to locate relevant articles. We
reviewed the bibliographies of included studies,
and ophthalmology and primary care texts. Local
ophthalmologists and authors were contacted to
identify any unpublished data. Controlled trials
that evaluated eye patching compared with no
patching in patients older than 6 years with
uncomplicated corneal abrasions were considered.
The outcomes of interest were healing rates and
degree of pain. RESULTS Seven trials were
identified for inclusion, of which five could be
statistically combined. Healing rates were
similar in the two groups. The summary ratios
(95 confidence interval) of healing rates in the
patch group as compared with the no-patch group
were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10)
at days 1 and 2, respectively. Six studies
evaluated pain four found no difference and two
favored not patching. No differences in
complication rates were noted between the patched
and nonpatched groups. CONCLUSIONS Eye patching
was not found to improve healing rates or reduce
pain in patients with corneal abrasions. Given
the theoretical harm of loss of binocular vision
and possible increased pain, we recommend the
route of harmless nonintervention in treating
corneal abrasions. Medical College of Wisconsin,
Waukesha, USA. PMID- 9789511
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Is patching indicated for corneal abrasion?
Flynn, CA, D'Amico, F, Smith, G. Should we patch
corneal abrasions? A meta-analysis. J Fam Pract
1998 47264
Should we patch corneal abrasions a
meta-analysis (Structured abstract) NHS Centre
for Reviews and Dissemination (2000)
This review was clearly written and presented.
Aims and inclusion criteria were stated. Results
from two independent literature searches were
compared. Relevant information on the included
studies was presented in tabular format. Validity
criteria were defined and results from the
validity assessment and the meta-analysis clearly
tabulated. Details were given of methods used to
assess validity and statistical heterogeneity
assessed and clinical heterogeneity reviewed. The
discussion includes consideration of the
following limitations of the review small number
of studies with small number of participants the
inability to combine all studies statistically
potential for publication bias and inter study
variations including cause and size of abrasion,
setting, and methods used for evaluation of
healing. By limiting the search to English
language studies identified in one database,
albeit with advice sought from experts, some
other relevant studies may have been omitted. No
details were given of methods used to select
primary studies or extract data and validity was
assessed by only one reviewer. The authors
conclusions were supported by the evidence
presented, though more details of methods used in
the review and the use of more than one
researcher to assess validity would improve the
quality of the review.
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Is patching indicated for corneal abrasion?
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Is patching indicated for corneal abrasion?
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Is patching indicated for corneal abrasion?
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Is patching indicated for corneal abrasion?
LeSage, N., et al, Ann Emerg Med 38(2)129,
August 2001. Efficacy of Eye Patching for
Traumatic Corneal Abrasions A Controlled Trial.
BACKGROUND Corneal abrasions generally heal
within several days. Eye patching is commonly
used in these patients based on the belief that
it reduces discomfort and might accelerate
healing. However patching impairs vision and may
foster conditions for the development of
infection. Several small and unblinded studies
have not reported that patching is beneficial (or
harmful). METHODS In this single-blind,
prospective study, from Laval University in
Quebec, 163 patients presenting to the ED with a
traumatic corneal abrasion were randomized to
patching or no patching treatment groups.
Additional treatment included application of
erythromycin ointment, with or without mydriatic
agents and/or opioid analgesics at the discretion
of the managing physician. On serial follow-up
visits, patients were evaluated by a clinician
blinded to group assignment RESULTS There were
no differences between the groups in the
cumulative rate of healing or reduction of
discomfort over time in the total study group or
In subgroups of patients with or without a
corneal foreign body, or with greater or lesser
degrees of initial pain. Rates of healing in the
patched and non-patched group were 51 and 60
after 24 hours, and 92 and 88 respectively,
after three days. Median discomfort scores on a
12cm visual analogue scale were 6.0 and 5.7 in
the patched and non-patched groups on
presentation, and 4.7 and 3.7, respectively
during the first 24 hours, indicating that both
groups experienced substantial discomfort during
this period CONCLUSIONS These results confirm
that patching has no apparent benefit (or harm)
in patients with a traumatic corneal abrasion,
and suggest that greater attention should be
focused on effective methods of relieving early
discomfort.
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Is patching indicated for corneal abrasion?
Michael JG. Management of corneal abrasion in
children a randomized clinical trial Annals of
Emergency Medicine July 2002
STUDY OBJECTIVE We compare percentage of
healing, comfort, and complications in children
with corneal abrasions treated with an eye patch
versus no eye patch. METHODS We performed a
randomized clinical trial of patients aged 3 to
17 years who were diagnosed with isolated corneal
abrasion. Patients were randomly assigned to an
eye patch or no patch group. Abrasion size was
documented with digital photographs and/or an eye
template diagram at presentation and at 20- to
24-hour follow-up examination. A reviewer masked
to treatment group determined percent healing by
measuring presentation and follow-up abrasion
sizes on the photographs/template. At follow-up,
interference with activities of daily living
(ADL) was measured with a visual analog scale and
the number of pain medication doses taken since
presentation was recorded. RESULTS A total of
37 patients were enrolled 17 with an eye patch
and 18 with no eye patch. The mean patient age
was 10 years, and two thirds of the patients were
male. The majority (86) of patients had 95 or
more healing at follow-up, and there was no
significant difference in percent healing between
the 2 groups, even when adjusted for age and
initial abrasion size (95 confidence interval
CI for the difference in means -11 to 8 and -13
to 5, respectively). There was no difference
between groups for number of pain medication
doses required. Among measurements of
interference with ADL, only the difficulty
walking score was found to be significantly
different between groups (patch mean 1.7 cm SD
2.1 cm versus no patch mean 0.3 cm SD 0.7 cm
95 CI for the difference in means 0.3 to
2.5). CONCLUSION This study suggests that eye
patching in children with corneal abrasions makes
no difference in the rate of healing. There was
no difference in discomfort and interference with
ADL, other than greater difficulty walking in the
patch group, and there were no complications in
either group.
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Is patching indicated for corneal abrasion?
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Is patching indicated for corneal abrasion?
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Is patching indicated for corneal abrasion?
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Cochrane Review in progress Expected publication
Second quarter 2005 Angus Turner
About the larger abrasions... I have not found
any study that specifically looks at the larger
ones. Kaiser 1995 does divide the patients into
two groups... those with large abrasions don't
have any significant differences with patch or no
patch... however, the numbers are small and
lacking the power to detect any difference. So,
it seems to me, there is no evidence as to what
we should do for a large abrasion. In my limited
personal experience for what it is worth, I have
found contact bandage lenses to really help
patients with large abrasions.
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Is patching indicated for corneal abrasion?
relieves pain
promotes healing
discomfort
loss of vision/depth perception
may conceal symptoms of disease progression
retards healing
increases risk of infection
Patching has been the standard of care for decades
Evidence
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Is cycloplegia indicated for corneal abrasion?
relieves pain
Evidence
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Is cycloplegia indicated for corneal abrasion?
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Is cycloplegia indicated for corneal abrasion?
Brahma AK. Topical analgesia for superficial
corneal injuries Journal of Accident and
Emergency Medicine 1996 May 13(3)186-8
Royal Eye Hospital, Manchester, United Kingdom.
OBJECTIVE To assess the analgesic effects of a
topical non-steroidal anti-inflammatory agent,
flurbiprofen 0.03, during healing after
superficial corneal injuries. METHODS 401
patients treated for corneal abrasion in a five
month period were randomly allocated to one of
four treatment groups polyvinyl alcohol alone
(control), homatropine 2, flurbiprofen 0.03, or
homatropine 2 followed by flurbiprofen 0.03.
Treatments were given for 48 h. Ocular pain was
recorded on a visual analogue scale by the
patients over the first 24 h, and use of oral
analgesics was also recorded. Usable responses
were received from 224 patients (55.8).
RESULTS Patients treated with flurbiprofen
had significantly lower pain scores for the 24 h
duration of the study than controls (P lt 0.05).
CONCLUSIONS Flurbiprofen eye drops provide
more effective pain relief than traditional
treatments for superficial corneal injuries.
PMID 8733656 PubMed - indexed for MEDLINE
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Is cycloplegia indicated for corneal abrasion?
relieves pain
glare
blocks accomodation
acute angle closure glaucoma
Bottom line
No evidence for cycloplegia, weak evidence
against it
Does the patient have ciliary spasm?
If ciliary spasm, two drops cyclopentolate or
homatropine in the ED x 1
No scopolamine, atropine, or phenylephrine
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Is topical analgesia indicated for corneal
abrasion?
relieves pain
Jean Coutu sells diclofenac eye drops (Voltaren
Ophthalmic) 2.5 ml for 14. Dose is one drop
qid. 1 ml
16 drops, so 2.5 ml 40 drops more than enough.
Evidence
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Is topical analgesia indicated for corneal
abrasion?
WEAVER, C.S., et al, Annals of Emerg Med
41(1)134, January 2003. Do Ophthalmic NSAIDs
Reduce The Pain Associated With Simple Corneal
Abrasion Without Delaying Healing?
METHODS The authors, from Indiana University
School of Medicine conducted an updated review of
the use of ophthalmic NSAIDs in patients with
corneal abrasions that involved five randomized
controlled trials (397 patients) published
between 1997 and 2001 RESULTS The ophthalmic
NSAID regimens studied included ketorolac 0.5
instilled four times daily, diclofenac 0.1
instilled four to six times daily, or
indomethacin 0.1 combined with gentamicin
instilled four times daily. The duration of
treatment was variable, ranging from 24 hours to
five to six days. Differences between the trials
in the timing and methods of assessing pain
reduction precluded statistical pooling of
results. All of the trials reported reduced pain
intensity with ophthalmic NSAID formulations of
variable clinical and statistical significance.
Of three studies that employed a 10cm visual
analogue scale, only two reported a difference
between the active treatment and control groups
of a magnitude previously noted to be clinically
important (i.e., a change of 1.3cm). Two of three
studies reporting on use of supplemental
analgesics found decreased use among patients
treated with ophthalmic NSAIDs and one study
reported earlier return to work. CONCLUSIONS
Although the data appear to support the use of
ophthalmic NSAIDs to relieve the pain of corneal
abrasions, the authors acknowledge the higher
cost of these agents compared with oral
analgesics. They suggest that the most likely
candidates for such treatment may be patients who
can afford ophthalmic NSAIDs, who might poorly
tolerate the side effects of oral opioids and who
must return to work immediately.
84
Is topical analgesia indicated for corneal
abrasion?
relieves pain
expensive
retards healing
Jean Coutu sells diclofenac eye drops (Voltaren
Ophthalmic) 2.5 ml for 14. Dose is one drop
qid. 1 ml 16 drops, so 2.5 ml 40 drops more
than enough.
Evidence
Bottom Line
Topical NSAIDs are safe and effective
85
Applying the Patch
Two gauze eye pads and three strips of tape are
required for patching. Antibiotic ointment is
applied to the eye by instilling a small amount
(1/2" to 1" ribbon) in the inferior cul-de-sac.
One pad is folded in half. The patient is asked
to close both eyes gently. There should be no
squeezing of the orbicularis muscles. The folded
patch is used to occupy the space over the globe
in the orbit and apply pressure to the globe. The
second pad is then placed over the folded pad.
The patient or an assistant is asked to apply
firm pressure to the second pad, while it is
being taped firmly with the three strips of tape.
These strips are most effective if place
obliquely from the midline over the nose toward
the cheekbone. The patient is then asked to open
the eyes and report if the lid under the patch
can be raised. If it can then the patch has not
been applied successfully and must be redone. The
patch is left in place overnight, and no more
than 24 hours. A patch that is worn too long may
interfere with the diagnosis of infection because
the patient cannot monitor vision and discharge.
86
Applying the Patch
87
Applying the Patch
There is no role for a "pirate's patch" in the
treatment of corneal abrasions.
88
Bandage Contact Lens
Donnenfeld ED, Selkin BA, Perry HD, Moadel K,
Selkin GT, Cohen AJ, Sperber LT. Controlled
evaluation of a bandage contact lens and a
topical nonsteroidal anti-inflammatory drug in
treating traumatic corneal abrasions
Ophthalmology. 1995 Jun102(6)979-84.
BACKGROUND Treating traumatic corneal abrasions
is a common problem for the ophthalmologist.
Traditional management has been the use of a
pressure patch. Three different therapeutic
modalities were evaluated for their efficacy in
treating traumatic corneal abrasions. METHODS
Forty-seven consecutive patients with traumatic
corneal abrasions were randomized prospectively
in a single-masked, controlled clinical trial
which compared the efficacy of (1) pressure
patching, (2) a bandage contact lens, and (3) a
bandage contact lens with a topical nonsteroidal
anti-inflammatory drug (0.5 ketorolac
tromethamine). RESULTS There was no
significant difference in the healing time of the
three groups. However, psychometric analysis
showed a significant decrease in pain in the
group that received a bandage contact lens with a
topical nonsteroidal anti-inflammatory drug.
There was a significant difference in the ability
to return to normal activities in both contact
lens groups compared with the pressure-patch
group. There was no significant difference among
the three groups with respect to photophobia,
redness, ocular irritation, headache, or tearing.
CONCLUSION Use of a bandage contact lens
significantly shortens the time required for a
patient to return to normal activities. Moreover,
addition of a nonsteroidal anti-inflammatory drug
to a treatment regimen significantly decreases
the pain associated with traumatic corneal
abrasions. Use of a bandage contact lens with a
topical nonsteroidal anti-inflammatory may prove
to be an effective adjunct in treating traumatic
corneal abrasions.
89
algorithm
90
Gratitude
Jake Moore
David Lederer
Deanna Cowan
Survey Respondants
Tereska Gesing
Jerry Dankoff
Paula Arruda
Danielle Bader
Elliot Perlman
Angus Turner