Corneal abrasion is a superficial disruption of the corneal epithelium, most commonly caused by fingernails, foreign bodies, contact lenses, or direct trauma. It is the most common eye injury presenting to emergency departments and the second most common ocular diagnosis in primary care. [1-2] Most simple abrasions heal within 24–48 hours. [3-4]
1. History
- Mechanism of injury: fingernail, foreign body (metal, wood, sand), contact lens, direct blow, tree branch, wind-blown debris
- Timing: when did the injury occur? (>2 days at presentation = complicated) [5]
- Symptom characterization: acute onset eye pain, foreign body sensation, tearing, photophobia, blepharospasm, blurred vision [1-2]
- Contact lens use: type, duration of wear, sleeping in lenses, recent change in brand — critical for infection risk stratification [1]
- Occupational exposure: grinding, welding, construction (metallic foreign bodies, UV exposure)
- Prior episodes: recurrent erosion syndrome presents with spontaneous pain on awakening without clear trauma [4]
- Important negatives: chemical or thermal exposure, high-velocity projectile (raises concern for penetrating injury), hammering metal on metal (intraocular foreign body)
2. Alarm Features
- Irregular or teardrop-shaped pupil → open globe injury [6]
- Positive Seidel test (streaming fluorescein) → corneal perforation
- Significant vision loss not improving with blinking [3]
- Hypopyon (layered white cells in anterior chamber) → infectious keratitis/endophthalmitis
- Corneal infiltrate or white opacity → microbial keratitis [7]
- High-velocity mechanism (hammering, grinding) → intraocular foreign body, open globe
- Pain dramatically out of proportion to findings → Acanthamoeba keratitis [7]
- Worsening symptoms after 24–48 hours despite treatment [3]
- Deep corneal epithelial defects → emergent ophthalmology evaluation [6]
3. Medications
Recommended treatments
- Topical antibiotics (prophylactic): erythromycin 0.5% ointment q8h, or polymyxin B/trimethoprim drops QID [5-6]
- Contact lens–related abrasions: use antipseudomonal coverage — fluoroquinolone drops (ciprofloxacin, ofloxacin, moxifloxacin) or aminoglycosides [1][3]
- Topical NSAIDs (strong evidence for pain reduction): ketorolac 0.5% q6–8h or diclofenac 0.1% QID — reduces pain at 24 and 48 hours and decreases oral analgesic use by ~53% [6][8]
- Oral analgesics: ibuprofen, acetaminophen, or combination; opioids rarely needed [5]
- Topical anesthetics (for home use): ACEP Level B recommendation — proparacaine or tetracaine q30min PRN for up to 24 hours, dispense no more than 1.5–2 mL, discard remainder after 24 hours [5]
- Artificial tears: frequent use for comfort [6]
- Cycloplegics (e.g., homatropine 2%, cyclopentolate 1%): may help with ciliary spasm in large abrasions, though evidence for uncomplicated abrasions is limited [6][8]
Contraindicated/Cautions
- Topical steroids: avoid — risk of delayed healing, elevated IOP, and masking infection
- Pressure patching: no longer recommended — does not improve pain and may delay healing [3][8]
- Prolonged topical anesthetic use (>24 hours): risk of corneal epithelial toxicity [2][6]
4. Diet
- No specific dietary modifications are required for corneal abrasion
- Adequate hydration supports general healing
- If oral NSAIDs are used, take with food to minimize GI side effects
5. Review of Systems
- Ophthalmologic: visual acuity changes, photophobia, discharge (purulent = infection), floaters or flashes (retinal pathology)
- ENT: concurrent facial trauma, sinusitis (orbital complications)
- Neurologic: headache (can accompany corneal abrasion), diplopia (orbital injury)
- Dermatologic: periorbital vesicles (HSV/VZV — herpetic eye disease is a complicating feature) [5]
- Systemic: fever, immunosuppression (increased infection risk)
6. Collateral History and Family History
- Collateral: witnesses to mechanism (especially in children, elderly, or altered patients); workplace safety officer for occupational injuries
- Family history: corneal dystrophies (e.g., epithelial basement membrane dystrophy) predispose to recurrent erosions [5]
- Social context: domestic violence screening if mechanism inconsistent with injury; child abuse consideration in pediatric cases with unexplained eye injuries
7. Risk Factors
- Contact lens wear — most important risk factor for microbial keratitis in the US [1]
- Occupational hazards: construction, metalworking, agriculture, woodworking (especially without eye protection)
- Sports and recreation: racquet sports, paintball, water sports
- Dry eye disease / blepharitis: impaired epithelial integrity
- Epithelial basement membrane dystrophy: predisposes to recurrent erosions [2][5]
- Immunosuppression: increased risk of secondary infection
- Prior corneal surgery or transplant [5]
- Pediatric age group: most common eye injury in children [1]
8. Differential Diagnosis
- Corneal foreign body (retained) — must evert lids and examine carefully; rust ring may remain after metallic FB removal
- Open globe / penetrating injury — irregular pupil, shallow anterior chamber, positive Seidel test; cannot-miss diagnosis
- Infectious keratitis (bacterial, fungal, Acanthamoeba, viral) — corneal infiltrate, hypopyon, pain out of proportion [7]
- Herpes simplex keratitis — dendritic ulcer on fluorescein staining; history of recurrent episodes
- Corneal ulcer — deeper defect with stromal involvement, white infiltrate
- UV keratitis (photokeratitis / welder's flash) — bilateral punctate staining, history of UV exposure 6–12 hours prior [5]
- Recurrent corneal erosion syndrome — spontaneous pain on awakening, history of prior abrasion [2][4]
- Acute angle-closure glaucoma — red eye, mid-dilated fixed pupil, elevated IOP, halos
- Iritis / anterior uveitis — photophobia, consensual pain, cells/flare in anterior chamber
- Conjunctivitis — diffuse injection, discharge, typically less pain
9. Past Medical History
- Prior corneal abrasions or recurrent erosions
- History of herpetic eye disease (HSV/VZV) — complicates management [5]
- Prior corneal surgery, LASIK, PRK, or corneal transplant
- Corneal dystrophies
- Autoimmune/connective tissue disease (rheumatoid arthritis, lupus — risk of peripheral ulcerative keratitis) [7]
- Diabetes (impaired corneal healing)
- Immunosuppression (HIV, transplant, chemotherapy)
- Dry eye disease, Sjögren syndrome
10. Physical Exam
- Visual acuity: document in each eye before and after treatment — essential medicolegal step
- External inspection: periorbital ecchymosis, lid laceration, proptosis, enophthalmos
- Pupil exam: shape (teardrop = open globe), reactivity, RAPD (optic nerve injury)
- Slit-lamp examination: gold standard — assess size, depth, and location of epithelial defect; look for Seidel sign, anterior chamber cells/flare, infiltrate, hypopyon [1]
- Fluorescein staining: abrasion appears yellow under white light, green under cobalt blue/Wood's lamp [3]
- Lid eversion: mandatory to rule out subtarsal foreign body (vertical linear abrasions = classic clue for retained FB under upper lid)
- IOP measurement: if open globe not suspected; elevated IOP suggests glaucoma
- Fundoscopic exam: if concern for posterior segment injury
11. Lab Studies
- Routine labs are not indicated for simple corneal abrasions
- Corneal cultures: obtain if infectious keratitis is suspected (corneal infiltrate, hypopyon, contact lens–related ulcer, worsening despite antibiotics) [7]
- Gram stain and culture of corneal scraping: for complicated or non-healing ulcers
12. Imaging
- Not routinely needed for simple corneal abrasions
- CT orbits (without contrast): if concern for intraocular foreign body (especially metallic — high-velocity mechanism, hammering metal on metal)
- Avoid MRI if metallic intraocular foreign body is suspected
- B-scan ultrasound: if posterior segment cannot be visualized (vitreous hemorrhage, concern for retinal detachment) — avoid if open globe suspected
- X-ray orbits: less sensitive than CT but can screen for radiopaque foreign bodies
13. Special Tests
- Seidel test: apply fluorescein over suspected perforation site — streaming of aqueous diluting the dye = positive (open globe) [6]
- Fluorescein staining with cobalt blue light: diagnostic for epithelial defect [3]
- Lid eversion: essential maneuver to detect subtarsal foreign body
- Tonometry: measure IOP if no concern for open globe
- Point-of-care ultrasound (POCUS): can identify lens dislocation, vitreous hemorrhage, retinal detachment in trauma; avoid direct pressure if open globe suspected
14. ECG
- Not applicable for isolated corneal abrasion
- Consider if polytrauma or if systemic analgesics (e.g., opioids) are administered in patients with cardiac risk factors
15. Assessment
Simple corneal abrasion (per ACEP definition): superficial epithelial defect, not unduly large, without complicating features (no penetration, no infection, no retained FB, no chemical/thermal cause, no underlying corneal pathology, no herpetic history, no recent ocular surgery). [5]
Complicated corneal abrasion: any of the above complicating features present — requires closer follow-up and often ophthalmology involvement.
Most simple abrasions heal within 24–48 hours without sequelae. [3-4] Complications to consider:
- Infectious keratitis (most serious complication, especially in contact lens wearers) [1]
- Recurrent corneal erosion (can develop weeks to months after initial injury) [2]
- Corneal scarring (deeper injuries, especially central — may impair vision permanently) [2]
- Traumatic iritis
16. Treatment Plan
Initial stabilization
- Irrigate the eye with normal saline or clean water to remove debris [9]
- Instill topical anesthetic (proparacaine 0.5%) for examination
- Remove any foreign body; evert lids to check for subtarsal FB
- Remove rust ring if present (may defer to ophthalmology if deep)
Pharmacologic management
Do NOT patch — no benefit and may delay healing. [3][8]
Bandage contact lens: option for larger abrasions — must use with concurrent antibiotic drops, remove within 24–48 hours, and ensure no retained foreign body. [6]
17. Disposition
Discharge criteria (most patients)
- Small (≤4 mm), uncomplicated abrasion
- Normal or near-normal visual acuity
- No complicating features
- Reliable patient with access to follow-up [3]
Ophthalmology consultation / referral indications
- Large or central abrasions
- Corneal infiltrate or ulcer
- Significant vision loss
- Suspected open globe or penetrating injury (emergent) [3][6]
- Retained deep foreign body or rust ring
- Herpetic eye disease
- Worsening symptoms despite 24–48 hours of treatment
- Recurrent erosion syndrome
Admission: rarely needed — consider for open globe injuries requiring surgical repair or severe bilateral injuries
18. Follow Up / Return Precautions
Follow-up timing
- Small (≤4 mm), uncomplicated abrasions with normal vision and improving symptoms: follow-up may not be necessary [3]
- All other patients: re-evaluate in 24 hours [3]
- Contact lens–related abrasions: 24-hour follow-up recommended given infection risk
Return precautions — instruct patients to return immediately for:
- Worsening pain or pain not improving after 24–48 hours
- Decreased vision
- Increasing redness or purulent discharge
- Sensitivity to light that worsens
- White spot on the cornea
Patient counseling
- Do not rub the eye
- Do not wear contact lenses until fully healed and cleared by a provider (typically ≥1 week)
- Wear protective eyewear for future at-risk activities
- Discard any dispensed topical anesthetic after 24 hours [5]
- Most abrasions heal within 24–48 hours; expect gradual improvement in pain and foreign body sensation [3-4]
References
1. Antibiotic Prophylaxis for Corneal Abrasion. — Ng SM, Leslie L, Tzang CC, et al. The Cochrane Database of Systematic Reviews. 2025.
2. Topical Non-Steroidal Anti-Inflammatory Drugs for Analgesia in Traumatic Corneal Abrasions. — Wakai A, Lawrenson JG, Lawrenson AL, et al. The Cochrane Database of Systematic Reviews. 2017.
3. Evaluation and Management of Corneal Abrasions. — Wipperman JL, Dorsch JN. American Family Physician. 2013.
4. Corneal Abrasions: Diagnosis and Management. — Torok PG, Mader TH. American Family Physician. 1996.
5. Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines From the American College of Emergency Physicians. — Green SM, Tomaszewski C, Valente JH, Lo B, Milne K. Annals of Emergency Medicine. 2024.
6. Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update. — Paterson R, Drake B, Tabin G, Cushing T. Wilderness & Environmental Medicine. 2024.
7. Bacterial Keratitis Preferred Practice Pattern®. — Rhee MK, Ahmad S, Amescua G, et al. Ophthalmology. 2024.
8. Topical Pain Control for Corneal Abrasions: A Systematic Review and Meta-Analysis. — Yu CW, Kirubarajan A, Yau M, Armstrong D, Johnson DE. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2021.
9. Topical Ophthalmic Anesthetics for Corneal Abrasions. — Sulewski M, Leslie L, Liu SH, et al. The Cochrane Database of Systematic Reviews. 2023.