Size, severity of injury, level of pain determine treatment for corneal abrasion

Determining the best treatment for a corneal abrasion depends on many factors, such as the severity of the injury and the degree of pain the patient is experiencing. But practitioners also must take into consideration the location of the abrasion, symptoms the patient may be exhibiting and how the incident occurred. “You must consider whether it was simply a scratch or a shearing injury that actually tore the epithelium away from the underlying basement membrane,” said William D. Townsend, OD, in private group practice in Canyon, Texas. “Was it caused by a plant-type material where you have to worry about a fungal infection later?”

Patients experience pain differently

---These multiple abrasions were caused by a foreign body that had become trapped under the eyelid.

The level of pain, as well, figures into the treatment plan, he said. Moreover, pain affects everyone differently, so pain management must be tailored to each individual. “You can have two patients with essentially identical wounds or injuries, and yet one person will be complaining that he or she is in horrible pain, while the other will say that it only hurts a little bit,” he said. “It’s important to understand that pain is individual. When you’re trying to manage the pain associated with corneal abrasion, you need to design your pain management based on the patient’s pain rather than the patient’s injury.”

Any symptoms that a patient may display also helps decide the course of treatment, said Louise Sclafani, OD, director of optometric services and contact lenses and refractive surgery at the University of Chicago department of ophthalmology. “If a patient is having a lot of sensitivity to light or excessive lacrimation, I would treat him or her differently from someone who has a small abrasion and is not very symptomatic,” she said. “It also depends on the location of the injury. If it’s central, I might be more aggressive in the treatment than if it’s peripheral.”

Abrasions from refractive surgery

---This burn and abrasion were caused by hot metal propelled into the patient’s cornea during an industrial accident.

As the demand for refractive surgery grows, practitioners are more likely to see different types of corneal abrasions stemming from a surgical procedure.

“In a sense, refractive surgery has reawakened our interest in treating corneal abrasions because many postrefractive surgery patients end up with some mild degree of what we could consider an abrasion,” said Robert M. Grohe, OD, director of contact lens services at Northwestern University Medical School in Chicago. “Photorefractive keratectomy can cause a fairly substantial epithelial defect, which clearly goes beyond just an abrasion. In laser in situ keratomileusis, even though there isn’t a massive area of open abrasion, there are peripheral areas of the cornea where the flap edge may exhibit a circumferential pattern of superficial punctate keratitis, adjacent to the microkeratome cut. I think a lot of us have reacquainted ourselves with this in terms of refractive surgery offering unusual, created abrasions that do not always completely heal.”

Treating mild abrasions

First, evaluate the cornea, and determine if the problem is confined to the cornea or if there is an anterior chamber reaction as well, said Dr. Grohe. “That’s important, because if there is an anterior chamber reaction, we’d want to add cycloplegia to the mix of treatment,” he said. “If that has been ruled out initially, and as long as the patient is not in a lot of pain, we would probably start him or her on an antibiotic such as Tobrex (tobramycin, Alcon) or Polytrim (trimethoprim sulfate, polymyxin B sulfate, Allergan) four times a day for 5 to 7 days.”

For a relatively minor noncontact lens abrasion, patients may complain of a foreign-body sensation. Evert the upper lid to check for any foreign bodies, recommended Dr. Townsend, and examine the margins of the injury to see if they are clean or if flap removal may be necessary.

“If there’s just a straight abrasion, not a flap, the next thing we look at is the anterior chamber. We want to know if there are cells and/or flare,” he said. “There is usually some degree of anterior chamber activity associated with corneal abrasion.”

Treating/preventing infection

Dr. Townsend recommended using an antibiotic for 4 to 5 days to help guard against infection. For a small abrasion less than 1 mm in size, Dr. Sclafani suggested using highly viscous lubricants such as Celluvisc (carboxymethylcellulose, Allergan) or GenTeal (hydroxypropyl methylcellulose, CIBA Vision) every few hours. For those wearing contact lenses, she said, use Polytrim to guard against infection.

Using prophylactic ointments and nonsteroidal drops will improve the patient’s comfort as well as help prevent infection, said Linda Casser, OD, associate dean for academic programs at the Pacific University College of Optometry. “Ointments provide some cushioning to the cornea and help with comfort,” she said. “Depending upon the size and level of discomfort, I may or may not cycloplege the patient. Certainly, the availability of nonsteroidal drops for a day or two while the lesion is healing has really proven to be very helpful in the management of these patients.”

Mild abrasions do not usually necessitate a follow-up visit for a few days, the practitioners said.

Moderate to severe abrasions

More serious abrasions stem from more linear cuts, such as fingernail injuries and paper cuts, said Dr. Townsend, when the epithelium is ripped from the base of the membrane. “Then you need to do everything you can to prevent a recurrent erosion,” he said.

“In an injury like that, you usually have loose margins, so we would examine the margins,” Dr. Townsend continued. “We use a Kimura spatula to clean away the debris and loose tissue until we reach the place where the tissue is firmly attached. We’ll instill topical Voltaren (diclofenac sodium, CIBA Vision) or Acular (ketorolac tromethamine, Allergan), because it helps prevent further pain. In pain management, you really cannot overestimate the value of pretreating with topical nonsteroidals. It’s much easier to prevent the escalation of pain than to bring it down.” Using cold packs also helps slow the transmission of pain through the nerve fibers and reduce edema, he said.

To alleviate anterior chamber activity, Dr. Townsend recommends dilating with homatropine 2.5% or 5%. He recommended using a nontoxic, broad-spectrum antibiotic, such as Polytrim, three times a day on the inflamed eye to prevent infections. Dr. Grohe also uses Polytrim or Tobrex for more moderate abrasions, which measure more than 1 mm in length or circumference, every 2 hours for 2 days and then four times a day for 5 days. A few drops of Cyclogyl (cyclopentolate HCl, Alcon), he said, on the first day will provide pain relief.

If an abrasion is large in diameter, such as 2 mm or greater, Dr. Grohe prefers to have a patient use a fluoroquinolone, such as Ocuflox (ofloxacin, Allergan), and treating it as a possible ulcer.

When the large abrasion is central in location, within the visual axis, clinicians may wish to comanage with a cornea specialist if some healing is not evident within 24 hours.

Applying a bandage lens

A bandage contact lens is often applied after a corneal abrasion occurs, particularly when the abrasion is more serious. Dr. Sclafani evaluates the symptoms the patient is experiencing when deciding to use a bandage lens. “If the patient has difficulty functioning, is tearing a lot, is having a lot of blepharospasm, is continually blinking and is causing more shearing effects of the abrasion, then I’m going to use a bandage contact lens,” she said. “My preference is an Acuvue 9.1 (Vistakon, Jacksonville, Fla). It’s a larger lens; I want it to tuck underneath the lid margin. Although it’s a little looser than an 8.4, usually the conjunctiva is a little tight anyway, so the lens fits snugly, and there isn’t too much movement. Generally, before I put the lens in, I give patients some 5% homatropine, and, depending on how sensitive they are, I might even prescribe it for them to take at home.”

The lens will remain on the eye until the patient is seen the next day, said Dr. Casser, at which time it will be determined whether the cornea requires more time with the lens on. “Depending on the appearance of the cornea, I may remove the lens, the lens may stay in place for another day or I may change it, depending on the healing process,” she said.

Bandage lenses have shown some success with postrefractive surgery patients in his practice, said Dr. Grohe, but are not always necessary and sometimes can present problems. “Part of the time, they get rubbed out of the eye,” he said. “Part of the time, nothing happens and part of the time, debris gets trapped beneath the lens. The last scenario is of greatest concern, which is why it’s better to make sure the patient stays within the viewing area on a daily basis until that’s resolved.”

Irrigation of the eye helps reduce this risk, Dr. Sclafani said.

A safe and soothing alternative to a bandage lens is the aggressive use of daytime lubricating drops such as GenTeal (CIBA Vision) every hour, followed by bedtime instillation of Celluvisc (Allergan).

Preventing recurrent erosion

While monitoring the cornea for signs that the tissue is healing, Dr. Casser suggests prescribing a bland lubricating ointment for 6 to 8 weeks to reduce the potential for recurrent erosion, or a hypertonic ointment, depending on the appearance of the cornea. Dr. Townsend prescribes the hyperosmotic agent Muro 128 ointment (sodium chloride, Bausch & Lomb) every night, in addition to a daily hypertonic drop, for 60 days.

“If you can prevent a recurrent erosion, you’ve done the patient a huge service, and you’re doing yourself a huge service as well,” he said. “If the patient develops a recurrent erosion, then you’ve got a problem that can last a lifetime. Many of these people end up having to undergo laser procedures or corneal stromal micropuncture. So if you can prevent that by simply keeping the patient on a hypertonic saline ointment for at least 60 days, you’re doing him or her a big favor.”

Unresolved corneal erosions present a challenge in terms of treatment, Dr. Grohe noted. “These patients are like a long-lost relative that comes to visit; they tend to hang around and have an indefinite time course.”

Should you pressure patch?

The practitioners agreed that they rarely patch a patient with a corneal abrasion due to the high risk of infection. “If the patient is a contact lens wearer, we definitely don’t patch, because there is a risk of superinfection under the patch that, even with the application of antibiotic ointment, may not heal,” Dr. Casser said. “The standard is to no longer proceed with a pressure patch; we’ve realized through studies in the past 4 to 5 years that we may be causing more problems than we’re solving with the patch.”

Dr. Casser said that on certain occasions, such as when patients have a very large abrasion or a large, recurrent erosion, she will patch the eye along with performing cycloplegia and prescribing a nonsteroidal drop and antibiotic ointment. “If I choose to pressure patch a recurrent erosion, I may even apply a hypertonic ointment along with the patch,” she said. “It helps with some of the epithelial edema.”

A patch may serve the special needs of children or older adults who may be rubbing their eyes a lot, said Dr. Sclafani. Also, she said, excessive lacrimation may hinder the ability of a bandage lens to stay on the cornea.

Excessive pain when blinking would indicate the use of a patch, said Dr. Grohe, with the maximum amount of wearing time being just 1 day. “With these types of patients, we have an obligation to keep their files handy and call them within 24 hours if they have not returned,” he said. “They must be pursued until you’re satisfied that they’re healed.”

Follow-up for serious abrasions

No matter how many follow-up visits a practitioner requires of a patient, it is important to convey that the patient should not hesitate to call or come into the office if a complication arises.

“Patients need to be aware that we are there, 24 hours a day, 7 days a week, and that they should call if they have any sense that something isn’t right or if things are getting worse,” advised Dr. Grohe. “Some patients will feel awkward or reluctant to call practitioners. If we’re proactive and mention that we want them to call if things are not going well, then patients are more likely to call us if things change for the worse. That helps both of us, because it’s not in the practitioner’s interest to have this injury progress to the point where it gets out of control. Then, it’s a very difficult situation to treat.”

The practitioners agreed that follow-up for severe abrasions should be in 24 hours. After that point, it depends on the size of the abrasion, pain that the patient is experiencing and the rate of healing. “I follow the patient on a daily basis until I’m sure that his or her corneal epithelium covers the lesion and there is no infection,” said Dr. Townsend. “When patients develop recurrent corneal erosion, it is important that certain steps be followed to reduce the risk of future episodes of erosion. The literature suggests that keeping a bandage lens on the eye for at least 2 months helps reduce the likelihood of recurrence. We put a bandage lens on the cornea of a patient with recurrent erosion and have them use an antibiotic (usually Polytrim) as well as the hypertonic agent. During the first two weeks we follow them closely for signs of healing and new epithelium being laid down over the area of damage. We see the patient every 2 weeks after that. If we have him or her on a bandage lens, we very carefully remove it and put on a fresh lens every 2 weeks.”

If Dr. Sclafani feels that a patient will most likely be noncompliant with his or her medications, she will request that he or she come in more frequently than normally would be necessary. “I’ll tell patients that I need to see them more often than necessary, so at least they will come in most of those times,” she said.

Keep in mind how rapidly many abrasions may heal, said Dr. Grohe, and learn to recognize when to take the treatment a step further. “The cornea has the ability to heal within 72 to 96 hours,” he said. “That’s a good thing for practitioners to keep in mind. If it does not, it also is an automatic prompt to a practitioner that there is something going on here besides just an abrasion. That certainly should signify at least a re-evaluation — if not a referral to a cornea specialist — particularly if the abrasion is central in location and has not responded to treatment.”

For Your Information:

• William D. Townsend, OD, is in private group practice and is a consultant at the VA Medical Center in Amarillo, Texas. He may be reached at 1801 4^th Ave., Suite C, Canyon, TX 79015; (806) 655-7748; fax: (806) 655-2871; e-mail: drbill@1s.net. Dr. Townsend has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Louise Sclafani, OD, is the director of optometric services and contact lenses and refractive surgery at the University of Chicago Department of Ophthalmology, as well as a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry. She may be reached at 939 East 57^th St., Chicago, IL 60637; (773) 702-6823; fax: (773) 702-0830; e-mail: lsclafan@mcis.bsd.uchicago.edu. Dr. Sclafani has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.
• Robert M. Grohe, OD, a member of the Primary Care Optometry News Editorial Board, is in group practice and may be reached at Eye Care Associates Ltd., 18019 Dixie Hwy., Homewood, IL 60430; (708) 799-2020; fax: (708) 799-5999; e-mail: rmg23eye@aol.com. Dr. Grohe has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Linda Casser, OD, a member of the Primary Care Optometry News Editorial Board, is the associate dean for academic programs at the Pacific University College of Optometry. She may be reached at 2043 College Way, Forest Grove, OR 97116; (503) 359-2766; fax: (503) 359-2929; e-mail: casserl@pacificu.edu. Dr. Casser did not disclose if she has a direct financial interest in the products mentioned in this article or if she is a paid consultant for any companies mentioned.