Corneal Abrasion and Ulceration

BASICS

As the most anterior eye structure, a cornea is unique: mechanical and immunologic eye protector, light refractor/transmitter, and conduit for nutrients and oxygen via tears to the eye.

DESCRIPTION

  • Corneal injuries via: a foreign body (most commonly abrasion), ultraviolet (UV) burns, or chemical contact burns.
    • Corneal abrasions: result from any single or repetitive violation by cutting or scratching the thin, protective, clear coat of the exposed corneal epithelium.
    • Corneal stromal ulceration: any violation of the epithelial layer of the cornea leading to direct exposure of the underlying corneal stromal layer, may result (especially with delay in diagnosis/treatment) in infectious keratitis which may lead to an infected corneal ulcer.
    • Superficial ulcers, limited to loss of the corneal epithelium, are the most common form of ulceration.
    • Peripheral ulcerative keratitis (PUK) is noninfectious, complicating many autoimmune diseases with corneal ulceration.
  • UV burns of the cornea (photokeratitis) occur when exposed to intense sunlight, tanning booth light, halogen lamp, welding torch, or close lightening flash with unprotected or inadequate UV eye protection.
    • Strictly involve a 6- to 12-hour latency of acute, intense pain in a photophobic red eye
  • Chemicals directly on the cornea may cause serious, extensive damage to the epithelial or deeper layers.
  • Corneal abrasion and keratitis/ulceration can each cause scarring which may lead to impaired vision or permanent vision loss.

EPIDEMIOLOGY

All unprotected eyes are vulnerable to corneal injuries.

Incidence

  • Corneal abrasions:
    • Eight percent of total ER visits are eye trauma-related; 64% of these eye complaints are abrasions via direct minor trauma.
    • Twelve percent of corneal abrasions relate to contact lenses, particularly in young people.
    • Only conjunctivitis and subconjunctival hemorrhage surpass corneal abrasion as a cause of red eye complaints.
  • Worldwide, infectious keratitis and ulceration is 5th leading cause of blindness.
  • Chemical ocular injuries: 67% occur in men at work, aged 20 to 30 years old; 33% occur by assault incidents in United Kingdom.
  • In United States, 1 million ER and clinic visits per year result in a keratitis diagnosis.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Corneal abrasions: usually caused by mechanical scratching, from various foreign bodies or chemical and flash (UV) burns
  • Recurring: Acute corneal injuries or spontaneous defects can cause corneal scarring and permanent vision loss.
  • Corneal ulcers: The injury precedes keratitis and infectious corneal ulceration.
    • Contact lenses use, impaired immunity (HIV), corneal trauma or abrasion, and ocular surface disease can promote keratitis or cause corneal ulceration. Ischemia of the cornea induces edema which plays a significant role in epithelial dysfunction. Trauma, ischemia, and increased intraocular pressure can result from edema which then itself can promote further edema.
  • Pathogens causing ulcerations include the following:
    • Gram-positive bacteria ~20–69%; Staphylococcus aureus and coagulase-negative Streptococcus are common.
    • Gram-negative bacteria ~21–35%; Pseudomonas sp. most common, especially contact lenses users
    • Herpes simplex (most common viral cause) with or without bacterial superinfection; herpes zoster
    • Fungal: Fusarium, Aspergillus, Curvularia, and Candida; rank order varies geographically.
    • Parasites: Acanthamoeba is very, very rare in United States, but 85% are in contact lenses users
  • Autoimmune disorders: Sjögren, PUK, rheumatoid arthritis, inflammatory bowel disease
  • Corneal ulceration is more common in immunocompromised: cancer, HIV, and diabetes mellitus (DM).
  • Ocular surface diseases: Chronic blepharitis, entropion, Graves eye disease, and dry eyes/corneal dystrophy/bullous keratopathy/mucous membrane pemphigoid promote ulceration.

RISK FACTORS

  • Acute eye trauma: direct contact trauma, chemical burn, UV overexposure
  • Contact lenses use:
    • The most common contributing factor for bacterial keratitis in United States
    • Risky handling of contact lenses (poor hand and lenses hygiene)
    • Extended wear lenses, excessive wear times
  • Perioperative time: sedation and general anesthesia
  • Lack of proper eye protection
  • Males, age 20 to 34 years old
  • Manufacturing, construction, agricultural work (equatorial especially)

GENERAL PREVENTION

COMMONLY ASSOCIATED CONDITIONS

  • Xerophthalmia (common) or exophthalmos (occasional); allergic eye disease (common)
  • Severe vitamin A deficiency (associated with corneal keratitis—rare)
  • Neuropathy of cranial nerve V1, the ophthalmic branch (rare)
  • DM (occasional), immunocompromise (e.g., HIV), connective tissue disease: bacterial (occasional) or fungal (rare) ulcers
  • Critically ill or patients under anesthesia with impaired blink reflex or lagophthalmos and those on intermittent positive pressure ventilation (occasional)

DIAGNOSIS

Key historical questions and a systematic eye examination keenly focus the diagnosis.

HISTORY

  • Ask about recent significant ocular trauma, and if so, consider penetrating injury.
  • Acute corneal foreign bodies: minor abrasions: abrupt foreign body sensation, severe photophobia/pain; but abrasions without foreign body sensation suggests acute keratitis or current erosion syndrome.
  • Excessive UV or welding exposure: 6- to 12-hour delay in usually severe, bilateral symptoms: significant pain, scleral injection, photophobia, facial erythema (UV)
  • Contact lenses misuse: pain and photophobia on awakening or interrupted sleep by searing eye pain: “classic” for recurrent erosion syndrome
  • Other symptoms include red eye, pain with extraocular muscle movement, eye twitching, excessive tearing, blurred or decreased vision, nausea, and headache.
  • Past medical/surgical history: diabetes, immunosuppression, contact lenses use/misuse, or refractive surgery, last tetanus shot date

PHYSICAL EXAM

  • First, 1 drop of ophthalmic topical ocular anesthetic (TOA) facilitates best exam.
  • Survey: orbit (palpation), eyelids, globe surface, pupils, and extraocular muscles
  • Document far or near visual acuity by Snellen chart, wall or hand held: A two-line decrease is significant; if only hand motion or light seen in a usually normal eye, then same day call to ophthalmologist.
  • Slit lamp is ideal or otoscope or ophthalmoscope or even penlight exam of cornea/associated structures.
  • Evert the upper lid and then retract lower lid to inspect for foreign body.
  • Fluorescein stain exam with Wood’s light for corneal surface defects: retention of yellow/green color at abrasion or full cornea in UV keratitis

DIFFERENTIAL DIAGNOSIS

  • Corneal abrasion: acute angle-closure glaucoma, acute conjunctivitis, adult blepharitis, corneal ulcer, infective keratitis, uveitis, iritis, entropion, epidemic keratoconjunctivitis
  • Corneal ulceration: contact lenses mechanical trauma; keratoconjunctivitis: atopic or sicca; keratitis: interstitial or infectious or neurotrophic or PUK; band keratopathy; and HLA-B27 syndromes

DIAGNOSTIC TESTS & INTERPRETATION

An “eye tray”: instruments and meds; lights

Initial Tests (lab, imaging)

  • Corneal ulcer: uncommon to culture (corneal scrape) but need same day discussion with ophthalmologist
  • Usually avoid prereferral definitive treatment with topical antibiotics; may obscure true culture findings
  • If suspicious for high-impact foreign body or direct injury: fluorescein (generous amount) stain exam with Wood’s lamp or slit lamp for ocular surface exam—if blue/green color flows from surface, it indicates corneal or scleral penetration (positive Siedel test)
  • If penetrating injury suspicious for retained foreign body: ocular CT if metallic or MRI if nonmetallic (1)[C]

Diagnostic Procedures/Other

  • 1–2 drops 0.5% proparacaine or tetracaine ophthalmic solution topical anesthetic for pain control
  • Tonometry for intraocular pressure testing (8 to 21 = normal) if need to rule out acute open-angle glaucoma
  • Evert the upper lid and retract the lower lid to inspect and sweep (with sterile, wet, cotton swab) for foreign body removal
  • Slit or Wood’s lamp exam, after fluorescein strip saturated with sterile: saline, water, or TOA, to stain cornea and identify abrasions, ulcerations, keratitis/infiltrates
  • Corneal trauma/foreign body/infection effects have planar geographic shape or more linear stains; contact lenses cause several punctate or curvilinear shape stains, and herpetic dendrites with terminal bulb pattern (atypical herpetic lesion may appear as >4 mm abrasion) (2)[C].

Test Interpretation

Scraping culture: fungal, bacterial identifies bacteria, yeast to help identify specific infection

TREATMENT

Goals: Control pain, prevent infection, and teach patient daily self-monitoring (vision degradation, excess pain).

GENERAL MEASURES

  • Normal saline irrigation of ocular surface and both fornices may flush away foreign body.
  • If patient is cooperative, adherent epithelial foreign body without stain may be removed with sterile moist cotton swab or 25-gauge needle by experienced operator.
  • Give tetanus booster as indicated for eye abrasions/punctures (1)[C].
  • Patching is not recommended (fails to reduce pain, delays healing, more risk of infection) (2)[C].

MEDICATION

  • Oral analgesic: narcotics, acetaminophen, or NSAIDs
  • Topical anesthetics include proparacaine hydrochloride 0.5%, tetracaine hydrochloride 0.5%.
    • Tetracaine does not require refrigeration; proparacaine does.
    • Patients should not use TOAs as overuse can cause superimposed infections or scaring, nor topical steroids.
  • If photophobia and pain, meiosis and limbal flush: topical cycloplegic agents like 1% cyclopentolate 1 drop every 8 hours for 1–2 days.
  • Ophthalmic NSAIDs: Diclofenac 0.1% 1 drop QID reduces moderate pain; limit to 1- to 2-day use as it may impair healing or rarely damage cornea (3)[C].
  • Caution: Frequent use of artificial tears may dilute other medications.

First Line

  • Topical ophthalmic antibiotics to prevent corneal infection, especially in contact lenses users, fingernail or plant matter involvement
  • Some ophthalmic antibiotics include polymyxin B/trimethoprim 1 drop q3h for 7 days for lower risk abrasions or erythromycin 0.5% ointment 1 ribbon q3h for 7 days.
    • Broad spectrum: polymyxin B/trimethoprim 1 drop q3h for 7 days or erythromycin ointment for lower risk abrasions
    • Higher risk abrasions (involving: contact lenses user, fingernail or plant matter) gram-negative coverage/antipseudomonals: ofloxacin 0.3% solution 1–2 drop q2–3h for 2 days, then same QID for 3 days or ciprofloxacin 0.3% solution, same dose/duration.
  • Fungal keratitis: if suspected, <24 hours, referral to ophthalmologist for antifungal—topical antifungal agents
  • Herpetic keratitis: <24 hours, referral to ophthalmologist for confirmation or may start (after phone consult ophthalmologist): trifluridine 1% solution 1 drop q2h while awake (2)[C]

ISSUES FOR REFERRAL

  • Lack of improvement by 24 hours or worsening symptoms
  • Any chemical burn
  • Any corneal ulcer or infiltrate
  • Any symptoms or incomplete healing by 3 to 4 days
  • Retained foreign body or any stain/ring
  • Any penetrating globe injury
  • Any hyphema (blood) or hypopyon (pus)
  • Anytime a vision loss of more than two lines on Snellen chart or abrupt decline to hand or light recognition only (2)[C]

ADDITIONAL THERAPIES

Novel approaches: amniotic membrane/fluid, autologous blood tears; proposed: topical insulin and substance P (3)[C]

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

It is best to follow up all corneal abrasions in 24 hours; especially lesions ≥4 mm, or decreased vision, or abrasions due to contact lenses, strict follow-up within 24 hours.

PATIENT EDUCATION

Corneal Abrasion and Erosion (English and Spanish versions by American Academy Ophthalmology [AAO]) (https://www.aao.org/eye-health/diseases/what-is-corneal-abrasion). See if you qualify for a no-cost eye exam from AAO’s EyeCare America program.

PROGNOSIS

  • Minor corneal abrasions <4 mm heal within 24 to 72 hours; larger ones, maximum of 5 days.
  • Among extended wear contact lenses users, risk of microbial keratitis is 15 times nonusers.
  • Daily wear contact users occasionally wearing through the night have 9 times risk for nonusers for microbial keratitis (2)[C].

COMPLICATIONS

  • Recurrence of abrasion or ulcer by reinjury or spontaneously
  • Conversion of abrasion to keratitis/ulcer
  • Scarring of the cornea may produce vision loss.
  • Exogenous endophthalmitis, risk loss of vision or eye

Authors

Jon S. Parham, DO, MPH, FAAFP
Luke T. Hentrich, PharmD

REFERENCES

  1. Ambikkumar A, Arthurs B, El-Hadad C. Corneal foreign bodies. CMAJ. 2022;194(11):E419.  [PMID:35314442]
  2. Amed F, House RJ, Feldman BH. Corneal abrasions and corneal foreign bodies. Prim Care. 2015;42(3):363–375.  [PMID:26319343]
  3. Dang DH, Riaz KM, Karamichos D. Treatment of non-infectious corneal injury: review of diagnostic agents, therapeutic medications and future targets. Drugs. 2022;82(2):145–167.  [PMID:35025078]

ADDITIONAL READING

Arbabi EM, Kelly RJ, Carrim ZI. Corneal ulcers in general practice. Br J Gen Pract. 2018;68(666):49–50.  [PMID:29284643]

CODES

ICD10

  • S05.00XA Inj conjunctiva and corneal abrasion w/o fb, unsp eye, init
  • H16.009 Unspecified corneal ulcer, unspecified eye
  • H16.049 Marginal corneal ulcer, unspecified eye
  • H16.019 Central corneal ulcer, unspecified eye
  • H16.012 Central corneal ulcer, left eye
  • H16.003 Unspecified corneal ulcer, bilateral
  • H16.013 Central corneal ulcer, bilateral
  • S05.01XA Inj conjunctiva and corneal abrasion w/o fb, right eye, init
  • H16.011 Central corneal ulcer, right eye
  • H16.043 Marginal corneal ulcer, bilateral
  • H16.001 Unspecified corneal ulcer, right eye
  • H16.041 Marginal corneal ulcer, right eye
  • H16.002 Unspecified corneal ulcer, left eye
  • S05.02XA Inj conjunctiva and corneal abrasion w/o fb, left eye, init
  • H16.042 Marginal corneal ulcer, left eye

SNOMED

  • 85848002 Corneal abrasion (disorder)
  • 91514001 Corneal ulcer (disorder)
  • 47398006 Marginal corneal ulcer (disorder)
  • 7426009 Central corneal ulcer

CLINICAL PEARLS

Last Updated: 2026

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