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
- Strong, face/periorbital, skin contact-fitting eyewear during:
- Work (auto mechanics, metalworkers, miners, etc.) or anywhere hammering, grinding, sawing
- Contact sports
- Occupational Safety and Health Administration mandates safety standards for at risk employees; see https://www.osha.gov/laws-regs/regulations/standardnumber/1926/1926.102.
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)
There's more to see -- the rest of this topic is available only to subscribers.
Citation
Domino, Frank J., et al., editors. "Corneal Abrasion and Ulceration." 5-Minute Clinical Consult, 33rd ed., Wolters Kluwer, 2025. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116946/all/Corneal_Abrasion_and_Ulceration.
Corneal Abrasion and Ulceration. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2025. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116946/all/Corneal_Abrasion_and_Ulceration. Accessed October 13, 2024.
Corneal Abrasion and Ulceration. (2025). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (33rd ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116946/all/Corneal_Abrasion_and_Ulceration
Corneal Abrasion and Ulceration [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2025. [cited 2024 October 13]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116946/all/Corneal_Abrasion_and_Ulceration.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC
T1 - Corneal Abrasion and Ulceration
ID - 116946
ED - Domino,Frank J,
ED - Baldor,Robert A,
ED - Golding,Jeremy,
ED - Stephens,Mark B,
BT - 5-Minute Clinical Consult, Updating
UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116946/all/Corneal_Abrasion_and_Ulceration
PB - Wolters Kluwer
ET - 33
DB - Medicine Central
DP - Unbound Medicine
ER -