Corneal Abrasion and Ulceration

Descriptive text is not available for this image 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)

Descriptive text is not available for this image 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

Descriptive text is not available for this image 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]

Descriptive text is not available for this image 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]

Descriptive text is not available for this image 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

  • Visual acuity testing is the vital sign at the beginning of every eye visit.
  • When corneal abrasion is healed and asymptomatic, contact lenses use may restart.
  • Eye patching is not recommended for corneal ulcerations or abrasions.
  • Consider topical NSAIDs and/or oral analgesics a maximum of 3 days for symptom control.
  • Treatment usually involves frequent topical anti-microbial application.
  • Prompt referral to an ophthalmologist should be made with suspicion of any ulcer (same-day phone), recurrence of abrasion, retained foreign body (same-day consult), hyphema or hypopyon (same day), viral keratitis (<24 hours), significant visual decrease (same-day phone), or lack of prompt improvement despite therapy (next day).

Last Updated: 2026

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