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)
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)[ ]
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)[ ].
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)[ ].
- Patching is not recommended (fails to reduce pain, delays healing, more risk of infection) (2)[ ].
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)[ ].
- 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)[ ]
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)[ ]
ADDITIONAL THERAPIES
Novel approaches: amniotic membrane/fluid, autologous blood tears; proposed: topical insulin and substance P (3)[ ]
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)[ ].
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
- [PMID:35314442] , , . Corneal foreign bodies. CMAJ. 2022;194(11):E419.
- [PMID:26319343] , , . Corneal abrasions and corneal foreign bodies. Prim Care. 2015;42(3):363–375.
- [PMID:35025078] , , . Treatment of non-infectious corneal injury: review of diagnostic agents, therapeutic medications and future targets. Drugs. 2022;82(2):145–167.
ADDITIONAL READING
[PMID:29284643] , , . Corneal ulcers in general practice. Br J Gen Pract. 2018;68(666):49–50.
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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