EM@3AM – Corneal Abrasion

Author: Wells Weymouth, MD (Resident Physician, SAUSHEC, USA) and Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 43-year-old male, with no significant medical history, presents to the ED for right eye pain. The patient notes his pain as constant and sharp (8/10); associated with light-sensitivity and blurred vision. He reports the onset of his symptoms two hours prior to arrival, while mowing his lawn. The man denies a requirement for glasses/contact lenses. He denies known ocular trauma, and he denies an ocular surgical history.

Triage VS: BP 136/86, HR 110, T 99.6 F oral, RR 14, SpO2 98% on room air.

OD: 20/30
OS: 20/20
OU: 20/20

Pertinent physical examination findings:
HEENT: PERRLA, 3 mm bilaterally; EOMI, visual fields intact. OD: Mild conjunctival injection. No FB on lid eversion.

Examination with Fluorescein:

This image was originally published in the Retina Image Bank. Jason S. Calhoun. Corneal Abrasion With Foreign Body Present. Retina Image Bank. 2013; 7362. © the American Society of Retina Specialists.

What are the next steps in your evaluation and treatment?

Answer: Corneal Abrasion1-8

  • Clinical Presentation: Patients often report pain, foreign body sensation, tearing, and light-sensitivity.
  • Evaluation, Treatment, and Disposition:
    • Treat pain and facilitate the exam: instill a topical anesthetic (e.g. tetracaine).
    • Utilize Seidel’s test to rule out open globe.
    • Evert the lid(s) to assess for foreign body (FB):
      • Maintain high suspicion in a patient whose cornea is marred by numerous vertical, linear, abrasions.2
    • Patients with corneal abrasions commonly display reactive miosis:
      • Large, non-reactive pupil => findings indicative of injury to the pupillary sphincter => investigate for intra-ocular FB .3
    • Treatment of corneal abrasions (< 50% of corneal involvement):4,5
      • Consider a cycloplegic (e.g. cyclopenolate or homatropine) to decrease ciliary spasm and reduce pain.
      • Provide outpatient analgesia (oral or topical NSAIDs advised).
      • Prescribe a topical antibiotic ointment (recommendation based in clinical practice; ointment preferred = lubricating; limited data suggests reduced time to epithelial healing):4
        • Non-contact lens wearers: erythromycin ointment.
        • Contact lens wearers: cover for Pseudomonas species (ophthalmic ciprofloxacin, ofloxacin, etc.)
      • Ophthalmology follow-up in 24-48 hours recommended. (Exception: Follow-up within 24 hours if vision loss is > one line on a Snellen chart.)6
      • Patching no longer recommended for abrasions involving < 50% of the cornea.5
    • Consult ophthalmology:7,8
      • Large abrasions (involving > 50% of the cornea).
        • Consider patching for improved pain control (no evidence of improved healing).5
      • Findings suggestive of corneal ulceration.
      • Inability to remove retained FB.
      • Hypopion
  •  Pearls:
    • Pediatric patients: consider corneal abrasion in the inconsolable infant.
    • Ophthalmic anesthetics (e.g. tetracaine) not advised for home use – risk of corneal toxicity and epithelial growth retardation.3


  1. Calhoun, J. S. (2013, July 08). Corneal Abrasion With Foreign Body Present. Retrieved July 22, 2017, from http://imagebank.asrs.org/file/7362/corneal-abrasion-with-foreign-body-present
  2. Wipperman, J. L., & Dorsch, J. N. (2013). Evaluation and management of corneal abrasions. American Family Physician, 87(2).
  3. Wilson, S. A., & Last, A. (2004). Management of corneal abrasions. American Family Physician, 70, 123-132.
  4. Fraser, S. (2010). Corneal abrasion. Clinical ophthalmology (Auckland, NZ), 4, 387.
  5. Weaver, C. S., & Terrell, K. M. (2003). Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing?. Annals of Emergency Medicine, 41(1), 134-140.
  6. Khaw, P. T., Shah, P., & Elkington, A. R. (2004). ABC of eyes: Injury to the eye. British Medical Journal, 328(7430), 36.
  7. Flynn, C. A., D’amico, F., & Smith, G. (1998). Should we patch corneal abrasions? A meta-analysis. Journal of Family Practice, 47(4), 264-271.
  8. Whitcher, J. P., Srinivasan, M., & Upadhyay, M. P. (2002). Prevention of corneal ulceration in the developing world. International Ophthalmology Clinics, 42(1), 71-77.


 For Additional Reading:

Ophthalmologic Medications: Pearls & Pitfalls in the ED:

Ophthalmologic Medications: Pearls & Pitfalls for the ED

2 thoughts on “EM@3AM – Corneal Abrasion”

  1. Several papers have been published on the safety of take home packs of tetracaine for 24 hours. A recent article in the Annals suggesting safety for simple abrasions only.
    All data on toxicity is from animal studies or low powered reviews and case reports.
    It is a very effective pain reliever and if given for less than 24 hours is unlikely to affect epithelialization if not contaminated/large abrasion.

    1. Sir,
      Appreciate the comment and thank you for reading!

      We offered expert advice based upon the references detailed in the post:

      The 2017 Waldman, et al. Annals publication was a retrospective study with wide confidence intervals. As the authors’ note, while tetracaine performed well in terms of analgesia and did not appear to impair healing, individuals with small corneal abrasions were more likely to require ED recheck and repeat fluorescein staining.

      In addition, a 2015 systematic review performed by Swaminathan, et al., published in the Journal of Emergency Medicine (which included two ED-based, randomized, double blinded, placebo-controlled studies of patients with corneal abrasions, and four studies investigating the application of topical anesthetics in patients who had undergone photo refractive keratectomy), concluded that limited data suggested that the use of dilute topical ophthalmologic proparacaine or tertacaine for a short time was effective, but that their safety for outpatient use was inconclusive.

      While tetracaine/proparacaine appear to offer the outpatient benefit of analgesia, and at this point human studies have failed to demonstrate impaired healing, this is likely an area that requires further research prior to definitive recommendations regarding home use.


      Waldman N, Winrow B, Densie I, Gray A, McMaster S, et al. Observational study to determine whether routinely sending patients home with a 24-hour supply of topical tetracaine from the emergency department for simple conceal abrasion pain is potentially safe. Ann Emerg Med. 2017 May 2; pii: S0196-0644(17)30195-6. doi: 10.1016/j.annemergmed.2017.02.016. [Epub ahead of print]

      Swaminathan A, Otterness K, Milne K, Rezaie S. The safety of topical anesthetics in the treatment of corneal abrasions: a review. J Emerg Med. 2015; 49(5):810-815.

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