Chapter XVII.5. Corneal Abrasion and Hyphema
Mark B. Lindquist
April 2022

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The editors and current author would like to thank and acknowledge the significant contribution of the previous author of this chapter from the 2004 first edition Dr. Peggy Liao. This current third edition chapter is a revision and update of the original authorís work.


An 8 year old boy presents to the emergency department with moderately severe left eye pain 6 hours after riding his bicycle through some low hanging leaves from a tree. He didn't notice the tree branches until a few leaves hit him in the face. He has no bleeding wounds.

Exam: VS are normal. He does not want to open his left eye because of discomfort. Proparacaine eye drops are instilled into his left eye. He has immediate pain relief and he is able to open his eye. His visual acuity is 20/20 in the right eye and 20/30 in the left eye. His pupils are equal and reactive. His conjunctiva is slightly injected. No hyphema is visible. A drop of saline is placed on a fluorescein paper strip. This drop is then touched to his lower eyelid so fluorescein dye flows over the surface of his eye. With an ultraviolet light, a 0.5 cm linear abrasion is seen in the lateral aspect of his left cornea.

His eye is rinsed with saline to remove excess fluorescein. Antibiotic ointment is instilled into his eye as well and a soft eye patch is placed over his eye. He is instructed to take over-the-counter analgesics for pain and is given the remainder of the antibiotic ointment tube to be used 2 to 3 times per day at home.

The next day he is checked by his primary care physician. The fluorescein exam is repeated and no corneal abrasion is seen. No further treatment is necessary.


The cornea is composed of three layers: the outer epithelium, the middle stroma and the inner endothelium. The outer epithelium is the only layer capable of regenerating. Injuries to the stroma and endothelium usually result in permanent scarring of the cornea, and reduced vision for the eye. The cornea has a high density of neuronal pain receptors, making injury to the cornea very painful.

Corneal Abrasion

Epithelial damage is commonly called corneal abrasion. The most common cause is external blunt trauma, such as foreign objects scratching the cornea. Foreign bodies should be removed as soon as possible if present. Other causes include chemical burns, thermal burns, ultraviolet burns (such as welding and sun lamps), or prolonged exposure to the ambient environment, such as decreased blinking and dry eyes, and contact lens wear. Occasionally, there is no history of trauma, especially in children when the history may be unreliable or in infants where they may accidentally scratch their eye with their fingernail Symptoms of corneal abrasion include pain, redness, photophobia, tearing, and foreign body sensation. Signs of corneal abrasion include conjunctival injection or redness, swollen eyelid, and sensitivity to light. Occasionally, a visible irregularity of the corneal surface can be seen (1,2).

Corneal abrasions are the most common eye injury in children, and are more likely to occur in males than females. Corneal abrasions are most commonly caused by mechanical trauma. Corneal abrasions are most frequently seen in males between the ages of 5 and 15 years (3).

It is very important to document visual acuity when examining a patient with an eye injury. A topical anesthetic, such as proparacaine or tetracaine, can be instilled to decrease pain for the patient to facilitate the examination. Proparacaine is preferred because it is painless on initial administration while tetracaine is painful upon initial administration. There is a concern that these topical anesthetics should not be used for home pain management because it can potentially increase their risk of delayed healing and corneal erosion since they can inhibit the blinking reflex and the normal eye protection reflexes (2). Other studies contradict this concluding that topical anesthetics provide patient comfort and do not increase the risk of complications (4,5). Typically, a single dose is given to aid with the eye examination. Visual acuity should then be obtained and documented. Take note of any periorbital injuries, such as eyelid trauma, or possible orbital wall fractures. These separate injuries should be treated appropriately as well.

Ideally, an eye should be examined with a slit lamp for signs of corneal abrasion. Fluorescein is applied topically, and using cobalt blue light, the size, shape and location of the abrasion should be documented. Slit lamp examination is also helpful in determining if the injury involves deeper layers of the cornea, and possibly penetrating injury to the eyeball. Despite this advantage, the slit lamp is expensive, requires patient cooperation, and most non-ophthalmologists do not use it routinely making the use of a plain ultraviolet light (Wood's lamp) with fluorescein to examine the cornea for abrasions, much easier and expedient. The differential diagnosis for corneal abrasions includes: conjunctivitis, hyphema, uveitis, keratitis, corneal ulcer, dry eye syndrome, and acute angle-closure glaucoma. The eyelids should be everted to look for foreign bodies, especially in children where there may be no history of trauma or foreign body. Non-pressure patching the eye was traditionally part of corneal abrasion treatment; however this treatment method is used less commonly today. There is no clear evidence that supports the use of patching to treat corneal abrasions. Patching is still used to treat large corneal abrasions (abrasions that involve >50% of the cornea) and in young children who struggle to refrain from rubbing their eyes (6). Treatment of corneal abrasions focuses primarily on promoting healing and alleviating pain. For uncomplicated corneal abrasions, antibiotic eye drops or ointment should be used. In patients who use contact lenses, antibiotic eye drops with antipseudomonal properties (e.g., moxifloxacin) should be used (1).

A bandage contact lens can be used to treat corneal abrasions under the care of an ophthalmologist, although data about their efficacy in pediatric patients is limited. This requires a high level of cooperation and medical monitoring. The bandage contact lens sits on top of the damaged cornea and protects it from the mechanical rubbing and blinking of the eyelids, allowing the cornea to heal. The protective effects of the bandage contact lens can also alleviate pain but it requires topical anesthetics and antibiotics (7).

Most corneal abrasions heal in 24 to 72 hours. If haziness is observed at any time, the patient should be treated for a corneal ulcer and referred immediately to an ophthalmologist. If additional analgesic therapy is needed, oral and/or topical NSAIDs can be used for pain management. Narcotic analgesics are sometimes necessary to treat the pain, although these are rarely given. Cycloplegic and mydriatics were previously used to manage pain secondary to corneal abrasions, but these medications are no longer recommended for uncomplicated corneal abrasions; however, these medications can be used in certain cases if indicated. In patients with large corneal abrasions, cycloplegic agents can be used to relieve the pain from ciliary spasm (2). Tetanus prophylaxis is not indicated for non-penetrating corneal abrasions without evidence of infection, perforation, or devitalized tissue, and is only necessary for penetrating eye injuries (6).

Excessive ultraviolet light exposure to the cornea (and retina as well) can occur when observing a welding arc or flame, or with extremely bright sunlight exposure such as looking at the sun, during high altitude skiing (commonly called snow blindness), and occasionally at the beach. The welding arc produces invisible high intensity ultraviolet radiation which must be blocked by an ultraviolet light shield. Just as in a sunburn, patients with ultraviolet corneal burns do not notice much discomfort initially, but after 1 to 2 hours have passed, the burning sensation becomes very painful. Fluorescein examination reveals multiple, tiny pitting defects of the corneal surface, called superficial punctate keratitis. Frequent topical antibiotic ointment is recommended and oral analgesics may be necessary for comfort. If only confined to the cornea, and not involving the retina, this problem is generally self-limited (8).

Hyphema

A hyphema is defined as blood in the anterior chamber of the eye. It is usually caused by blunt trauma. The incidence of traumatic hyphema is approximately 17 to 20 out of 100,000 children annually (9). The eyeball is compressed and it results in distortion of the iris and angle, thus causing tears in the iris and the angle vessels. It can present as a microhyphema, where only floating anterior chamber red blood cells are present, a thin rim of blood in the inferior iris (with the patient sitting erect), a visible blood clot, or as a red eye with the entire anterior chamber filled with blood. The blood is generally reabsorbed by the trabecular meshwork over time. The greatest danger of hyphema is re-bleeding, which usually occurs within the first week after the initial injury. Re-bleeding is probably caused by clot retraction and fibrinolysis. Re-bleeds are associated with an increased incidence of glaucoma and reduced final visual acuity (10).

The management of hyphema remains controversial, but most experts agree that children should be placed on bed rest with bathroom privileges for at least 5 days and refrain from strenuous activities for 10 days. The head of the bed should also be elevated by at least 30 degrees. Elevating the head allows the hyphema to settle within the inferior portion of the anterior chamber, which improves vision and trabecular outflow. An eye shield is recommended in the initial days to reduce the chance of further blunt injury. Topical corticosteroids, oral corticosteroid, and epsilon-aminocaproic acid (EACA) (an anti-fibrinolytic agent, i.e., a pro-coagulant) have all been advocated to reduce the incidence of re-bleeds. EACA can be administered topically under the recommendation of an ophthalmologist. If it is given systemically (oral or IV), it should be used with great caution since it can cause clots elsewhere. Corticosteroids can also help mitigate inflammation. If needed, beta-blockers, alpha agonists, and carbonic anhydrase inhibitors can be used to reduce intraocular pressure. NSAIDs and aspirin-containing products should not be used for analgesia as these can increase risk for further bleeding. For some patients, hospitalization and sedation may be required in order to ensure compliance with treatment recommendations. Occasionally, surgical evacuation of a blood clot is necessary to decrease complications, such as uncontrollable intraocular pressure, and corneal blood staining (permanent opacification of the cornea from infiltration of hemoglobin and hemosiderin) (10,11).


Questions
1. True/False: Tetanus shots should be given following all corneal abrasions for tetanus prophylaxis?

2. A 4 year old boy was playing with sparklers on the 4th of July. He held it up high and his parents think that some sparks fell into his eye. He has some small blisters around his eyelids and he is complaining of intense eye pain. He refuses to open his eyes for an examination because of pain. Which of the following are possible options (more than one correct answer is possible)?
. . . . a. topical proparacaine as a single dose to facilitate an examination
. . . . b. intranasal fentanyl to facilitate an examination
. . . . c. topical proparacaine now and p.r.n. at home for discomfort
. . . . d. oral acetaminophen

3. A 10 year old boy presents to the pediatrician with a red and teary eye for a day. He had been to a soccer practice on the day before presentation and the red eye began after that. The pediatrician does not see a corneal abrasion with fluorescein and sends him home with topical antibiotics. He still has the same symptoms the next day. What should the pediatrician do?

4. How does the antibiotic regimen differ for a patient with a corneal abrasion in a contact lens wearer compared to a patient that does not use contact lenses?

5. A 4 year old boy presents to the emergency room with a red and painful right eye after a swing had accidentally hit the eye on the playground. On examination, he does not like to have the left eye covered because he "cannot see". The eyelids are swollen and ecchymotic and the conjunctiva has hemorrhages. The physician sees blood covering 65% of the anterior chamber. What is the appropriate management?


References
1. Fusco N, Stead TG, Lebowitz D, Ganti L. Traumatic Corneal Abrasion. Cureus. 2019;11(4). doi:10.7759/cureus.4396
2. Olitsky SE, Marsh JD. Chapter 653. Injuries to the Eye. In: Behrman RE, St Geme JW, et al (eds). Nelson Textbook of Pediatrics, 21st edition. 2020, Elsevier, Philadelphia, PA. pp. 3393-3397.e1.
3. Jolly R, Arjunan M, Theodorou M, Dahlmann-Noor AH. Eye injuries in children - incidence and outcomes: An observational study at a dedicated childrenís eye casualty. Eur J Ophthalmol. 2019;29(5):499-503. doi:10.1177/1120672118803512
4. Shipman S, Painter K, Keuchel M, Bogie C. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Ann Emerg Med 2021;77(3):338-344. doi: 10.1016/j.annemergmed.2020.08.036.
5. 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. doi: 10.1016/j.jemermed.2015.06.069.
6. Domingo E, Moshirfar M, Zabbo CP. Corneal Abrasion. In: StatPearls. StatPearls Publishing; 2022. http://www.ncbi.nlm.nih.gov/books/NBK532960/ Accessed May 15, 2022.
7. Hassan HT. The evaluation of bandage soft contact lenses as a primary treatment for traumatic corneal abrasions. Int J Clin Exp Ophthalmol. 2020;4(1):041-048. doi:10.29328/journal.ijceo.1001032
8. Delic NC, Lyons JG, Di Girolamo N, Halliday GM. Damaging Effects of Ultraviolet Radiation on the Cornea. Photochemistry and Photobiology. 2017;93(4):920-929. doi:10.1111/php.12686
9. Richards MD, Barnes K, Yardley AM, Hanman K, Lam GC, Mackey DA. Traumatic hyphaema in children: a retrospective and prospective study of outcomes at an Australian paediatric centre. BMJ Open Ophthalmol. 2019;4(1):e000215. doi: 10.1136/bmjophth-2018-000215.
10. Chen EJ, Fasiuddin A. Management of Traumatic Hyphema and Prevention of Its Complications. Cureus. 13(6):e15771. doi:10.7759/cureus.15771
11. Gragg J, Blair K, Baker MB. Hyphema. In: StatPearls. StatPearls Publishing; 2022. http://www.ncbi.nlm.nih.gov/books/NBK507802/ Accessed May 21, 2022.


Answers to questions
1. False. Tetanus prophylaxis is only necessary for penetrating injuries of the eye, and does not need to be given for simple corneal abrasions.
2. Choices a and b are both reasonable answers. Choice d would be too slow for an office or emergency department, but it would be reasonable if one is willing to wait for it to take effect. It would also be less likely to help adequately since the patient is having intense pain. Choice c is controversial because the prolonged use of corneal topical anesthetics is said to increase the risk of corneal complications because this blocks the eye's natural protection reflexes to minimize further corneal injury; however there is evidence that refutes this.
3. The differential diagnosis consists of corneal foreign body, conjunctival foreign body, early conjunctivitis. The eyelids should be everted to look for small foreign bodies. If possible, the cornea should be inspected again under magnification to look for a foreign body as well. Ophthalmology consultation should be obtained if the cause of the pain cannot be determined.
4. A patient with a corneal abrasion that uses contact lenses should be prescribed an antibiotic that covers for pseudomonas (such as moxifloxacin). Prescribing an antibiotic that covers for pseudomonas is not necessary for a patient with a corneal abrasion who does not use contact lenses.
5. The patient should have an ophthalmology consult as soon as possible. A metal shield should be placed on the eye, NOT a gauze eye patch (which can press on the eyeball), to decrease further chance of injuring the eye. He should likely be admitted to the hospital for bedrest and eye monitoring to assess for re-bleeding.


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