Preparation

• Gloves
• Fluorescein stain
• Ophthalmic anesthetic drops (e.g., tetracaine)
• Ophthalmoscope
• Cotton-tipped applicator

Procedure Steps

Step 1: Health history and physical assessment

Assess timing of the complaint, mechanism of injury, eye surgeries, prescription drop use, corrective glasses/contact lens use. Anesthetize as needed to facilitate a thorough eye examination.

Physical assessment:

• Visual acuity (Snellen eye chart, near vision)
• Visual fields (confrontation test)
• Extraocular muscle function (corneal light reflex, cover test, cardinal positions of gaze)
• External eye structures
• Anterior eyeball structures (cornea and lens, iris and pupil)
• Ocular fundus (elicit red light reflex at minimum)

Step 2: Instill ophthalmic anesthetic drops

Anesthetic can make assessment of the pupils and fundus difficult due to pupillary constriction.

Pull down on the lower eye lid to create a well. Tilt the client’s head back and instill 1-2 drops. Have the patient blink to distribute the drops. Instill just prior to evaluation. Tetracaine: onset of action 30 seconds; duration of action 10-20 minutes.

Step 3: Instill fluorescein stain

Pull down the lower lid and allow a drop of the fluorescein stain to run off into the eye. Have the patient blink to distribute the stain over the ocular surface.

Note: The fluorescein stain examination should only be completed after the assessment of visual acuity, penlight examination of the pupils, and the fundus. Instillation prior may interfere with visual acuity measurement and visualization of the pupils and fundus.

Step 4: Inspect the cornea

Stained abrasion appears yellow with the naked eye; visualization is enhanced with the use of a cobalt blue filter on an ophthalmoscope. There is increased uptake of the dye by the abrasion or ulcer. Abrasions appear linear and ulcers appear rounded and crater-like.

Step 5: Assess for retained foreign body under the upper lid

• Ask patient to keep both eyes open and look down to keep the eyelid relaxed
• Slide upper lid along bony orbit to life up the eyelashes
• Grasp the eyelashes between your thumb and forefinger and pull down and outward
• Use the other hand to place the cotton-tipped applicator on the upper eye lid
• Push down with the stick as the lashes are lifted up to flip the upper eyelid inside out. Do not push on the eyeball with the stick
• Maintain the everted position by holding the lashes against the bony orbit rim
• Inspect for foreign bodies, color changes, swelling, or lesions
• See chapter titled “Removal of Foreign Body (Eye)” if present.

Step 6: Prescribe topical antibiotic therapy if corneal abrasion present

Avoid use of antibiotic preparations that contain corticosteroids as this can delay healing.

Non contact lens wearers:
• Erythromycin ointment QID x 3-5 days
Contact lens wearers:
• Choose antibiotic with pseudomonas coverage such as a fluoroquinolone

Video

Aftercare

• Oral NSAIDs for pain relief.
• Avoid rubbing the eye to prevent further damage.
• Avoid use of contact lenses until symptoms have resolved.
• Small corneal abrasions are self-limited and typically heal within 24-48 hours.
• Topical antibiotics are recommended for corneal abrasions to prevent secondary bacterial infection.
  • Consider ointment versus drops as ointment functions as a lubricant.
  • Antibiotic preparations containing corticosteroids should be avoided as they slow epithelial healing and can increase the risk of secondary infection.
  • Non-contact lens wearers: Erythromycin ointment.
  • Contact lens wearers: requires Pseudomonas coverage (i.e., ciprofloxacin).

Patient Education

Follow-up

• Consider daily follow-up for large corneal ulcers until healing has occurred due to increased risk of secondary bacterial infection
• Return if symptoms persist beyond 48 hours
• Return of symptoms continue to worsen in the initial 24-48 hours
• Pediatric patients who are unwilling to open their eye after 24 hours should be referred to ophthalmology

Key Takeaways

• Assessment for corneal abrasion is one part of the comprehensive eye exam.
• The fluorescein stain examination should only be completed after the assessment of visual acuity, penlight examination of the pupils, and the fundus.
• Small corneal abrasions are self-limited and typically heal within 24-48 hours.
• Ophthalmic antibiotics are recommended if a corneal abrasion or ulcer is present to prevent a secondary bacterial infection.