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INTRODUCTION

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Corneal Perforation and Rust Ring. This patient was using a compressed air wire wheel brush when a wire came loose and lodged in the cornea. He was not wearing safety glasses. The wire was removed in the operating room where it was found to penetrate fully through the cornea and required one corneal suture. Interestingly, the rust ring had formed around the wire only about 3 hours after this injury occurred. (Used with permission from Brice Critser, CRA, The University of Iowa and EyeRounds.org.)

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The authors acknowledge the special contributions of Dallas E. Peak and Carey D. Chisholm for contributions to prior editions.

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CORNEAL ABRASION

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Clinical Summary

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Corneal abrasions present with acute onset of eye discomfort, tearing, and often a foreign-body sensation. A “ciliary flush” (conjunctival injection hugging the limbus) may be seen. Large abrasions or those in the central visual axis may affect visual acuity. Photophobia and headache from ciliary muscle spasm may be present. Associated findings or complications include traumatic iritis, hypopyon, or a corneal ulcer. Fluorescein examination, preferably with a slit lamp, reveals the defect.

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Management and Disposition

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Instillation of topical anesthetic drops facilitates examination while relieving pain and blepharospasm. Consider using a short-acting cycloplegic (eg, cyclopentolate 1%, homatropine 5%) to reduce pain from ciliary spasm in patients who complain of headache or photophobia. Consider oral opioid analgesics for pain control. Nonsteroidal anti-inflammatory drug (NSAID) eye drops (eg, diclofenac or ketorolac) are equally effective and avoid risks of sedation. Neither treatment with topical antibiotics, nor patching, nor tetanus prophylaxis for uncomplicated corneal abrasions has scientific validation. Follow-up is advised for any patient with complications, or who is still symptomatic after 24 hours.

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Pearls

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  1. Mucus may simulate fluorescein uptake, but its position changes with blinking.

  2. Multiple linear corneal abrasions, the “ice-rink sign,” may result from an embedded foreign body (FB) adhered to the upper lid. Always evert the lid to evaluate this.

  3. Whenever the mechanism includes grinding or striking metal, or high-velocity injuries from mowers or string trimmers, maintain a high index of suspicion for penetrating injury. Fluorescein streaming away from an “abrasion” (Seidel test) may be an indication of a corneal perforation.

  4. Routine prophylactic treatment with topical antibiotics remains controversial. When used, inexpensive, broad-spectrum antibiotic drops (sulfacetamide sodium or trimethoprim/polymyxin B) allow clearer vision than lubricating ointments, which may feel better, but blur vision. Avoid topical neomycin antibiotics because of a high risk of irritant allergy symptoms in many people.

  5. An “abrasion” in a contact lens wearer should alert one to suspect a corneal ulcer. Consult ophthalmology while the patient is in the emergency department.

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FIGURE 4.1

Corneal Abrasion. A small abrasion is seen at the 3-o’clock position, just across the larger white reflection ...

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