Rosen & Barkin's 5-Minute Emergency Medicine Consult (178 page)

• Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: Meta-analysis of randomized trials.
  Acad Emerg Med.
  2005;12:467–473.
  
• Ehlers JP, Shah CP, eds.
  The Wills Eye Manual
  . 5th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2008.
  
• Jacobs DS. (2012). Corneal abrasions and corneal foreign bodies. Retrieved from
  www.uptodate.com
  
• Koenig KL. (2010). Dilute proparacaine for pain from corneal abrasion. Retrieved from Journal Watch Specialties (online).
  
• Turner A, Rabiu M. (2009). Patching for corneal abrasion.
  Retrieved from Cochrane Database Syst Rev.
  
• Van Niel CW. (2010). Corneal abrasions in crying infants: A red herring. Retrieved from Journal Watch Specialties (online).
  
• Verma A. (2011). Corneal abrasion. Retrieved from
  www.emedicine.com
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conjunctivitis
  
• Corneal Burn
  
• Corneal Foreign Body
  
• Red Eye
  
• Ultraviolet Keratitis
  

CODES

918.1 Superficial injury of cornea

BASICS

• Inappropriate exposure of cornea to chemicals, heat, cold, electrical, or radiant energy causing damage to the cornea and often extending to adjacent structures
  
• Severity of injury related to duration of exposure, type of agent, anion concentration, pH level of solution
  
• Alkalis:
  
  • Cause immediate rise in pH level
    
  • Highly soluble in lipids, so rapidly penetrate the eye, causing severe corneal injury and continue to penetrate over time if no intervention undertaken
    
  • Penetration can occur in <1 min.
    
  • Exception: Calcium alkalis penetrate relatively poorly secondary to soap formation; can cause corneal opacification, so may appear worse but actually have better prognosis than other alkali burns.
    
• Acids:
  
  • Immediately coagulate proteins of corneal epithelium
    
  • Cause opacification
    
  • Coagulation produces barrier to deeper penetration
    
  • Exception: Lipophilicity of hydrofluoric (HF) acid causes it to act similar to a base with more rapid penetration
    
• Thermal burns:
  
  • Affect eyelids more than globe due to reflex blinking and Bell phenomenon (eyes roll up and outward)
    
  • Cause direct injury to cornea
    
  • Damage primarily depends on duration and intensity of heat
    
• Electrical injury:
  
  • Occurs with current flow through head, with input at or near eye
    
• Radiation injury:
  
  • Due to ultraviolet light exposure to cornea
    

• Alkalis:
  
  • Ammonia:
    
    • Fertilizer, refrigerant, household ammonia, cleansing agents
      
  • Potassium hydroxide:
    
    • Caustic potash
      
  • Magnesium hydroxide:
    
    • Sparklers, flares, fireworks
      
  • Lye: NaOH:
    
    • Caustic soda, drain cleaners
      
  • Lime: CaOH
    ₂
    or MgOH
    ₂
    :
    
    • Fresh lime, quicklime, calcium hydrate, slaked lime, hydrated lime, plaster, mortar, cement, whitewash
      
  • Nonspecific alkali:
    
    • Motor vehicle airbag on inflation releases alkali.
      
• Acids:
  
  • Sulfuric acid: H
    ₂
    SO
    ₄
    :
    
    • Car battery acid, toilet cleaner
      
  • Sulfurous acid: H
    ₂
    SO
    ₃
    :
    
    • Preservatives (fruit and vegetable)
      
  • Acetic acid: CH
    ₃
    CO
    ₂
    H:
    
    • Vinegar
      
• Bleach
  
• Refrigerants:
  
  • HF acid:
    
    • Etching silicon/glass
      
    • Cleaning brick
      
    • Electropolishing metals
      
    • Control of fermentation in breweries
      
    • Commercial/household rust removal
      
• Thermal:
  
  • Hot liquids, molten metal
    
  • Flames
    
  • Hot smoke/gases
    
  • Flash burn
    
  • Steam
    
  • Cigarette burns
    
• Radiation:
  
  • Sun lamps
    
  • Tanning booths
    
  • High-altitude sunlight
    
  • Reflection off snow/water
    
  • Arc welding
    

Consider child abuse or neglect.

DIAGNOSIS

• Severe ocular pain
  
• Photophobia
  
• Lacrimation
  
• Foreign body sensation
  
• Conjunctival injection
  
• Corneal edema
  
• Corneal opacification
  
• Impaired visual acuity
  
• Limbal blanching
  
• Lens opacification
  
• Vesicles clear fluid (hypothermal injury)
  
• Vesicles hemorrhagic fluid
  
• Necrosis of iris, ciliary body
  

• Type of exposure:
  
  • Inspect any bottles accompanying the patient for active and inactive ingredients
    
• Vehicle of exposure:
  
  • Aerosol: Common
    
  • Propellant: May result in intraocular foreign body/perforation
    
• Duration of exposure
  
• Time of onset
  
• Time irrigation initiated
  
• Pre-existing visual impairment
  
• Protective eyewear
  
• Contact lens use
  
• Treatment before arrival
  

Complete eye exam (after irrigation):

• Visual acuity
  
• Bright white light for visual inspection of cornea/conjunctivae/limbus
  
• Slit-lamp to evaluate anterior segment inflammation
  
• Fluorescein stain:
  
  • Corneal epithelial damage:
    
    • Punctate corneal lesions with discrete lower border from inferior lid seen in UV radiation burns
      
  • Perforation (Seidel test)
    
• Check for lenticular clarity
  
• Fundus exam
  
• Measure intraocular pressure (especially in delayed presentation)
  
• Lid/eyelash exam
  
• Check pH with acid/alkali burns with litmus paper or pH indicator on urine dipstick
  

• Fluorescein stain
  
• Check pH
  

• Infection:
  
  • Viral keratitis
    
  • Corneal ulcer
    
• Corneal erosion syndrome:
  
  • Corneal foreign body
    
  • Corneal abrasion
    
  • Hypothermal injury
    

Handheld slit-lamp and Wood lamp helpful in exam of child’s eye

TREATMENT

• Irrigate at scene 15–30 min unless other coexisting life-threatening conditions require immediate transfer
  
• Bring bottle of substance to hospital
  
• Continuous irrigation en route to hospital with NS or water
  

• Chemical exposure:
  
  • Suspect acid or alkali in all exposures to unknown substances
    
  • Irrigate with any available diluting substance but preferably water or NS
    
• Thermal exposure:
  
  • Cool-moist dressing with overlying ice packs