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Corneal Abrasion, Exposure Keratopathy, Ulceration

Jonathan A. Barnett

Background

  • Corneal abrasion = corneal epithelial defect (KED): an area of missing corneal epithelium. This is akin to a scratch on the skin. Most common causes include trauma, excessive surface dryness, infection, and neurotrophic disease

  • Exposure keratopathy = development of corneal epithelial defects secondary to incomplete closure of the eyelids (i.e., prolonged exposure of the cornea to air). Most often occurs in patients who are intubated/sedated, have poor orbicularis tone/paralysis (Bell palsy), or have abnormal blink rate (e.g., Parkinson’s).

  • Corneal ulceration = the injury extends past the corneal epithelium and ‘ulcerates’ into the underlying stroma. Ulcerations are often infectious and develop after untreated abrasions (abrasions are essentially open wounds). In rare cases ulcerations can also be sterile (autoimmune/inflammatory).

Presentation and Evaluation

  • Abrasions and ulcerations are often extremely painful. May be exacerbated by blinking.

  • Conjunctival injection; but sometimes the eye can appear normal, or only have trace redness, and the pain may seem out of proportion to external appearance.

  • Mucus discharge /crusting

  • Photophobia and tearing

  • Blurry vision

  • Ulcerations will present with the above, but also have a whitish infiltrate in the cornea. The conjunctival injection and discharge will often be a lot worse.

  • 1 drop of Proparacaine 0.5% will improve pain

    • Note: Proparacaine is used only for diagnostic, and not therapeutic, purposes. Do not administer proparacaine on a scheduled or PRN basis for pain. The duration of action is only 15 minutes, and repeated chronic use can lead to corneal melt/ulceration.

  • 1 drop of Fluorescein followed by shining a blue light (or Wood’s lamp) will reveal the KED.

Management

  • VUMC Perioperative Corneal Abrasion Protocol

    • If patient is recently postop, or underwent recent extubation, and presents with eye pain/burning, blurry vision, redness, photophobia, VUMC has a periop corneal abrasion protocol (do not place ophthalmology consult):

      • Erythromycin ophthalmic ointment TID into the lower fornix of eye x5 days

      • If the pain and redness do not improve within 48 hours, then consult ophthalmology

  • Corneal Abrasion

    • If patient’s signs and symptoms are consistent with a corneal abrasion, try erythromycin ophthalmic ointment TID as above.

    • If the pain and redness do not improve within 48 hours, or have other concerns, consult ophthalmology

  • Exposure Keratopathy

    • If patient is intubated and sedated, or cannot otherwise fully close his/her eyes, take the following measures to prevent development of corneal abrasion or ulceration:

      • Moisture chambers (aka bubble shields) to eyes at all times

      • Copious amount of lubricating ophthalmic ointment (e.g., Lubrifresh) in eyes TID

  • Corneal Ulceration

    • If you see whitish material in the cornea itself, this is likely a corneal ulceration and warrants an ophthalmology consult.