Managing corneal abrasions in primary care By Scott J. Saccomano, PhD, RN, GNP-BC and Lucille R. Ferrara, EdD, RN, MBA, FNP-BC Abstract: Corneal abrasion is a common eye injury that occurs in all age-groups. A focused history and physical exam can identify patients with corneal abrasions and improve intervention time. Minor corneal abrasions usually heal within 48 hours without complications or eye dama
This week we will look at 2 conditions that are frequently seen in primary care settings, corneal abrasions and otitis media. For each condition, describe the pathophysiology, signs and symptoms, diagnostic criteria, treatment and potential complications. Be sure to discuss antibiotic use in both conditions
NPR0914_Online Exclusive_Puneet.indd 1 The Nurse Practitioner Copyright © 2014 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited. orneal abrasion is a common eye injury that occurs in all age-groups. Contact lens wearers are a par- ticularly vulnerable population for a corneal abra- sion. Aside from contact lens use, corneal abrasions usually result from tangential impacts or the presence of foreign body debris.1 They are the most common nonpenetrating eye injury in children.2 Corneal abrasions are a direct result of ocular trauma and account for more than 65,000 work- related eye injuries.1 The majority of work-related eye inju- ries occur in men between ages 25 and 44, and most of these are automotive workers between ages 20 and 29.3,4 ■ Populations affected by corneal abrasion Corneal abrasion should be among the differential diagnoses in infants and newborns with sudden onset of unexplained crying. Fingernail length and the method used to trim the fi ngernails are common causes of corneal abrasions in this population.5 Other differentials should also be considered to rule out more serious causes of unexplained crying. In younger children and adolescents, objects (mainly toys) are a common cause of corneal abrasions as well as sports injuries, such as those caused by paintball.6 Chronic dry eye is a common cause for corneal abrasions in older adults, which can be prevented with lubricants and ointments.7 Other causes of corneal abrasions include dust, chemicals, damaged or soiled contact lenses, sand, animal paws, and common foreign objects, such as makeup brushes. Eye injuries sustained intraoperatively during eyelid surgery have also been documented. ■ Pathophysiology The cornea is the clear, transparent, anterior surface of the eye covering the pupil and the iris that protects the eye from harmful matter, such as dust and germs (see Transverse section of the eyeball). As the outermost lens of the eye, the cornea regulates and controls the majority of the eye’s focusing function. In addition, the cornea is a fi lter, screen- ing out some of the most dangerous and damaging UV waves from the sun. A constant wash of tears protects the cornea from dryness. The cornea receives light transmission through the lens to the retina and separates the anterior chamber fl uid from the external environment.4,8 The cornea has fi ve layers: the outer most layer is the epithelium, followed by the Bowman membrane, the stroma, C Managing corneal abrasions in primary care By Scott J. Saccomano, PhD, RN, GNP-BC and Lucille R. Ferrara, EdD, RN, MBA, FNP-BC Abstract: Corneal abrasion is a common eye injury that occurs in all age-groups. A focused history and physical exam can identify patients with corneal abrasions and improve intervention time. Minor corneal abrasions usually heal within 48 hours without complications or eye damage. Keywords: abrasion, blurred vision, cornea, corneal abrasion, eye, eye pain, red eye, vision NPR0914_Online Exclusive_Puneet.indd 1NPR0914_Online Exclusive_Puneet.indd 1 12/08/14 6:31 PM12/08/14 6:31 PM 2 The Nurse Practitioner Copyright © 2014 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited. Management of corneal abrasions the Descemet membrane, and the endothelium. The surface epithelial layer provides a barrier function to prevent the passage of foreign materials into the eye and other corneal layers. The Bowman layer is a thicker basement protecting the cornea from injury. The stromal layer is composed of a matrix of collagen fibers providing strength, form, and elasticity to the cornea. The Descemet layer lies between the stroma and the endothelium in an inner layer of the base- ment membrane and is composed of endothelial cells pro- tecting the cornea from injury and infection. The last layer, the endothelium, is a barrier and pump that prevents the cornea from getting too wet and also keeps it clear. The cornea’s transparency is due to the lack of blood vessels or cells. However, it is innervated by low-threshold pain fi bers, meaning that even a minor injury (such as a corneal abra- sion) can cause signifi cant pain.1,4,8,9 A corneal abrasion is a defect in the superfi cial surface of the cornea. The injury is limited to the outer epithelium and penetrates into the Bowman layer. The term “corneal ulcer” is used in the event of severe corneal injuries Transverse section of the eyeball The following illustration shows (A) the transverse section of the eyeball and (B) an enlargement of the anterior and posterior chambers of the eye, showing the layers of the cornea, the iris, aqueous drainage system, and the ciliary body. Source: Porth CM. Essentials of Pathophysiology Concepts of Altered Health States. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:970. Pupil Conjunctiva Posterior chamber Retina B A Choroid Sclera Lateral rectus muscle Fovea centralis Optic nerve Medial rectus muscle Retinal blood vessel Vitreous body Sclera Lens Optic disk Anterior chamber Zonular fibers Ciliary body Ora serrata Canal of Schlemm Trabecular meshwork Epithelium Stroma Cornea Endothelium Dilator muscle Pigment layer Sphincter muscle Descemet membrane Bowman membrane Iris Lens NPR0914_Online Exclusive_Puneet.indd 2NPR0914_Online Exclusive_Puneet.indd 2 12/08/14 6:31 PM12/08/14 6:31 PM 3 The Nurse Practitioner Copyright © 2014 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited. Management of corneal abrasions penetrating deeper through the stromal layer. Upon injury, the epithelium adjacent to the injury multiplies to fi ll in the injured area. Epithelial injuries usually heal quickly and completely within 24 to 48 hours. Injuries to the depth of the Bowman layer may leave permanent scarring.10 The healing process begins as the epithelial cells undergo mito- sis, enabling newly- generated cells to enter and cover the defect; healthy cells patch the injury, preventing infection and minimizing visual defects.11 Corneal abrasions within the spectrum of mechanical ophthalmic trauma can be categorized into closed and/or open globe injuries, eyelid wounds, and orbital injuries.4,12 ■ Diagnosis Clinical presentation and eye exam are key factors in diagnosing corneal abrasion. An in-depth patient history is key for arriving at an accurate diagnosis and will guide the physical exam. Mon- ocular eye pain is a hallmark symptom associated with corneal abrasion and is the usual presenting complaint either in the offi ce or the ED. Eye pain can range from mild to moderate depending on the severity of the abrasion. Patients may also be uncomfortable with activities, such as driving, reading, report sleep disruption, and increased time off from work. In addition to eye pain, patients can report other symptoms, such as tearing, painful extraocular eye movements, photophobia, and a scratch- ing or gritty sensation of “foreign body” in the eye. Decreased or blurred vision and conjunctival redness may also be present in the affected eye.4,10,13 History and eye exam. General history should include past and present illnesses, current medications, and allergies to any medications or eye drops. The patient’s ocular history should include the following9,14,15: • Any changes in visual acuity noted? • Any vision problems prior to this incident? • Does the patient wear contact lenses? • Does the patient wear glasses? • Has there been a history of eye trauma in the past? • How did it start? • How long has eye discomfort been present? • Was the onset of symptoms sudden or gradual? • Ask the location and radiation of eye “foreign body sensation.” • Was protective eyewear being used at time of injury? • Was this a chemical injury? If so, what chemical, and what action was taken? • What is the patient’s occupation? • Has the patient been exposed to bright UV light, such as sunlight or tanning beds? • Was there recent eye trauma? • Did the patient participate recently in any sports activities? • Is there excessive eye rubbing or scratching? • Does the patient apply eye makeup? If so, how frequently and what is the application technique? The history can determine clues to the precipitating events or other possible diagnosis. Wearing contact lenses can cause trauma and dry eye if not removed when required.16 Changes in visual acuity can indicate a possible lesion, onset symptoms can aid in diagnosis, and a history of past eye problems may reveal eye distortion from previous trauma. When patients are exposed to bright UV lights such as sunlight and tanning beds, the cornea can be damaged even with closed eyelids.4 Symptoms may not necessarily occur immediately after the injury, and patients may not be aware of a specifi c event that may have contributed to the eye injury. Eye exam includes eye inspection, visual acuity, and eye movement. The eye exam begins with inspection. The cor- nea should be assessed for transparency and should be smooth, clear, and shiny. Any infl ammation of the eyelids should also be assessed, including any eye redness. It is important to note the distribution of eyelashes and the presence or absence of any infl ammation at the base of the eyelashes. The conjunctiva and sclera should be evaluated for any discharge. The amount and type of discharge should be noted if present. The eyes are to be inspected for any foreign body by everting the eyelids to inspect the eye for substances, such as sand, ash, dirt, sawdust, or other foreign Corneal abrasion with fl uorescein staining Source: Gerstenblith AT and Rabinowitz MP. The Wills Eye Manual: Offi ce and Emergency Room Diagnosis and Treatment of Eye Disease. 6th. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. NPR0914_Online Exclusive_Puneet.indd 3NPR0914_Online Exclusive_Puneet.indd 3 12/08/14 6:31 PM12/08/14 6:31 PM 4 The Nurse Practitioner Copyright © 2014 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited. Management of corneal abrasions particles that can get trapped under the eyelid and cause pain when blinking.9,15,17,18 The Snellen chart helps assess whether or not the patient’s visual acuity is normal. Visual acuity may be affected by a corneal abrasion in the visual axis.18 A decrease in visual acuity is suggestive of more severe ocular conditions (requir- ing immediate referral to an ophthalmologist), such as keratitis, glaucoma, or infl ammation of the iris. Visual fi elds