1. Corneal Injury
Presented by
Atul Lawrence
M.Sc Nursing 1st year
RPCON

2. Anatomy
The cornea is a transparent cover over
the anterior part of the eye that
serves several purposes: protection,
refraction, and filtration of some
ultraviolet light. It has no blood
vessels and receives nutrients
through tears as well as from the
aqueous humor. It is innervated
primarily by the ophthalmic division
of the trigeminal nerve as well as the
oculomotor nerve.

3. Cont…
 The
cornea is composed of the
following 5 layers (anterior to
posterior):
 Corneal epithelium
 Bowman layer
 Corneal stroma
 Descemet membrane
 Corneal endothelium

5. Corneal injury
Corneal injury describes an injury
to the cornea. The cornea is the
crystal clear (transparent) tissue
covering the front of the eye. It
works with the lens of the eye to
focus images on the retina.

6. Causes

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Injuries to the outer surface of the cornea, called
corneal abrasions, may be caused by:
Chemical irritation from almost any fluid that gets into
the eye
Overuse of contact lenses or lenses that don't fit
correctly
Reaction or sensitivity to contact lens solutions and
cosmetics
Scratches or scrapes on the surface of the cornea
(called an abrasion)
Something getting into the eye (such as sand or dust)
Sunlight, sun lamps, snow or water reflections, or arcwelding

7. Cont..

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Infections may also damage the cornea.
You are more likely to develop a corneal injury if
you:
Are exposed to sunlight or artificial ultraviolet
light for long periods of time
Have ill-fitting contact lenses or overuse your
contact lenses
Have very dry eyes
Work in a dusty environment
High-speed particles, such as chips from
hammering metal on metal, may become
embedded in the surface of the cornea. Rarely,
they may pass through the cornea and go deeper
into the eye.

8. Corneal abrasion
Corneal abrasion is probably the most
common eye injury and perhaps one
of the most neglected. It occurs
because of a disruption in the
integrity of the corneal epithelium or
because the corneal surface scraped
away or denuded as a result of
physical external forces. Corneal
epithelial abrasions can be small or
large

9. Cont…


Corneal abrasions usually heal rapidly, without
serious sequelae. But deep corneal involvement
may result in facet formation in the epithelium or
scar formation in the stroma.
Corneal abrasions occur in any situation that
causes epithelial compromise. Examples include
corneal or epithelial disease (eg, dry eye),
superficial corneal injury or ocular injuries (eg,
those due to foreign bodies).

11. Pathophysiology

12. Potential causes of corneal abrasion
include the following:

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Injury (eg, fingers, fingernails, paper, mascara
brushes, tree branches, self-inflicted rubbing,
pepper-spray exposure, automotive frontal air
bags)
Blowing dust, sand, or debris
Extended contact lens wear
Ocular foreign bodies embedded under an eyelid
Iatrogenic - Unconscious patients, accidental
injury by health care workers, improper eyelid
patching in patients with Bell palsy, and other
neuropathies in which the eyelid cannot be closed
voluntarily
Corneal foreign bodies

13. Cont…
UV keratitis - History of exposure to
electric arc welding or tanning beds
without proper eye protection, history of
prolonged exposure to bright sunlight
without sunglasses (eg, snow blindness)
 In persons with trachoma, the constant
corneal abrasion by lashes and inadequate
tears can produce corneal erosions,
ulceration, and scarring. These constitute
the major pathway to blindness in
trachoma.


14. 
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Contact lens trauma
Contact lens–induced epithelial defects or direct trauma
during lens insertion or removal can cause corneal
abrasions.
The most common trauma is an inferior abrasion of the
cornea caused by lens removal. Sometimes, the person's
fingernail slices the contact lens and also the cornea.
More often, the lens becomes slightly dehydrated at the
end of the day because of insufficient blinking. The lens
adheres to the cornea, removing the epithelium. This area
may not heal well, especially if the epithelial cells are
continually torn away. After the contact lens is removed,
the patient may feel discomfort; however, no pain occurs
when the lens is worn because it acts as a bandage.
Patients who incompletely blink and those who work in a
dry environment, read most of the day, or look at TV or
computer screens should be warned about this
complication.

15. Cont…
A foreign body may become trapped under a contact lens
and produce linear scratch marks on the cornea. The
total irregularity of these wavy abrasions is the clue to
this cause of injury.
 overnight wearing of soft lenses, which do not provide
sufficient oxygen transmissibility to prevent hypoxia,
causes superficial desquamation of epithelium and
increases the propensity for abrasions.
 Corneal swelling induced by overnight wearing of
contact lenses is the most important factor. The cornea
normally swells 2-4% during sleep. With a contact lens,
overnight swelling increases to an average of 15%, and
gross stromal edema can be present on awakening. In
some patients, induced corneal swelling can be
sufficient to cause bullae; these can rupture, leading to
epithelial defects.

17. Sports-related injury
Corneal abrasions can occur in almost all
sports. They most frequently occur in
young people.
 In places where soccer is played
frequently, impact with the soccer ball
causes approximately one third of all
sports-related eye injuries. Contrary to
previous ophthalmologic teaching that
balls larger than 4 inches in diameter
rarely cause eye injury, 8.6-inch soccer
balls cause most soccer-related eye
injuries, both serious


18. Cont…
 Approximately
1 in 10 college
basketball players has an eye injury
each year. Most basketball-related
eye injuries are corneal abrasions
caused by an opponent's finger or
elbow striking the player's eye.
 The incidence of severe eye injuries
in wrestling is low.

19. Eyelid surgery
 In
patients undergoing eyelid
surgery, corneal abrasion can result
from sutures inadvertently placed
through the tarsus or conjunctival
surface. After sutures are placed, the
lid should be everted to check that
they are not exposed.
 The globe and cornea should be
protected during dissection and
suture placement. A contact lens
corneal protector or lid plate can be
used.

20. Anesthesia


General anesthesia is more likely to cause adverse
systemic effects than local or ocular complications.
Ocular problems that do occur are usually not
serious and include corneal abrasion, chemical
keratitis, hemorrhagic retinopathy, and retinal
ischemia (rare).
The incidence of corneal abrasion from general
anesthesia is as high as 44%. Simple precautions,
such as instilling a bland ointment or taping the
lids of the nonoperative eye closed, may prevent
surface trauma produced by the surgical drape,
anesthetic mask, or exposure. Decreased tear
production under general anesthesia, proptosis,
and a poor Bell phenomenon may worsen corneal
exposure, requiring eyelid suturing in some
susceptible patients.

21. Tonometry
The plunger can cause corneal abrasion if the
eye or tonometer moves during measurement.
In addition, if the disinfectant solution (eg,
alcohol) is not removed from the plunger, it can
cause a local chemical keratitis where it
touches the cornea.
 The Schiøtz tonometer must be used in the
supine position or in the sitting position with
the head back far enough to be horizontal. An
initial blink or avoidance reaction may occur as
the patient sees the tonometer descending
toward the eye.


22. Physical Examination
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Visual acuity should be assessed. If the abrasion affects
the visual axis, there may be a deficit in acuity that
should be apparent when compared to the uninjured
eye.
If the examination is limited by pain, a topical
anesthetic such as tetracaine or proparacaine may be
used. The amount of anesthetic used should be
minimal, as these agents have been shown to slow
wound healing.
Visual inspection for foreign objects should be
performed. Both upper and lower eyelids should be
flipped in order to look for foreign bodies that may be
lodged in the upper eyelid, causing injury with eye
blinking.
The cornea can become hazy if there is edema due to
the abrasion. Conjunctival injection, usually located

23. Slit Lamp Examination
A topical anesthetic (ie, proparacaine,
tetracaine) may facilitate the slitlamp examination. Severe
photophobia that causes
blepharospasm may require
instillation of a cycloplegic agent (ie,
cyclopentolate [Cyclogyl],
homatropine) 20-30 minutes prior to
examination.

24. fluorescein instillation
 Perform
fluorescein instillation and
examination with blue light. Fluorescein
can permanently stain soft contact
lenses. Do not forget to remove such
lenses before applying the stain.
 Fluorescein is applied using a paper
strip applicator that is gently placed
over the inferior cul-de-sac of the eye
and allowing saline or anesthetic
solution to drop into the eye. Once the
patient blinks, the dye is spread over
the cornea.

25. Treatment
Corneal abrasions heal with time.
Prophylactic topical antibiotics are given
in patients with abrasions from contact
lenses. Traditionally, topical antibiotics
were used for prophylaxis even in noninfected corneal abrasions not related to
contact lenses, but this practice has been
called into question.

26. Cont…
Patching the eye has been used to help
relieve the pain associated with corneal
abrasion, but research has not shown
benefit from patching. Patching should
not be performed in patients at high
risk of infection, such as those who
wear contact lenses and those with
trauma caused by vegetable matter,
because of potential incubation of
infecting organisms and promoting
subsequent infectious keratitis.

27. Cont..
Some ophthalmologists advocate the use of
diclofenac (Voltaren) or ketorolac (Acular)
drops with a disposable soft contact lens in
addition to antibiotic drops. This therapy may
be an effective alternative to patching, as it
allows the patient to maintain binocular vision
during treatment and reduces inflammation.
 Patients with all but the most minor abrasions
usually require a strong oral narcotic analgesic
initially. In addition, topical cycloplegics may be
required to relieve pain and photophobia in
patients with large abrasions until their healing
is nearly complete.


28. Cont.
Emergent ophthalmologic consultation
is warranted for suspected retained
intraocular foreign bodies. Urgent
consultation is needed for suspected
corneal ulcerations (microbial
keratitis).

29. Cont.
Fluoroquinolones (eg, ofloxacin) are probably the
most common agents used for prophylaxis with
corneal abrasions because of their broadspectrum coverage and low toxicity and
because of the low resistance of commonly
acquired organisms to these drugs. In addition,
fluoroquinolones have proven efficacy in the
treatment of bacterial corneal ulcers. Prolonged
and low-frequency dosing should be avoided to
discourage the emergence of resistant
organisms due to subinhibitory antibiotic
concentrations on the ocular surface.

30. Cont..
For large or dirty abrasions, many practitioners
prescribe broad-spectrum antibiotic drops, such
as trimethoprim/polymyxin B (Polytrim) or
sulfacetamide sodium (Sulamyd, Bleph-10),
which are inexpensive and least likely to cause
complications. Alternatives are an
aminoglycoside or a fluoroquinolone.
 Abrasions due to contact lenses warrant
antibiotic treatment because of their propensity
to become infected corneal ulcers. Coverage for
gram-negative organisms
(especially Pseudomonas species) with agents
such as gentamicin (Garamycin), tobramycin
(Tobrex), norfloxacin (Chibroxin), or
ciprofloxacin (Ciloxan) is recommended.


31. Cont..
Antibiotic drops are more comfortable
than ointments but must be
administered every 2-3 hours.
Antibiotic ointments (eg, bacitracin,
polymyxin/bacitracin, erythromycin,
ciprofloxacin) retain their antibacterial
effect longer than drops and thus can
be used less often (every 4-6 h), but
they are more uncomfortable because
they can cause visual blurring.
Ointments are frequently used in
children whose crying washes out the
drops.

32. Cont..
Avoid antibiotics containing neomycin
(eg, Neosporin) because of the high
incidence of allergy to neomycin in
the general population. The use of
prophylactic periocular injections or
systemic administration of antibiotics
after corneal abrasions is
controversial.

33. Pain Management

The pain of corneal abrasions may be severe
and should be treated with nonsteroidal antiinflammatory drops and, if necessary, a soft
bandage contact lens. Narcotic analgesia is
occasionally required on a short-term basis.
These are continued until the pain decreases to
the point that it can be managed with over-thecounter analgesics.

34. Cont..
 Instillation
of a long-acting cycloplegic
agent can provide significant relief for
patients with marked photophobia and
blepharospasm. These agents relax any
ciliary muscle spasm that may cause a
deep, aching pain and photophobia.
Cycloplegic agents are mydriatics;
therefore, to prevent an episode
of acute angle closure glaucoma, ensure
that the patient does not have narrowangle glaucoma.

35. Management of Small Corneal Abrasions
Small abrasions can be managed on an
outpatient basis. Ice compresses should be
used for 24-48 hours to reduce edema. Warm
compresses can be used thereafter.
 Inform patients about the signs of wound
infection, including increasing pain, erythema,
edema, and purulent discharge. This helps in
making the decision for early antibiotic
intervention.
 Patients must be informed about the signs and
symptoms of complications, such as foreign
body sensation, conjunctival injection, and
decreased vision, so that treatment can be
initiated promptly.


36. Patching
"Eye patching was not found to
improve healing rates or reduce pain
in patients with corneal abrasions.
Given the theoretical harm of loss of
binocular vision and possible
increased pain, the route of harmless
nonintervention in treating corneal
abrasions is recommended."

37. Follow-Up Care

Close follow-up care of corneal abrasions is
necessary because of the danger of the
abrasion progressing to an ulcer. Essentially all
corneal ulcers begin with an abrasion.
Abrasions resulting from vegetable matter are
at high risk for fungal ulcers. Abrasions
resulting from contact lens wear should be
monitored forPseudomonas infection and
amebic keratitis.

38. Cont..
Patients with abrasions should receive
follow-up care until healing is complete
and the fluorescein stain is negative, to
confirm that a corneal ulcer has not
developed. However, minor abrasions
should heal within 24-48 hours and do
not require follow-up if the patient is
completely asymptomatic at 48 hours.
Reexamine large abrasions frequently
until reepithelialization occurs and the
potential for infection no longer exists.

39. Cont..
Advise eye rest (i.e., no reading or work that
requires substantial eye movement that might
interfere with re epithelialization). Advise
patients to avoid bright light or to wear
sunglasses for comfort if they have notable
photophobia.
 Patient with corneal abrasions that do not
resolve with the use of routine prophylactic
antibiotics must be evaluated for conditions
that impede healing; examples are infection,
neurotrophic keratopathy, and topical
anesthetic abuse.


40. Nursing Diagnosis for Corneal
Injury
1. Acute Pain related to trauma, increased
IOP, surgical intervention or
administration of inflammatory eye
drops dilator
Nursing interventions:
- Give the medication to control pain
- Give cold compress on demand for blunt
trauma
- Reduce lighting levels
- Encourage use of sunglasses in strong light

41. Cont..
Risk for self-care deficit related to damage
vision
Nursing interventions:
- Give instructions to the patient or the people
closest to the signs and symptoms,
complications should be immediately reported
to the doctor
- Provide verbal and written instructions to
patients and the right means of technique in
delivering drugs
- Evaluate the need for assistance after
discharge
- Teach patients and families of sight guidance
techniques

42. Cont..
Risk for Injury related to damage vision
Nursing interventions:
- Help the patient when able to do until a
stable postoperative ambulation
- Orient the patient in the room
- Discuss the need for the use of metal
shields or goggles when necessary
- Do not put pressure on the affected eye
trauma
- Use proper procedures when providing eye
drugs

43. Cont..
Anxiety related to damage to sensory and
lack of understanding of post-operative
care, drug delivery
Nursing interventions:
- Assess the degree and duration of visual
impairment
- Orient the patient to the new environment
- Describe the routine perioperative
- Encourage to perform daily living habits when
able
- Encourage the participation of the family or
the people who matter in patient care.

44. BIBLIOGRAPHY
Brunner, suddharth. Medical surgical
nursing. Virginia: a wulters kluwer
company; 2004: 964-968
 Joyce m black. Medical surgical nursing.
New York: web Saunders company;
2003:1245 - 1249
 Gerard j tortora. Principal of anatomy and
physiology. USA. JOHN wiley publisher;
2006: 686- 688
 lippincott. Manual of nursing practice.
Newyork: a wulter kluwers company;
2006: 962-972
