• Assess:
• Whether the injury was due to chemicals or a high-velocity foreign body.
• The degree of injury. Test visual acuity and extra-ocular eye muscles, and examine both pupils for size, shape and reaction to light.
• The size, shape, and position of the corneal abrasion using fluorescein stain, and document carefully.
• Corneal oedema, epithelial disruption, or anterior chamber penetration, using a slit lamp (if available) to reveal any problems.
• Refer urgently to the emergency eye service:
• All high-velocity injuries and chemical injuries.
• If there is a foreign body that cannot be removed.
• If any of the following clinical features are present:
• Pain which is not relieved by topical local anaesthetic.
• A reduction in visual acuity.
• Large abrasions, corneal opacities, or rust rings.
• Hyphaema (blood in the anterior chamber of the eye).
• A distorted pupil.
• Suspected damage to the retina.
• Deep laceration of the orbit.
• Subconjunctival haemorrhage.
• Any lacerations.
• Remove foreign body if present (and appropriate), see Removing a corneal foreign body.
• Offer paracetamol or ibuprofen for pain relief.
• To prevent secondary infection prescribe:
• Topical chloramphenicol first-line for 7 days.
• Consider prescribing fusidic acid (7 days) as an alternative.
• Follow up:
• Re-examine the eye after 24 hours with fluorescein:
• If the corneal abrasion is reducing in size, re-examine daily to confirm that the abrasion is healing. If it has not healed after 72 hours, refer urgently to specialist eye services in secondary care.
• If the corneal abrasion is not reducing in size, refer urgently to secondary care.
• Any worsening symptoms such as increased pain or reduced visual acuity should prompt a thorough re-examination for a foreign body, and an urgent referral to the emergency eye service.

• Determine how the injury was caused, in particular if it was due to chemicals or a high-velocity foreign body. It is important not to miss a penetrating eye injury.
• Ask specifically about activities that may have caused a high-velocity injury (e.g. chiselling, grinding, hammering, or lawn mowing), as a foreign body may enter the eye without the person realizing.
• Ask about specific causes of a corneal injury, such as trauma from grit, wood chip, fingernails, hairbrush, or contact-lens problems (e.g. poor fit, trapped foreign body, sensitivity to solutions, infection).
• Assess for the degree of injury:
• Test visual acuity in both eyes with a Snellen chart, and document carefully.
• Test the extra-ocular eye muscles by assessing eye movements in all directions and eyelid function.
• Examine both pupils for size shape and reaction to light.
• Look for the presence of a subconjunctival haemorrhage.
• Look for the presence of a hyphaema (blood in the anterior chamber).
• Use fluorescein stain to assess the size, shape, and position of the corneal abrasion, and document carefully.
• Use a slit lamp (if available) to reveal corneal oedema, epithelial disruption, or anterior chamber penetration.
• Evert the upper lid to exclude a subtarsal foreign body, unless a penetrating eye injury is suspected.
• Consider using a topical anaesthetic (e.g. proxymetacaine, or tetracaine) if examination is difficult. Topical anaesthetics are also available combined with fluorescein.

• Documentation of visual acuity and the size of the abrasion is essential for follow up and medico-legal purposes.

• These recommendations are based on published expert opinion [Khaw et al, 2004a; Aslam et al, 2007].

• Refer immediately to the emergency eye service:
• All high-velocity injuries (e.g. injuries occurring while hammering, chiselling, grinding, or lawn mowing), or an injury caused by glass, knives, thorns, darts, or pencils, should be treated as penetrating injuries until proved otherwise, as a foreign body may not be visible.
• All chemical injuries: see Managing an ocular chemical injury for emergency management while awaiting transfer to secondary care.
• If there is a foreign body that cannot be removed. Those in or near the centre of the cornea increase the risk of permanent loss of vision.
• If any of the following clinical features are present:
• Pain which is not relieved by topical local anaesthetic should be assumed to be due to something more serious than a superficial corneal injury (e.g. corneal ulceration, iritis, acute glaucoma).
• A reduction in visual acuity.
• Large abrasions (over more than 60% of the cornea).
• Corneal opacities.
• Rust rings that remain after removal of a metallic foreign body, as these may cause permanent damage.
• Hyphaema (blood in the anterior chamber of the eye), as this is associated with a risk of further haemorrhage.
• A distorted pupil, as this may be associated with a penetrating injury.
• Suspected damage to the retina.
• Deep laceration of the orbit, which may indicate intraorbital and ocular penetration, and retained foreign bodies.
• Subconjunctival haemorrhage, if it tracks posteriorly and there is a history consistent with a possible orbital fracture.
• Marginal lacerations, as the lacrimal ducts may be damaged.
• Also urgently refer people with:
• Persistent symptoms after 72 hours.
• Worsening symptoms.
• A corneal abrasion which shows no improvement (healing) on a daily basis.
• Recurrent abrasions may be referred non-urgently. These usually occur at night when there is little secretion of tears and the epithelium may be torn off.

• Recurrent abrasions: treatment is long term, and a surgical procedure (e.g. epithelial debridement, or corneal stroma puncture) may be needed [Khaw et al, 2004a].

These recommendations are based on published expert opinion [Eagling and Roper-Hall, 1986; McGuinness, 1998; Shields, 2000a; Shields, 2000b; Khaw et al, 2004a; Wilson and Last, 2004].

• Remove contact lenses if present.
• Immediately irrigate the affected eye thoroughly with water or 0.9% saline for at least 10–15 minutes, and arrange for the person to go for urgent ophthalmological assessment.

• Acidic and alkaline solutions may cause corneal burns. Alkaline solutions in particular may penetrate all layers of the eye and find their way into the chambers, causing iritis, anterior and posterior synechia, corneal opacification, cataracts, glaucoma, and retinal atrophy.

• These recommendations are based on published expert opinion from the National Poisons Information Service (NPIS) [NPIS, 2007].

• Only remove a corneal foreign body if you are confident and experienced with this procedure.
• Use a topical anaesthetic such as tetracaine, oxybuprocaine, or proxymetacaine to prevent pain during the examination.
• Refer to secondary care if the topical anaesthetic does not remove the pain (a more serious problem may exist).
• Irrigate the eye with water, or remove the foreign body with a cotton wool bud or a triangle of card.
• If this is unsuccessful, and only if you are experienced, carefully lift the foreign body using the tip of a sterile 25-gauge needle.
• Refer to secondary care if you are not experienced in this procedure, or this is unsuccessful.
• Evert the upper lid to exclude a subtarsal foreign body, particularly if there are vertical corneal scratches or a feeling that the foreign body is still there. This should never be done if there is any possibility of a penetrating eye injury, as the contents of the eye may prolapse.
• Advise the person that 10–15 minutes after the numbing effect of the drops have worn off, the eye may feel uncomfortable until the abrasion heals.

• These recommendations are based on published expert opinion [Khaw et al, 2004a].
• Removing a foreign body: corneal foreign bodies are often more difficult to remove if they are metallic because they may be rusted on. If they are not removed they will prevent healing and rust may permanently stain the cornea.

• Remove the foreign body if present (and this is appropriate), see Removing a corneal foreign body.
• Offer or advise analgesia for pain relief.
• Paracetamol or ibuprofen is recommended first-line.
• Consider offering a one off dose of a cycloplegic (e.g. cyclopentolate 0.5%) if available.
• To prevent secondary infection prescribe:
• Topical chloramphenicol first-line, four times a day, for 7 days.
• Consider prescribing fusidic acid, twice a day (7 days), as an alternative if:
• Treatment four times a day is impractical (e.g. children or elderly people).
• The person is pregnant.
• There is a personal or family history of blood dyscrasias, such as aplastic anaemia.
• The person is intolerant of chloramphenicol.
• Advise the person not to wear contact lenses until the corneal abrasion has completely healed and, where possible, for 24 hours after finishing treatment with topical antibiotics.

• Topical antibiotics:
• CKS found no published evidence that antibiotic eye drops or ointment are effective for preventing infection after a corneal injury. However, expert consensus is that they should be used to prevent secondary infection which is a rare but devastating consequence of corneal injury [Khaw et al, 2004b].
• Chloramphenicol is recommended first-line and fusidic acid is an alternative. For a more detailed discussion, see the CKS topic on Conjunctivitis - infective.
• Topical cycloplegics:
• Cycloplegics are claimed to reduce ocular pain and inflammation by alleviating ciliary spasm. There are no controlled studies to support this hypothesis [Sabri et al, 1998; Carley and Carley, 2001]. However some experts recommend a one off dose to reduce headache from ciliary muscle spasm.
• Removal of contact lenses:
• Contact lenses must not be worn during treatment because some preservatives, particularly benzalkonium chloride, accumulate in contact lenses and cause irritation.

• Chloramphenicol 1% eye ointment is preferred to eye drops.
• Consider prescribing chloramphenicol 0.5% eye drops for daytime use, together with chloramphenicol 1% eye ointment for use at night.
• Eye drops may be more practical for daytime use (ointments can smear and cause blurred vision).

• These recommendations are based on pragmatic advice and published expert opinion [Khaw et al, 2004b; Wilson and Last, 2004].
• CKS found no good published evidence that eye ointment is better than eye drops for preventing infection after a corneal injury. However, expert consensus is that eye ointments are preferred because they are thought to be more lubricating [Khaw et al, 2004b; Wilson and Last, 2004].

• Re-examine the eye, using fluorescein stain, after 24 hours:
• If the corneal abrasion is reducing in size, re-examine daily to confirm the abrasion is healing. If it has not healed after 72 hours, refer urgently to specialist eye services in secondary care.
• If the corneal abrasion is not reducing in size, refer urgently to secondary care.
• Any worsening symptoms such as increased pain or reduced visual acuity should prompt a thorough re-examination for a foreign body, and an urgent referral to specialist eye services in secondary care.

• These recommendations are based on published expert opinion [Khaw et al, 2004a; Aslam et al, 2007].

• Corneal patches:
• Evidence indicates that treating simple corneal abrasions with a patch does not improve healing rates on the first day post-injury and does not reduce pain. In addition, the use of patches results in a loss of binocular vision [Turner and Rabiu, 2006].
• Topical anaesthetics (except as part of the examination):
• Topical anaesthetics should not be used, except as part of the examination. They abolish the corneal reflex, which increases the risk of further corneal damage. They slow healing and aggravate associated keratitis [Wilson and Last, 2004].
• Diclofenac eye drops:
• Diclofenac eye drops are licensed to treat pain after a corneal abrasion [BNF 54, 2007]. There is evidence for the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for pain associated with a corneal abrasion; but insufficient evidence to be certain about the efficacy of topical NSAIDs.
• In primary care oral analgesia should be adequate to alleviate pain of a corneal abrasion and will usually be initiated first (if required); making the use of topical NSAIDs unlikely. Topical NSAIDs should not be used as a substitute for oral analgesia, a statement which was highlighted by the CKS external review experts. If pain does persist with oral analgesia or has not resolved within 1-2 days, then referral to secondary care is recommended, further limiting the use of topical NSAIDs in a primary care setting.
• Topical corticosteroids:
• Topical corticosteroids should not be used. They slow corneal epithelial and stromal healing, increase the risk of infection, and cause serious scarring and visual loss if a dendritic ulcer has been missed [Shields, 2000a].
• Tetanus immunization (not routinely needed for non-penetrating injuries).