• 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.
• 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 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.
• Consider using a topical anaesthetic (e.g. proxymetacaine, or tetracaine) if examination is difficult. Topical anaesthetics are also available combined with fluorescein.

In depth

• Refer immediately to the emergency eye service:
• All high-velocity injuries.
• All 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.
• Rust rings that remain after removal of a metallic foreign body.
• Hyphaema.
• A distorted pupil.
• Suspected damage to the retina.
• Deep laceration of the orbit.
• Subconjunctival haemorrhage, if it tracks posteriorly and there is a history consistent with a possible orbital fracture.
• Marginal lacerations.
• 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.

In depth

• Remove the foreign body if present (and this is appropriate).
• 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. in 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.

In depth

• 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.

In depth