Corneal Injury

Objectives

To identify and manage corneal abrasions, a disruption of epithelial surface of the cornea usually caused by sub-tarsal foreign body, mechanical trauma or contact lens use.

Scope

This guideline describes the features and management of corneal abrasions with additional advice to support the recognition and management of related diagnoses, including corneal keratitis.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a role in a forward medical location or in an emergency department on deployed operations

Initial Assessment & Management

Corneal abrasions usually occur with a history of trauma to the eye, although in many cases this may have been apparently minor.

Symptoms

  • Pain - Patients typically present with sudden onset pain to the eye, which can range from mild to severe.
  • Vision - Blurred vision is common and some patients experience photophobia.
  • Red, watery eye - The affected eye(s) will often appear red and will usually be watery.
  • Headache The patient may complain of generalised headache as well as eye pain.

Signs

  • Eyelid may be oedematous and inflamed
  • Conjunctival hyperaemia may give the eye a 'bloodshot' appearance
  • Corneal epithelial defect on fluorescein staining after examining for corneal infiltrate.
  • Traumatic corneal abrasions usually appear as linear or geographic shapes. A foreign body under the upper lid may produce multiple vertical lines on the cornea
Use fluorescein to stain the eye (after checking for allergies) then examine under the cobalt blue filter of an opthalmoscope. Defects in the cornea will fluoresce appearing bright green. Always check for corneal infiltrate (white patch) first as these can cease to be visible after staining.

Management

Give oral analgesia in accordance with standard guidelines.

Topical anaesthetic (for example, tetracaine 0.5%) may aid examination but may not be available in forward locations.

If topical anaesthetic is used, the patient must be advised to ensure that the anaesthetised eye is protected from further injury, dust and bacterial contamination

Topical cylcoplegia (for example, cyclopentolate 0.5%) can reduce discomfort but is unlikely to be available in forward locations.

Look for and remove sub-tarsal foreign bodies as detailed below.

Provide a broad-spectrum antibiotic ointment (usually chloramphenicol 1%), four times daily for 5 days. The ointment has a soothing effect while concurrently reducing the risk of bacterial infection.

Ensure the patient is advised to avoid rubbing the eye, and consider wearing sunglasses and/or avoiding areas under bright light in order to help with light sensitivity.

Advise on eye protection and review the patient after 48 hours.

Contact lenses: If contact lenses have been worn then the risk of corneal ulceration is greatly heightened - any corneal epithelial defect should be managed as suspected bacterial keratitis.Contact lenses must not be worn until the cornea has fully healed - although note that in general contact lenses are not suitable for the operational environment and normally should not be used on operations: the patient should therefore be advised not to resume the use of lenses until after the deployment.

 

RED FLAGS

Most corneal abrasions heal well with the above treatment and should not usually require further care. The following are red flags that should prompt consideration of referral to a higher echelon of care or reach-back to ophthalmology if possible.

Worsening vision. Test visual acuity with Snellen chart but take into consideration that watering/lacrimation can worsen visual acuity. Vision that fails to improve with pinhole is of greater concern.

Symptoms (such as pain, photophobia, foreign body sensation or redness) are not improving

The abrasion has increased in size

A corneal infiltrate, ulcer or infection has developed. A corneal infiltrate will appear as a white patch under or around the epithelial defect.

A rust ring is present

The abrasion does not resolve completely within 4 days

Fungal keratitis may be associated with contaminated injury. Consider this differential diagnosis if there may be biological contamination associated with the mechanism of injury (for example, injury from a tree branch or contamination with soil) and/or if symptoms recur or worsen after 7-14 days. Fungal keratitis is a sight-threatening emergency.

If delayed healing but no other red flags, consider changing antibiotic ointment in accordance with guidelines and local sensitivities. However, ophthalmology input will be required if there is no improvement following this.

Advanced Assessment & Management

The deployed Emergency Department is likely to have available topical local anaesthetic (for example, tetracaine 0.5%) and topical cylcoplegia (for example, cyclopentolate 0.5%), that are unlikely to be available in forward locations. These may be used to facilitate examination and ease symptoms.

If topical anaesthetic is used, the patient must be advised to ensure that the anaesthetised eye is protected from further injury, dust and bacterial contamination

Otherwise, no specific advanced management is required as a corneal abrasion is a self-limiting condition. However, if any of the red flag criteria are identified, reach-back or evacuation to an ophthalmologist should be prioritised.

Corneal Ulcer (Keratitis)

A corneal ulcer (keratitis) is an inflammatory response of the cornea due to bacteria that can be mistaken for a corneal abrasion, but can cause significant loss of vision. This is an ophthalmic emergency.

Symptoms

Like a corneal abrasion, a corneal ulcer typically presents with discomfort in the affected eye. The patient may report the sensation of a foreign body and progressively worsening pain. Lacrimation and reddening of the eye are common, as is photophobia.

Signs

  • Reduced visual acuity due to corneal oedema
  • Hypopyon (purulent exudate in the anterior chamber)
  • Conjunctival hyperaemia
  • Conjunctival inflammation
  • Visible ulcer following fluorescein staining
Under fluorescein staining, a corneal abrasion has clearly defined borders and uniform uptake of fluoroscein whereas an ulcer typically has irregular borders.
Always examine for infiltrates (white patchy areas) before using fluoroscein as they may cease to be visible after stain has been applied.  

Ulcers associated with contact lenses are typically distinct circular white lesions 0.5-2mm across or sometimes larger, but any epithelial defect in a contact lens wearers should be treated as an ulcer until proven otherwise. 

Management

Give oral analgesia and, if available, use a topical anaesthetic and a topical cycloplegic as above.

If not topical anaesthetic is available, 2-3ml lignocaine (ideally 2%) may be directly applied to the corneal surface as a temporising measure.

Shield the eye. Aim to evacuate or reach-back to an ophthalmologist if possible.

If ophthalmologist review is not available within 6 hours:

  • Commence ofloxacin 0.3% (1 drop hourly)

  • If not available then other fluoroquinolone eye drops may be used (for example ciprofloxacin or moxifloxacin).

 

Topical fluoroquinolines are unlikely to be available in forward locations so evacuation to a deployed Emergency Department will be necessary. If this is impossible then a systemic fluoroquinolone may be helpful in temporising until evacuation to an area where topical treatment is available.

Corneal Foreign Body

This is a common ophthalmic injuries, and the problem is frequently (although not always) clear from the history, which may include a description of a foreign body entering the eye via wind or high velocity mechanism (such as hammering or metal grinding).

Symptoms

  • Usually unilateral
  • Irritation/sensation of foreign body/pain
  • Photophobia
  • Lacrimation
  • Blurred vision
  • Reddening of the affected eye 

Signs

  • The foreign body may be visible, adherent to ocular surface
  • Linear vertical corneal scratches (suggestive of a foreign body trapped under the eyelid)
  • Rust ring from embedded ferrous foreign body
  • If longstanding, a ring of oedema around the injury site
  • Subconjunctival haemorrhage may be present

It is vital to confirm that a foreign body has not penetrated the globe as this would represent an open globe injury. Guidance on the management of such injuries is available here. 

Management

Check visual acuity before and after foreign body removal

If may be possible to wash out small loose foreign bodies with sterile water or normal saline

If this fails, apply topical anaesthetic if available.

If the foreign body is under the eyelid, evert the eyelid to access it. Foreign bodies are more commonly found under the upper lid.

Eyelid eversion: gently pull the eyelid out using the thumb and index finger of one hand. With the other hand, press the index finger down gently on the centre of the eyelid and the eyelid should evert.

If a foreign body is adherent or embedded in the cornea, but not causing an open globe injury, it may be possible to flick the foreign body off the cornea.

The bevel of a needle may be used to do this: approach from the side; do not point the tip of the needle at the eye, and use a scraping motion with the edge of the needle bevel, never the point.

A safer option is to fold a piece of stiff paper or cut a piece of card into a sharp point - this will generally be pointed and firm enough to flick off a foreign body without accidentally penetrating the cornea.

Following removal of the foreign body:

  • Give simple oral analgesia if discomfort persists
  • Provide a broad-spectrum antibiotic ointment (for example chloramphenicol 1%) four times daily for 5 days to soothe symptoms and reduce the risk of infection. Ocular lubricants, if available, may also be used to provide symptomatic relief.
  • Ensure the patient is advised to avoid rubbing the eye, and consider wearing sunglasses and/or avoiding areas under bright light in order to help with light sensitivity.
  • Advise on eye protection.
  • Contact lenses must not be worn until the cornea has fully healed - although note that in general contact lenses are not suitable for the operational environment and normally should not be used on operations: the patient should therefore normally be advised not to resume the use of lenses until after the deployment.
  • If topical anaesthetic has been used, ensure the patient understands the need to protect the anaesthetised eye from injury, dust and bacterial contamination

Escalation

Discuss with ophthalmology if a retained foreign body that cannot be removed safely at the current echelon of care:

    • Retained foreign bodies composed of organic material should be referred to ophthalmology as these are associated with a higher risk of infection and complications.
    • Retained foreign bodies in or near the centre of the cornea are associated with an increased risk of permanent visual loss and such patients should be prioritised accordingly.
    • Any rust rings apparent following removal of a ferrous foreign body will require ophthalmology assessment for removal within 24-48 hours.

Last reviewed: 28/03/2026

Next review date: 28/03/2027