What is Corneal Injury?

About 3% of all emergency room visits are due to injuries to the eye, most of which involve damage to the cornea, the outer layer of the eye. The severity of corneal injuries can range from minor and insignificant, to those which could potentially threaten vision. These injuries can typically be grouped into two categories: traumatic and exposure-related.

Traumatic injuries include things like corneal abrasions (scratches) and foreign bodies lodged in the eye. On the other hand, exposure-related injuries could be caused by burns from chemicals, heat, or radiation.

More serious corneal injuries can involve piercing trauma that may affect the front and back section of the eye, burns to the eye surface that lead to a deficiency in limbal stem cells (cells that help the cornea regenerate), and secondary glaucoma, a condition that causes damage to the optic nerve and can lead to blindness.

This review looks at the main types of corneal injury, how they are assessed, how they can be treated immediately, and any long-term effects they can have.

What Causes Corneal Injury?

A corneal abrasion is a scratch or scrape on your eye’s cornea, the clear front cover of your eye. Anything from a fingernail or contact lens to plant branches or small foreign objects airborne into the eyes can cause such a scrape. If your eyes aren’t properly protected, there’s a higher risk of serious damage from high-speed objects piercing the cornea.

Corneal perforation, which is a deep cut or tear in the cornea, is often accidental, but can also happen when high-speed objects like tools from a workshop, for example, angle grinders or metal objects, hit the eye. Whether or not protective eyewear was worn at the time of injury. Knowing the type of object involved and how fast it was moving can help in treating the injury.

Burns affecting the eye can be split into three types: chemical, radiation, and thermal burns.

Chemical burns on the eye usually happen from getting into direct contact with harmful substances. Alkali burns from household cleaning products that contain ammonia or lye are more common than acid burns. Acid burns are more often seen in industrial work environments or may be the result of an intentional attack.

Radiation burns often come from overexposure to ultraviolet or UV light sources, like from a tanning bed, high-altitude environments, welding arcs, or even rare occurrences like a solar eclipse.

Thermal burns are relatively less frequent but can happen from hot items such as a curling iron or in case of any fire-related accidents.

Risk Factors and Frequency for Corneal Injury

Eye traumas make up around 3% of all visits to the emergency department. A majority, approximately 80%, of these visits are due to corneal abrasions or objects stuck in the eye. The risk of corneal abrasion is highest among working-age individuals, especially car industry workers between the ages of 20 and 29.

Chemical burns to the eye requires immediate medical attention. They account for between 11.5% and 22.1% of all eye injuries. Surprisingly, the young children, particularly those aged 1 to 2 years, are the most at risk of this type of injury in the U.S.

Chemical burn injuries are most common among people aged 18 to 64, becoming the second common cause of work-related eye injuries after foreign objects in the eye. Disturbingly, assaults and hate crimes have led to a rise in these types of injuries, including up to 33% of severe eye burns.

Signs and Symptoms of Corneal Injury

If someone has a small scratch on their cornea, they’ll most likely experience a feeling of discomfort or like something is stuck in their eye. Symptoms might not show up immediately and could take several hours to become noticeable. For injuries caused by chemical substances in the eye, the symptoms are usually immediate.

Medical professionals should inquire about the person’s work environment, especially if there’s a use of fast-moving machinery or metalworking. These types of injuries can be connected with more severe conditions like a cut on the cornea or even a puncturing of the eyeball. If a person complains about eye pain after striking metal against metal, it should raise suspicion about a metal piece injuring the eye, potentially leading to the rupture of the eyeball. Therefore, such cases must be carefully examined.

In the case of chemical burns to the eye, knowing what chemical caused the burn is crucial as it can affect the course of treatment and the likely outcome. Moreover, questions should be raised about whether the patient swallowed or breathed in any chemical substances. This is important because swelling of the airway from chemical ingestion or inhalation could potentially lead to choking.

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Testing for Corneal Injury

Corneal abrasions and tears can result in redness of the eye, swollen eyelids, teary eyes, and spasms of the eyelid. These defects can often be seen under magnification. If the pain is severe, a numbing eye drop may be used to help complete the eye exam. If applying a numbing eye drop lowers the pain, the cause is likely a superficial injury on the cornea, the clear, front surface of the eye. It is crucial for anyone complaining of eye discomfort to have their vision tested, which should be done with any prescription glasses or contact lenses they normally use. Vision is usually normal in the case of a corneal abrasion unless there is associated inflammation or the injury is centrally located on the cornea. Using a special dye called fluorescein and a cobalt blue light can help reveal the corneal abrasion as a bright green, superficial corneal defect.

For foreign bodies lodged in the cornea, symptoms can be identical to corneal abrasions with the feelings of pain, something in the eye, tearing, and spasms of the eyelid. Using numbing eye drops can help in examining the eye, and a special lamp, called a slit lamp, can aid diagnosis. Foreign objects may get lodged under the upper eyelid and repeatedly scrape the cornea each time the patient blinks. These repeated scrapes can cause multiple line-shaped or curved corneal abrasions. Therefore, the upper eyelid should be turned inside out and examined when a foreign body is suspected. For metallic foreign bodies, a rust-colored ring can form around the impact site within hours.

For corneal lacerations or perforations, indicators include an oddly-shaped iris, signs of blood in the front chamber of the eye, reduced vision, and a shallow anterior (front) chamber in the eye. Leakage of the eye’s fluid seen during a fluorescein test suggests a corneal perforation. However, for small tears, it’s possible for this test to be negative while the overall eye looks normal. The full thickness of the cornea should be examined with a slit lamp. If there’s any suspicion of an eye penetration injury, a CT scan of the orbit (eye socket) should be done. It’s important to consult an eye specialist when there’s a strong suspicion of such injuries, even if the CT scan looks normal.

Chemical eye burns are an eye emergency because they can lead to scar formation and permanent vision loss, or even loss of the eye. It’s crucial that the eyes are rinsed out and any chemical substance is removed immediately, before any other eye examinations or vision tests are done. Once the eye irrigation is completed, vision and internal eye pressure should be checked. It’s also essential to determine whether the patient has breathed in or swallowed any chemical substance, which could potentially cause breathing problems. Patients suffering from radiation burns can experience severe pain and discomfort. Along with reduced eyesight, tearing, and swelling of the conjunctiva (clear tissue over the white part of the eye), fluorescein dye can reveal distinctive superficial stains on the cornea. There are grading systems that can be used to assess the extent of ischemic (lack of blood flow) damage and predict future vision.

Treatment Options for Corneal Injury

Corneal abrasions, or scratches on the surface of the eye, usually heal on their own. Treatment focuses on relieving pain and preventing infection. Large or severely painful abrasions may be treated with a pain-relieving eye drop which relaxes the eye’s muscles and relieves spasms. Typically, a single dose of this medication will suffice due to the quick healing of the cornea. It’s important to note that local anaesthetic eye drops should not be prescribed for use at home as they can slow down the healing process, affect natural blinking, and delay the identification of further eye problems or complications.

In instances not involving contact lenses, an antibiotic ointment such as erythromycin can be prescribed. Contact lens wearers, however, often require stronger antibiotics. In these cases, medications like ciprofloxacin or ofloxacin can offer protection from potential infections. Tetanus shots might be necessary in some cases, depending on the patient’s medical history. Patients are usually advised not to wear contacts until the abrasion fully heals. A follow-up check within 24 to 48 hours is usually needed to ensure the injury is healing properly.

Foreign bodies in the cornea should be removed as soon as they are identified. This is typically done under magnification, after the application of a topical anaesthetic. Sterile needles or special eye instruments may be used for the removal. If there is any chance that the foreign body has pierced the entire cornea, the injury should be managed as a ‘globe perforation’, or a possible rupture of the entire eye, which requires further medical attention. After the foreign body is removed, any remaining injury is treated similarly to corneal abrasions.

Corneal perforations, or complete tears in the cornea, can quickly lead to serious complications if left unnoticed. They should be managed in the same way as ruptures of the globe of the eye, with a protective eye shield and IV antibiotics to prevent infections. A combination of a third-generation cephalosporin, gentamycin, and vancomycin are typically used.

For radiation burns of the eye (ultraviolet keratitis), treatment mainly includes pain management and preventative antibiotics. Strong painkillers may be required. As this is usually a self-limiting condition, if symptoms persist after 24 hours, a follow-up with an ophthalmologist is needed. Patients should be educated on the potential harmful effects of ultraviolet radiation, including the development of cataracts, benign eye growths called pterygia, and skin cancer.

Chemical burns to the eye should be flushed with plenty of water immediately at the scene of the injury and upon arriving at the hospital. Continuous irrigation of the affected eye can be achieved with the use of irrigation devices. If available, buffered eyewash solutions could be more beneficial for flushing out caustic substances than standard normal saline. It is recommended that irrigation be continued until the pH of the eye is neutral and remains stable for at least 30 minutes after the last irrigation. Any patient with cloudiness or damage on the corneal surface should be urgently referred to an ophthalmologist. The principles of acute treatment include the removal of harmful chemicals, promoting the healing of the eye’s surface, controlling inflammation, preventing infections, and managing pain. A swift and frequent review is crucial to monitor healing and detect any possible complications, such as increased eye pressure.

These are some conditions that might be mistaken for each other because they present similar symptoms:

  • Acute angle-closure glaucoma (a type of eye condition causing rapid vision loss)
  • Acute conjunctivitis, also known as pink eye (an inflammation of the eye)
  • Adult blepharitis (an eyelid infection)
  • Corneal foreign body (an object in the eye)
  • Corneal ulcer (an open sore on the eye)
  • Entropion (a condition in which the eyelid turns inward)
  • Epidemic Keratoconjunctivitis (a severe type of pink eye)
  • Iritis and uveitis (inflammation inside the eye)
  • Map-dot fingerprint dystrophy (an irregularity in the eye’s outermost layer)
  • Trichiasis (a condition in which the eyelashes grow in the wrong direction)

It’s essential to tell your doctor about all your symptoms, so they can properly figure out what’s going on. This list is not exhaustive, and many more conditions may mirror these symptoms.

What to expect with Corneal Injury

Superficial scratches or foreign objects on the surface of the eye tend to have a positive outlook, especially if the main line of vision is not affected. For deeper scarring that affects the principal line of vision, laser treatment or partial cornea transplantation may be used for long-term vision improvement. However, ocular chemical burns resulting in over 50% damage to the conjunctiva (the clear tissue covering the white part of the eye) or more than 6 clock hours of damage to the limbus (the border between the cornea and the white of the eye) tend to have a poor visual outcome.

Possible Complications When Diagnosed with Corneal Injury

Corneal injuries can lead to various complications. These complications can range from scarring that affects your field of vision, to decreased or failed function of limbal stem cells in the eye. In addition, injuries to the cornea can also cause weak adhesions between the healed corneal epithelium (the outer layer of the cornea) and the underlying layers of the cornea, leading to something called recurrent corneal erosion. Other possible complications include secondary glaucoma, a condition often caused by damage to the mesh-like structure in the eye that drains fluid, called the trabecular meshwork. Traumatic cataracts and retinal detachment are also potential complications. In severe cases, a corneal injury could even result in vision loss or loss of the entire eye.

Potential Complications Include:

  • Visual-field affecting Scarring
  • Recurrent corneal erosion
  • Reduced limbal stem cell function or failure
  • Secondary glaucoma
  • Traumatic cataract
  • Detachment of the retina
  • Loss of vision or the entire eye

Preventing Corneal Injury

Many injuries to the cornea, the clear front surface of the eye, can occur during everyday activities at home or work, like accidents involving body parts, sports equipment, or work tools. Despite the ease of access to protective eyewear, it’s often neglected. Shockingly, some serious eye injuries caused by chemicals are the result of assaults. Patients who delay seeking help or who don’t properly follow treatment and check-up schedules might face worse outcomes for their vision.

Raising awareness about this issue among the general public and educating patients could potentially improve the outcome of treatments for these people. It’s important to remember that preventing injuries by using protective measures can go a long way in safeguarding your vision.

Frequently asked questions

Corneal injury refers to damage to the cornea, the outer layer of the eye. It can be caused by traumatic injuries such as scratches or foreign bodies, as well as exposure-related injuries from burns. Severe corneal injuries can have long-term effects and potentially threaten vision.

Corneal injuries make up around 3% of all visits to the emergency department.

Signs and symptoms of corneal injury include: - Feeling of discomfort or like something is stuck in the eye - Delayed onset of symptoms, which may take several hours to become noticeable - Immediate symptoms in the case of injuries caused by chemical substances in the eye - Eye pain after striking metal against metal, which may indicate a metal piece injuring the eye and potentially leading to the rupture of the eyeball It is important for medical professionals to inquire about the person's work environment, especially if there is a use of fast-moving machinery or metalworking, as these types of injuries can be connected with more severe conditions like a cut on the cornea or puncturing of the eyeball. In the case of chemical burns to the eye, knowing what chemical caused the burn is crucial as it can affect the course of treatment and the likely outcome. Additionally, questions should be raised about whether the patient swallowed or breathed in any chemical substances, as swelling of the airway from chemical ingestion or inhalation could potentially lead to choking.

A corneal injury can occur from a scratch or scrape on the eye's cornea, which can be caused by various objects such as fingernails, contact lenses, plant branches, or small foreign objects airborne into the eyes.

Acute angle-closure glaucoma, Acute conjunctivitis, Adult blepharitis, Corneal foreign body, Corneal ulcer, Entropion, Epidemic Keratoconjunctivitis, Iritis and uveitis, Map-dot fingerprint dystrophy, Trichiasis

The types of tests that may be needed for corneal injury include: - Vision testing with prescription glasses or contact lenses - Examination of the cornea under magnification - Use of a special dye called fluorescein and a cobalt blue light to reveal corneal abrasions - Slit lamp examination to aid in the diagnosis of foreign bodies - CT scan of the orbit (eye socket) if there is suspicion of an eye penetration injury - Eye irrigation to remove chemical substances in the case of chemical burns - Assessment of internal eye pressure - Use of fluorescein dye to reveal superficial stains on the cornea in the case of radiation burns - Follow-up checks within 24 to 48 hours to monitor healing and detect complications.

Corneal injuries are treated based on the specific type of injury. Corneal abrasions usually heal on their own, with treatment focused on relieving pain and preventing infection. Pain-relieving eye drops may be used for large or severely painful abrasions. Antibiotic ointments or stronger antibiotics may be prescribed depending on whether the patient wears contact lenses. Foreign bodies in the cornea should be removed as soon as possible, and corneal perforations require a protective eye shield and IV antibiotics. Radiation burns and chemical burns have their own specific treatments, including pain management, preventative antibiotics, and flushing the eye with water for chemical burns. Regular follow-up with an ophthalmologist is important to monitor healing and detect complications.

When treating corneal injuries, there are potential side effects to be aware of. These side effects can include: - Slowed down healing process - Affecting natural blinking - Delayed identification of further eye problems or complications It's important to note that local anaesthetic eye drops should not be prescribed for use at home as they can have these negative effects.

The prognosis for corneal injury depends on the severity and type of injury. Superficial scratches or foreign objects on the surface of the eye tend to have a positive outlook, especially if the main line of vision is not affected. However, ocular chemical burns resulting in significant damage to the conjunctiva or limbus tend to have a poor visual outcome.

An ophthalmologist.

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