A 25-year-old construction worker comes to the emergency department because of a 4-hour history of severe pain, tearing, and a gritty sensation in his right eye. He reports that the symptoms began while he was using a high-speed metal grinder without eye protection. He has significant photophobia and difficulty keeping the eye open. He does not wear contact lenses. Physical examination shows significant conjunctival injection of the right eye. Visual acuity is 20/20 in both eyes. The pupils are equal, round, and reactive to light. Fluorescein staining is performed and reveals a thin, linear area of yellow-green uptake on the cornea. Eversion of the eyelid shows no foreign body, and there is no evidence of globe penetration or an intraocular foreign body.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
B) Erythromycin ophthalmic ointment
This patient has a simple corneal abrasion, likely caused by a small piece of debris. In a patient who does not wear contact lenses, the most appropriate management for a small, non-infected corneal abrasion is a topical antibiotic ointment, such as erythromycin. This provides both prophylaxis against infection and lubrication to reduce the friction of the eyelid over the damaged epithelium, which helps with pain and promotes healing. Most simple abrasions heal within 24–48 hours.
Answer choice A: Ciprofloxacin ophthalmic drops, is incorrect. Ciprofloxacin or other fluoroquinolones are the preferred agents for patients who wear contact lenses. This is because contact lens wearers are at high risk for Pseudomonas aeruginosa keratitis, which requires specific antipseudomonal coverage. In a non-contact lens wearer like this construction worker, erythromycin is sufficient and more cost-effective.
Answer choice C: Ketorolac ophthalmic drops, is incorrect. While topical nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac can provide analgesia for corneal abrasions, they are generally used as adjunctive therapy rather than the primary next step. Lubricating antibiotic ointment is the standard first-line treatment for both protection and symptom relief.
Answer choice D: Pressure patching, is incorrect. Pressure patching was historically used to reduce pain by preventing eyelid movement. However, it is no longer recommended because it does not speed healing and may actually increase the risk of infection by creating a warm, moist environment conducive to bacterial growth. It is strictly contraindicated if there is any suspicion of a contaminated wound or a fungal/pseudomonal infection.
Answer choice E: Topical anesthetic drops, is incorrect. While topical anesthetics, such as proparacaine, are used in the office to facilitate a thorough eye examination, they should never be prescribed for home use. Repeated use of topical anesthetics is toxic to the corneal epithelium, can mask worsening symptoms, and inhibits the normal healing process.
Key Learning Point
The management of corneal abrasion involves topical antibiotic prophylaxis and pain control. For most patients, a lubricating ointment like erythromycin is preferred. However, for patients who wear contact lenses, topical fluoroquinolones should be used to provide coverage against Pseudomonas aeruginosa.
