The patient has a superficial, traumatic corneal abrasion based on clinical signs and symptoms. The differential diagnosis would include an infectious keratitis, herpetic keratitis, corneoscleral laceration, recurrent corneal erosion, neurotrophic epithelial defect, contact lens-associated keratopathy.
A corneal abrasion is a disruption in the epithelium of the cornea. Intense irritation, foreign-body sensation, excessive tearing, and/or an inability to open the eye due to pain can occur as the cornea is richly innervated. This can be caused by trauma, contact lens use, or a foreign body. Thus, a careful history including trauma or contact lens use is important when a patient presents with significant eye redness, pain and tearing. Lid eversion is critical to rule out a foreign body lodge under the upper or lower lids.
Check visual acuity. Vision might be decreased if the abrasion is in the visual axis.
Fluorescein will stain the corneal epithelial basement membrane, which is exposed when the epithelial cells are removed with an abrasion. To apply fluorescein to the eye use a drop that contains both fluorescein and an anesthetic agent or apply a drop of anesthetic to the tip of a fluorescein strip and gently placed the orange drop on the inferior conjunctiva by pulling the eyelid down. View the cornea under a cobalt blue light. A bright green stain highlights the areas of corneal abrasion. Fluorescein can also help demonstrate a full thickness corneal laceration with leakage of aqueous humor, the Seidel sign. The drop of anesthetic will make the patient feel more comfortable and able to open the eye. However, NEVER GIVE A PATIENT A BOTTLE OF ANESTHETIC DROPS TO TAKE HOME. A persistent epithelial defect and corneal melt can occur resulting in permanent vision loss.
A simple corneal abrasion can be treated with lubrication, antibiotic ointments or antibiotic drops (ex. Erythromycin ointment four times per day for five). Symptoms should start to improve within 24-48 hours. Severe corneal abrasions can result in corneal scars, epithelial irregularity or recurrent erosion syndrome. Patients should NOT use their contact lenses until the epithelium is completely healed.