A 24-year-old man comes to the physician due to right eye pain for the last 12 hours. When he opens his right eyelid, he feels a foreign body sensation in the eye. Prior to onset of the pain, he was hiking off-trail with a friend and was hit in the face with 2 tree branches. The patient has rubbed his eyelid several times and washed the eye with ocular solution without any relief. He does not wear contact lenses.
Examination of the right eye shows a small, round, and reactive pupil. The conjunctiva is red with no purulent discharge. There is no evidence of penetrating injury or visible foreign body. The anterior chamber is clear. There is a red reflex. Fluorescein staining under cobalt blue filter of an ophthalmoscope shows a small linear stain across the central cornea. Visual acuity screening shows 20/40 in the affected eye.
In addition to measures that reduce pain, which of the following is the best management for this patient?

Question

A 24-year-old man comes to the physician due to right eye pain for the last 12 hours.  When he opens his right eyelid, he feels a foreign body sensation in the eye.  Prior to onset of the pain, he was hiking off-trail with a friend and was hit in the face with 2 tree branches.  The patient has rubbed his eyelid several times and washed the eye with ocular solution without any relief.  He does not wear contact lenses.
Examination of the right eye shows a small, round, and reactive pupil.  The conjunctiva is red with no purulent discharge.  There is no evidence of penetrating injury or visible foreign body.  The anterior chamber is clear.  There is a red reflex.  Fluorescein staining under cobalt blue filter of an ophthalmoscope shows a small linear stain across the central cornea.  Visual acuity screening shows 20/40 in the affected eye.
In addition to measures that reduce pain, which of the following is the best management for this patient?

Quizplus · Accepted Answer

11ec193a_989a_7677_853d_f3c40e019e24_MD0002_00 This patient's eye pain and foreign body sensation that cause him to keep the affected eye shut are highly suggestive of a corneal abrasion. Corneal abrasions can be spontaneous or due to trauma/foreign body, contact lenses, or herpes simplex type 1 infection. Patients usually present with the following findings: Normal visual acuity (unless abrasion is within the visual field)Normal pupil and anterior chamberCorneal abrasion seen through fluorescein staining under cobalt blue filterCorneal edema developing after 12 hours Normal visual acuity (unless abrasion is within the visual field) Normal pupil and anterior chamber Corneal abrasion seen through fluorescein staining under cobalt blue filter Corneal edema developing after 12 hours Urgent ophthalmology referral is indicated for penetrating trauma, corneal infiltrate/opacity (white spot), foreign bodies that cannot be easily removed, significant decrease in vision (eg, >1-2 lines on Snellen chart), or symptoms that worsen or do not improve. After ruling out potential ocular emergencies, most ophthalmologists prescribe antibiotic ointment (not drops) until symptom resolution. This helps to prevent an infection from complicating the healing process. Most abrasions heal spontaneously within 24-72 hours without any complications. Follow-up is required for large abrasions (>3 mm), or any abrasion associated with contact lenses or decreased vision. (Choice A) Eye patches do not provide significant benefit for small corneal abrasions and have low patient compliance. They should not be applied for >24 hours to avoid causing further complications. In addition, they should not be used in contact lens abrasion or with infectious infiltrates due to the risk of causing or worsening an infection. (Choice C) Topical corticosteroids should not be used for a traumatic corneal abrasion as they do not facilitate healing. In addition, they can alter the body's defense if an infection is present. (Choice D) Topical ganciclovir or trifluorothymidine is the treatment of choice for herpes simplex virus keratitis, which usually presents with a branching or dendritic pattern under fluorescein examination. This patient's linear pattern makes this less likely. (Choice E) Topical pilocarpine is a parasympathomimetic that can be part of the treatment of acute angle-closure glaucoma (ACG). ACG typically presents in older adults with painful loss of vision, conjunctival erythema, and a poorly reactive mid-dilated pupil. This patient's young age, normal pupillary response, and linear fluorescein stain on the cornea make the diagnosis unlikely. acute angle-closure glaucoma (ACG) Educational objective: Corneal abrasion typically presents with eye pain and a foreign body sensation resulting in difficultly keeping the eye open. Urgent ophthalmology referral is indicated for penetrating trauma, corneal infiltrate/opacity, foreign bodies that cannot be easily removed, or a significant decrease in vision. Antibiotic ointment is the first-line therapy. __________ References: Evaluation and management of corneal abrasions. (http://www.ncbi.nlm.nih.gov/pubmed/23317075)

A 24-Year-Old Man Comes to the Physician Due to Right