Topical Pain Control for Corneal Abrasions

05 Oct
October 5, 2017

Corneal abrasions account for 10% of all ocular complaints, and are the most common cause of ocular trauma (Alotaibi 2011, Bhatia 2013).  The diagnosis of corneal abrasions typically involves fluorescein staining of the eye and visualization of the abrasion via slit lamp exam. This review focuses specifically on pain control for corneal abrasions.

Although corneal abrasions typically heal within 24-72 hours without complications, the pain in the acute phase is usually significant (Wilson 2004).  Treatments described include patching, topical anesthetics, topical NSAIDS, cycloplegics or oral analgesics.  Utilization of topical anesthetics has been described in a previous post.  Oral analgesics are usually prescribed as a rescue modality when topical treatment is ineffective at managing pain. 

Patching

Patching used to be standard of care.  The reasoning for its use was that it would reduce blinking and corneal trauma caused by eyelid closure thereby reducing pain (Thiel 2017). However, it was found that patients have poorer outcomes with patching. This is due to decreased oxygen delivery to the eye and higher risks of infection due to increased moisture (Thiel 2017).

Cycloplegics

Some textbooks report that cycloplegics may be considered as an adjunct for pain control due to causing relief from ciliary muscle spasm, photophobia, and blepharospasm (Bhatia 2013, Butler 2017).  However, review of the literature demonstrates that the evidence behind this practice is sparse and does not support its widespread use. A study of 40 patients who were randomized to receive 5% homotropine vs placebo found no differences in pain scores (Meek 2010). Another study of 401 patients randomized to lubrication alone vs 2%
homatrapine (single dose) vs flubiprofen 0.03% QDS vs flubiprofen 0.03% qds and homatropine found no difference between homatropine and other treatments (Brahma 1996).

Topical NSAIDS

In the year 2000, there were around 200 cases of corneal melting described by 106 physicians associated with a specific generic form of topical ketorolac (Flach 2000). Although that product was removed from the market, there still remains reluctance to use topical NSAIDS due to the potential for serious toxicity.  Since then, there have been a few case reports and case series that do mention an association with topical NSAIDS and corneal pathology. However, these cases are in mostly in post ocular surgery patients, and include patients who are on the topical NSAIDS for much longer than is recommended for corneal abrasion treatment

There have been multiple randomized controlled trials that have demonstrated, however, that topical NSAIDS used for corneal abrasions for 1-3 days are not associated with any adverse outcomes

StudyNTrial TypeDesignOutcomesInclusionExclusionResults
Brahma 1996401Randomized Controlled TrialAll received chloramphenicol eye ointment, an eye patch and paracetamol as rescue analgesia. Randomized to 1 of 4 treatment arms: (x 48 hrs)
1. Polyvinyl EtOH alone (control)
2. Homotropine
3. Flurbiprofen (NSAID)
4. Homatropine with flurbiprofen
Main: Pain as measured by 10-point VAS at 6 hr intervals x 24 hrs.

Secondary: Use of oral analgesia, sleep disturbance, and time off work
All patients with corneal abrasions and foreign bodies attending the emergency eye center at Manchester Royal Eye Hospital< 16 y/o, Pregnant, history of HSV keratitis, Hypersensitivity to NSAIDs
224/401 returned questionnaires (planned on getting 200 back)

Groups 3 and 4 (flurbiprofen groups) – Reduced pain scores, less oral analgesia, better sleep, less time off work.

No difference in adverse outcomes.
Kaiser 1997100Randomized, Double Blinded Controlled TrialAll got cycloplegic (1% cyclopentolate, 2.5% phenylephrine, 0.25% tropicamide) and erythromycin or polymyxin B ointment. Then got either ketorolac (0.5%) or placebo x 5 days or until healed. Followed from 3-8 months for complications.

Participants permitted to use mild oral analgesics, including acetaminophen, ibuprofen, or aspirin
Six subjective symptoms monitored daily (Pain via VAS, photophobia, tearing, foreign body sensation, "blurry vision, ability to return to normal activities), evaluation of corneal abrasion, and determination of adverse events. Long-term complications were determined 3 to 8 months after randomization All patients seen at the Massachusetts Eye and Ear Infirmary's (MEEI) Emergency Unit with a diagnosis of traumatic corneal abrasion or removal of superficial corneal foreign body of less than 36 hours' duration < 18 y/o, history of eye trauma or disease in the affected eye, complicated abrasion, treatment prior to enrollment, contact lenses, Abrasion > 10mm2 Decreased pain, photophobia, foreign body sensation, less time to resumption of ADL in ketorolac group. No difference in adverse events at 3-8 months.
Jayamanne 199740Randomized, Double Blinded Controlled TrialAll received topical chloramphenicol ointment Meds taken for 48 hours.

Participants permitted to take whatever oral pain medicine they wanted (OTC)
Pain (VAS), foreign body sensation, light sensitivity and headache-like deep pain within the eye at 0, 1 and 2 days. All patients presenting to the eye casualty department at Newcastle General Hospital within 24 hours with a unilateral corneal abrasion and no other injury < 18 y/o, previous corneal pathology, diabetes, hypersensitivity to either NSAIDs or chloramphenicol Decreased pain, foreign body sensation, light sensitivity, headache-like deep pain in ketorolac group. No adverse reactions.

No adverse events. No difference in healing time.
Szucs 200049Randomized, Double Blinded Controlled TrialAll received topical anesthetic and cycloplegic (cyclopentolate 0.5%) in the ED, then discharged on either placebo drops or diclofenac 0.1%. Additionally, all pts received a topical antibiotic (gentamycin), oxycodone- acetaminophen as a rescue analgesic, and a pain diary.

Were to use drugs x 24-36 hrs.
Main: Pain as measured by 10-point VAS 2 hours after discharge, then at 24-36 hours

Secondary: Use of rescue oral analgesic and any adverse effects
All consecutive consenting patients aged 18 years or older who presented to the ED with a traumatic corneal abrasion were eligible for the study. < 18 y/o, pregnant, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hrs, minimal pain score (NPIS <3), Allergy to NSAIDLess pain, less use of oral analgesics in Ketorolac group. F

No difference in adverse outcomes
Goyal 200185Randomized, Double Blinded Controlled TrialAll received cyclopentolate 0.5% at arrival, and discharged with chloramphenicol. Then got either placebo or ketorolac (0.5%)Subjective symptoms of pain, photophobia, grittiness, watering and blurring of vision. Additionally, use of oral analgesics and adverse outcomes.
All patients seen with traumatic or foreign body removal related corneal abrasion of less than forty-eight hours’ duration <16 y/o or >80 y/o Signs of infection, contact lens, lesion > 1/3 surface of corneal, previous corneal surface diseaseLess oral analgesics in ketorolac (otherwise no difference) x 1 day.

No difference in adverse outcomes
Alberti 2001123Randomized, Double Blinded Controlled TrialAll could get anesthetic eye drops at presentation is necessary. Half received indomethacin 0.1%/gentamycin drops, half received gentamycin alone. All got eye patches, and oral analgesia x 4-5 days. Pain via VAS and level of photophobia, tearing, burning, irritation (itching or stinging) and foreign body sensation (scale of 0-3) at day 0, 1, and 4/5.

Additionally, Conjunctival hyperemia and ciliary injection were each assessed at the day 0, day 1, and day 4/5 visits using the same 0-3 severity scale. The surface area of the corneal abrasion was measured at each visit (length x width). All use of systemic analgesics was recorded.
All patients with traumatic corneal abrasion or requiring ablation of a superficial corneal foreign body and/or curettage, VAS > 20 mm.<18 y/o, hypersensitivity to NSAID or gentamycin. NSAID within the past 5 days, any systemic analgesia within previous 24 hours, evolutive ocular pathology (such as glaucoma or uveitis), any other concomitant traumatic lesion Less pain in indomethacin group.

No adverse events

Clinical Bottom Line:

In summary, patching can lead to harm and should be avoided, while cycloplegics have not been shown to help with pain. Although topical treatment with anesthetics and NSAIDS have traditionally been avoided due to concern for worse outcomes,  multiple placebo-controlled randomized controlled trials have demonstrated better patient outcomes without any increased incidence of adverse events in uncomplicated traumatic abrasions presenting to the emergency department if used for only 24-36 hours.

Guest Contributor

Jacob Avila MD, RDMS
Ultrasound Director and Assistant Professor
Department of Emergency Medicine, University of Kentucky, Lexington
Creator of the 5 Minute Sono Podcast/Website

References:

  1. Alotaibi AG, Osman EA, Allam KH, Abdel-Rahim AM, Abu-Amero KK. One month outcome of ocular related emergencies in a tertiary hospital in Central Saudi Arabia. Saudi medical journal. 2011; 32(12):1256-60. [pubmed]
  2. Bhatia, K., & Sharma, R. (2013). Chapter 26: Eye Emergencies. In Emergency Medicine Clinical Essentials(2nd ed., pp. 209-225). Philadelphia: Elsevier.
  3. Wilson SA, Last A. Management of corneal abrasions. American family physician. 2004; 70(1):123-8. [pubmed]
  4. Flach A. Topically applied nonsteroidal anti-inflammatory drugs and corneal problems: an interim review and comment. Ophthalmology. 2000; 107(7):1224-6. [pubmed]
  5. Lin JC, Rapuano CJ, Laibson PR, Eagle RC, Cohen EJ. Corneal melting associated with use of topical nonsteroidal anti-inflammatory drugs after ocular surgery. Archives of ophthalmology (Chicago, Ill. : 1960). 2000; 118(8):1129-32. [pubmed]
  6. Guidera AC, Luchs JI, Udell IJ. Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs. Ophthalmology. 2001; 108(5):936-44. [pubmed]
  7. Isawi H, Dhaliwal DK. Corneal melting and perforation in Stevens Johnson syndrome following topical bromfenac use. Journal of cataract and refractive surgery. 2007; 33(9):1644-6. [pubmed]
  8. Bekendam PD, Narváez J, Agarwal M. Case of corneal melting associated with the use of topical nepafenac. Cornea. 2007; 26(8):1002-3. [pubmed]
  9. Di Pacuale MA. Corneal Melting After Use of Nepafenac in a Patient with Chronic Cystoid Macular Edema. Eye Contact Lens 2008; 34(2): 129 – 30. [pubmed]
Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami) and Salim Rezaie (Twitter: @srrezaie)
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
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