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Eyes Injuries

Corneal superficial injury

Last revised in December 2024

Superficial corneal injuries are non-penetrating injuries affecting the outermost layer of the cornea.

Corneal superficial injury: Summary

  • Superficial corneal injuries are non-penetrating injuries affecting the outermost layer of the cornea.
  • Corneal abrasions are defects in the epithelial surface of the cornea — most heal within 1–2 days.
  • Superficial corneal injuries typically present with sudden onset pain, discomfort or foreign body sensation of the eye and tearing.
  • The mechanism of injury and material involved should be determined, of particular importance are injuries due to chemicals, high-velocity foreign bodies or sharp objects.
  • There is usually a history of a precipitating event such as:
    • An object striking the eye.
    • A foreign body entering the eye.
    • Difficult contact lens removal.
  • Red flags for serious causes of red eye (such as significant changes in vision, significant trauma or marked eye pain, headache, or photophobia) should be excluded.
  • The eye should be examined to:
    • Exclude penetrating or perforating injuries.
    • Check visual acuity.
    • Identify foreign bodies — subtarsal foreign bodies should be located by everting the upper eyelid.
    • Identify corneal abrasions — fluorescein should be used to stain the conjunctiva and cornea. An abrasion will fluoresce bright green with a cobalt-blue filter.
  • Immediate referral to the emergency eye service is required for:
    • A suspected penetrating eye injury or intraocular foreign body. All high-velocity injuries (for example due to hammering, chiselling, grinding, or lawn mowing), or injuries caused by sharp objects (for example glass, knives, thorns, darts, or pencils) should be treated as penetrating injuries until proven otherwise.
    • All chemical injuries. The affected eye should be immediately and copiously irrigated with normal saline or water for at least 20–30 minutes, and urgent ophthalmological assessment arranged.
    • A foreign body that cannot be removed, or if the person is unable to tolerate examination.
  • Other indications for immediate referral include:
    • Any red flag symptom or sign for a serious eye condition such as severe pain, pupillary abnormalities or a significant reduction in visual acuity.
    • Hyphema (blood in the anterior chamber) or hypopyon (inflammatory exudate in the anterior chamber).
    • Large or deep abrasions.
    • Corneal opacities.
  • Indications for discussion with ophthalmology regarding urgency of referral include:
    • Superficial corneal injury due to contact lens use.
    • Recurrent erosion syndrome.
    • Persistent or worsening symptoms after 24 hours.
    • Rust rings that remain after removal of a metallic foreign body.
  • Loose superficial foreign bodies should be removed if the expertise and equipment are available in primary care.
  • Analgesia and ocular lubricants should be offered for pain relief.
  • The need for topical antibiotics such as chloramphenicol to prevent secondary infection should be considered.
  • Advice should be given on suitable eye protection to prevent injury in the future. The person should be advised to avoid rubbing or touching the eye and contact lenses until the eye recovers.
  • Follow up should be arranged in 24 hours to ensure the abrasion is healing as expected — the person should be advised to seek urgent medical review if symptoms worsen or new features develop in the interim.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the diagnosis and management of corneal superficial injury in primary care.

This CKS topic does not cover the management of deeper injuries which have penetrated the Bowman's membrane of the cornea.

There are separate CKS topics on Blepharitis, Conjunctivitis - allergic, Conjunctivitis - infective, Dry eye syndrome, and Herpes simplex - ocular.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

December 2024 — minor update. Some typographical errors have been corrected.

Previous changes

June 2022 — reviewed. A literature search was conducted in May 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Updated literature has been incorporated to provide supporting evidence for the guidance. No major changes to the clinical recommendations have been made.

June 2017 — reviewed. A literature search was conducted in April 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

December 2013 — minor update. The link to the UKMI drugs in lactation website has been removed as this no longer exists.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency. Prescriptions have been updated to reflect the revised dosing. 

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

February 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

January to April 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

March 2007 — minor update. The advice that eye patches are not recommended has been made clearer. 

October 2006 — minor update. Analgesia prescriptions updated due to new ibuprofen dose recommendations for children by the British National Formulary. 

November 2005 — minor technical update. 

August 2004 — reviewed. Validated in November 2004 and issued in April 2005.

August 2001 — reviewed. Validated in November 2001 and issued in April 2002.

August 1998 — written replacing guidance on Superficial injury, corneal.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 May 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 May 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 May 2022.

Systematic reviews and meta-analyses

New systematic review or meta-analysis studies published since 1 May 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 May 2022.

New policies

No new national policies or guidelines since 1 May 2022.

New safety alerts

No new safety alerts since 1 May 2022.

Changes in product availability

No changes in product availability since 1 May 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Assess a person with suspected superficial corneal injury.
  • Identify foreign bodies and remove them where appropriate.
  • Manage the symptoms of superficial corneal injury and prevent secondary infection.
  • Refer to ophthalmology or seek advice as appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE Quality standards

No NICE quality standards were found in this review.

Background information

What is it?

  • Superficial corneal injuries are non-penetrating injuries affecting the outermost layer of the cornea.
  • The cornea is made up of 5 distinct layers —the corneal epithelium (the outermost layer), the Bowman membrane, the stroma, Descemet's membrane, and the endothelium (the innermost layer).
  • The cornea is susceptible to injury as it is the most anterior part of the eye.
  • Relatively minor superficial injuries can cause significant pain as the cornea is densely innervated with sensory fibres from the ophthalmic branch of the trigeminal nerve.
  • Corneal abrasions are defects in the epithelial surface of the cornea.

[Browner, 2012; Wipperman, 2013; Saccomano, 2014; Ahmed, 2015; Root, 2017; BMJ Best Practice, 2021]

What causes it?

Superficial corneal injuries can be caused by:

  • Mechanical trauma such as from a fingernail, twig, paper edge, mascara brush or trichiasis (eyelashes growing inwards).
  • Foreign bodies such as dust, glass, or rust.
  • Chemical, radiation or flash burns.
    • Chemical burns (with acid or alkali in the form of liquids, powder, or gas) can seriously and permanently damage the epithelium of the conjunctiva and cornea, resulting in ischemia of the conjunctival and scleral vessels.
    • Exposure to bright ultraviolet light such as sunlight and tanning beds can damage the cornea even when the eyelids are closed.
  • Contact lenses during insertion or more commonly on removal.
    • Areas of the corneal epithelium can become adherent to contact lenses and removed with them if the lens and eye are dehydrated or the lens is ill-fitting.
  • Recurrent erosions are spontaneous abrasions which can develop in people with structural defects of the corneal epithelium due to a previous injury or anterior basement membrane dystrophy.

[Gelston, 2013; Wipperman, 2013; Saccomano, 2014; Ahmed, 2015; Root, 2017; College of Optometrists, 2022; BMJ Best Practice, 2021; Moorfields Eye Hospital, 2017]

How common is it?

  • Superficial corneal injuries are common.
  • It is estimated that corneal abrasions are the third leading cause of red eye, following conjunctivitis and subconjunctival haemorrhage. [Wipperman, 2013].
  • Although common in both men and women across all age groups, the incidence of corneal abrasion is highest among working-age males [Willman, Fu and Melanson, 2022; Ahmed, 2015].
  • Recently published estimates as to the incidence of superficial corneal injury presentation in primary care are lacking:
  • A survey of people attending an eye casualty department in the UK (n = 6,576) found that trauma was the most common cause of presentation — 32% of people (n = 2,106) were diagnosed with foreign body and 13% (n = 849) with corneal abrasion [Chiapella, 1985].
  • A study using data from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, and the National Hospital Discharge Survey for 2001 in the United States (n = 422,604 patient visits) found the incidence of superficial injury of the eye and adnexa to be approximately 3 per 1000 people and the incidence of foreign body on the external eye to be 2 per 1000 people [McGwin, 2015].
  • A study [Wong, 1998] looking at work-related eye injuries in a large car manufacturing company in the United States over a 3 year period (n = 1,983) found that:
    • Superficial corneal foreign body was the most common type of injury (69.2%) with an incidence of 10.3 per 1,000 employee-years.
    • Corneal abrasion was the second most common injury (17.5%) with an incidence 2.6 injuries per 1000 employee-years.
    • One third of workers who had sustained an eye injury were unable to return to normal duties for at least 1 day.

[BMJ Best Practice, 2021]

What are the complications?

Serious complications resulting from superficial corneal injury are rare. They include:

  • Corneal ulceration.
  • Infective keratitis.
  • Iritis.
  • Recurrent erosion syndrome — spontaneous abrasions can occur days to years after an initial abrasion heals.

[Wipperman, 2013; Ahmed, 2015; BMJ Best Practice, 2021]

What is the prognosis?

  • The prognosis for most superficial corneal injuries is good:
    • Most uncomplicated small corneal abrasions will heal rapidly within 1–2 days without visual impairment.
    • Lesions affecting more than 50% of the corneal surface may take 4–5 days to heal.
  • A small number of abrasions do not heal spontaneously and debridement may be needed to encourage healing.
  • Chemical injuries are potentially sight threatening and prognosis depends on:
    • The pH concentration of the chemical.
    • Duration of contact with the ocular surface.
    • How quickly the eye is irrigated after chemical injury.

[Browner, 2012; Gelston, 2013; Wipperman, 2013; Saccomano, 2014; Ahmed, 2015; Fraenkel, 2017; BMJ Best Practice, 2021]

Diagnosis

What are the clinical features of corneal superficial injury?

  • Superficial corneal injury is typically unilateral and clinical features include:
    • Sudden onset of eye pain on blinking — severity of pain can range from mild to severe.
    • Discomfort or foreign body sensation which may be described as a ‘gritty’ or ‘scratching’.
    • Lacrimation (tearing).
    • Photophobia — serious systemic conditions such as meningitis should always be considered in a person presenting with photophobia.
    • Decreased or blurred vision due to epithelial disruption and stromal oedema.
    • Conjunctival redness.
    • Blepharospasm (abnormal contraction of the eyelid).
  • There is usually a history of a precipitating event such as:
    • An object striking the eye, or a foreign body entering the eye (for example fingernails, animal claws, tree branches, pieces of paper/cardboard, make-up applicators, glass, metal or dust).
      • People with certain occupations are more at risk of this, for example, those involving grinding or cutting tools, particularly if protective eyewear is not worn.
    • Difficult contact lens removal.
      • Abrasions are more likely if lenses do not fit properly, are over worn or inadequately cleaned, or where the lens or eye are dehydrated.
    • Excessive eye rubbing - minimal trauma can lead to a corneal abrasion.
    • Recurrent erosions can occur spontaneously in those with previous corneal injuries.
      • Pain onset may typically occur at night or first thing in the morning.
    • Children may not be able to recall or vocalise an event, but the clinical presentation is usually the same as in adults.
  • If a corneal foreign body is present, signs may include:
    • A visible foreign body on the ocular surface.
    • Linear scratches on the cornea.
    • Subtarsal foreign bodies typically produce vertical tracks due to repeated scratching with blinking.
    • Rust rings from a metallic foreign body.
    • More severe direct trauma injuries may involve deeper structures of the eye, and may result in scar formation or a ruptured globe.

Basis for recommendation

The information on the clinical features of superficial corneal injury is based on the clinical guidelines Corneal (or other superficial ocular) foreign body [College of Optometrists, 2022] and Sub-tarsal foreign body [College of Optometrists, 2021] and expert opinion in review articles [Browner, 2012; Wipperman, 2013; Saccomano, 2014; Ahmed, 2015; Fraenkel, 2017; Root, 2017; BMJ Best Practice, 2019; BMJ Best Practice, 2021].

How should I assess a person with suspected superficial corneal injury?

Diagnosis of superficial corneal injury should be based on both history and clinical examination.

Take a history, asking about:

  • Clinical features including:
    • Pain or discomfort (onset is usually sudden).
    • Foreign body sensation (even when none is present).
    • Changes in vision.
    • Photophobia — serious systemic conditions such as meningitis should always be considered in a person presenting with photophobia.
    • Tearing.
    • Blepharospasm.
    • Red flag symptoms such as:
      • Significant changes in vision.
      • Significant trauma.
      • Marked eye pain, headache or photophobia.
  • Circumstances surrounding onset (with details of mechanism and material involved) and precipitating factors including:
    • Occupation or recreational activity.
      • High-velocity injuries (for example in hammering, metal or machine workers), can cause penetrating eye injuries necessitating urgent referral.
      • Metallic (ferrous) material can leave a rust ring.
      • Vegetative material is associated with increased risk of fungal infection.
    • Sporting activity.
    • Contact lens wear.
      • Ask about ill-fitting lenses and prolonged use (for example sleeping in contact lenses).
      • When the eye or the lens becomes dry, the lens may adhere to the corneal epithelium, and cause injury on removal.
    • Aggressive eye rubbing.
    • Exposure to chemicals or ultraviolet light (such as household cleaning products, sunlight or a tanning bed).
      • If a possible chemical injury has occurred, check what action if any has been taken – immediate irrigation of the affected eye is essential.
    • Past medical history including:

Examine the person:

  • Check for signs of perforation and penetrating eye injury that indicate the need for emergency referral to ophthalmology.
    • A ruptured globe may present with blue, brown or black material on the surface of the eye (iris or choroid plugging the wound).
    • Check pupillary shape and response using a penlight or ophthalmoscope and suspect penetrating trauma if the pupil is dilated, nonreactive or irregular, or the iris is protruding.
  • Assess visual acuity with a Snellen chart.
  • Systematically examine the eye:
    • Topical anaesthetic may be needed to ease symptoms and aid examination where the person is experiencing significant pain.
      • One drop of topical anaesthetic should provide pain relief for 10 to 20 minutes.
      • Following examination, the person should be advised to protect the anaesthetised eye from injury, dust and bacterial contamination.
      • Repeat doses should be avoided as they can cause corneal epithelium toxicity and impair healing.
    • The conjunctiva — look for hyperaemia and foreign bodies.
      • If a penetrating injury has been excluded the upper eyelids can be everted to check for foreign bodies.
    • The cornea —  look for foreign bodies, and clouding, opacity or infiltrates which may indicate chemical injury, corneal ulcer or infection.
      • Suspected chemical injuries require immediate copious irrigation prior to emergency assessment by ophthalmology.
      • If there is no indication for immediate referral, fluorescein and the cobalt blue filter on an ophthalmoscope or Wood’s lamp can be used to identify corneal epithelial defects — defects will fluoresce bright green.
      • If fluorescein staining appears to stream or change colour, refer immediately as this is indicative of a penetrating globe injury.
      • Traumatic corneal abrasions usually appear as linear or geographic shapes.
      • A foreign body under the upper lid may produce multiple vertical lines on the superior cornea.
      • Injury from contact lenses may be seen as several punctate lesions coalescing around a central defect, and can involve the entire corneal surface.
    • The eyelids — look for oedema and erythema.
      • Swelling and burns to the eyelids can occur with chemical injury.
    • The sclera — look for signs of other conditions such as scleritis or episcleritis.
    • The anterior chamber — look for blood (hyphema) or pus (hypopyon) as these symptoms require urgent referral.
    • Eye movements.

Basis for recommendation

The recommendations on assessment of a person with suspected superficial corneal injury is based on the clinical guidelines Corneal (or other superficial ocular) foreign body [College of Optometrists, 2022] and Sub-tarsal foreign body [College of Optometrists, 2021], and expert opinion in review articles [Browner, 2012; Gelston, 2013; Wipperman, 2013; Saccomano, 2014; Ahmed, 2015; Kuffova, 2015; Pflipsen, 2016; Fraenkel, 2017; Root, 2017; Fraser, 2019; BMJ Best Practice, 2021; BMJ Best Practice, 2019].

Onset

  • Time of the incident is important — superficial foreign bodies occurring on the day of presentation are more amenable to removal in primary care as it is unlikely that encroaching corneal epithelium or a rust ring will have had time to develop [Fraenkel, 2017].

Precipitating factors

  • The presence of a corneal abrasion without a history of ocular injury may indicate other conditions such as recurrent erosion syndrome, infective keratitis, or inflammatory keratitis [Ahmed, 2015].
  • For contact lens wearers, when the eye or the lens becomes dry (for example, after prolonged use such as inadvertently sleeping with contact lenses in), the lens may adhere to the corneal epithelium, and cause injury upon removal [BMJ Best Practice, 2021].

Visual acuity

Ultraviolet (UV) light exposure

  • Exposure to bright UV lights such as sunlight and tanning beds can damage the cornea even when the eyelids are closed [Saccomano, 2014].

Topical anaesthetic

  • Use of topical anaesthetic may ease examination. One drop of topical anaesthetic should provide pain relief for 10 to 20 minutes [BMJ Best Practice, 2021].
  • Foreign bodies should be removed under topical anaesthesia [College of Optometrists, 2022].
  • Guidelines from Moorfields Eye Hospital and the College of Optometrists both suggest the use of one drop of proxymetacaine 0.5% w/v [Moorfields Eye Hospital, 2017; College of Optometrists, 2022]. 
  • Repeat doses should be avoided as they can cause corneal epithelium toxicity and impair corneal healing [Fraser, 2019].
  • If a topical ocular anaesthetic is used to aid examination of the eye, the person should be advised to protect the anaesthetised eye from injury, dust and bacterial contamination for the likely duration of the anaesthetic action [ABPI, 2016].

Fundoscopic examination

  • Fundoscopic examination is often difficult as the pupil may be small and the person photophobic [BMJ Best Practice, 2021].

Fluorescein

  • Fluorescein stains any exposed corneal stroma and basement membrane – it does not stain intact conjunctival or corneal epithelium. Its use is important in identifying corneal abrasions which can be subtle and otherwise missed [Ahmed, 2015].
  • Fluorescein that changes colour or seems to stream (positive Seidel's test) may be indicative of a penetrating globe rupture [BMJ Best Practice, 2021].

What else might it be?

There are many causes of red and/or painful eye, some of which are serious or sight threatening and require same day assessment by ophthalmology — for further information, see the CKS topic on Red eye. The differential diagnosis for superficial corneal injury includes:

  • Serious conditions such as:
    • Penetrating eye injury.
    • Acute angle-closure glaucoma.
    • Uveitis.
    • Optic neuritis.
    • Iritis.
    • Infective keratitis – bacterial, fungal and herpetic.
    • Corneal ulcer.
  • Other eye conditions such as:
    • Recurrent erosion syndrome.
    • Conjunctivitis.
    • Dry eye syndrome.
    • Trichiasis.
    • Keratoconjunctivitis.
    • Exposure keratopathy.

Basis for recommendation

The information on the differential diagnosis of superficial corneal injury is based on the clinical guidelines Corneal (or other superficial ocular) foreign body [College of Optometrists, 2022] and Sub-tarsal foreign body [College of Optometrists, 2021], and expert opinion in review articles [Browner, 2012; Wipperman, 2013; Saccomano, 2014; Ahmed, 2015; Kuffova, 2015; Fraenkel, 2017; Root, 2017; BMJ Best Practice, 2021; BMJ Best Practice, 2019].

Management

Scenario: Management of corneal superficial injury

From age 1 month onwards.

When should I refer to an ophthalmologist?

  • Refer the person immediately to the emergency eye service if:
    • A suspected penetrating eye injury has occurred or an intraocular foreign body is suspected — all high-velocity injuries (such as from drilling, lawn moving or hammering) or injuries caused by sharp objects (such as glass, knives, pencils or thorns) should be treated as penetrating injuries until proven otherwise.
      • Advise the person not to place pressure on the eye and to limit coughing or straining to prevent extrusion of intraocular contents.
      • Do not remove foreign bodies that are visible and protruding out of the globe.
    • Significant orbital or peri-ocular trauma has occurred.
    • A chemical injury has occurred.
      • Immediately irrigate the eye with copious irrigation fluid (such as lactated Ringer's solution, normal saline, or water if other irrigation solutions are not available) for 20—30 minutes and refer as an emergency to ophthalmology.
      • Copious irrigation to neutralize the ocular surface is essential to limit permanent damage and visual loss.
    • A retained foreign body that cannot be removed safely in primary care is present.
      • Foreign bodies composed of organic material (such as seeds, soil, insect scales or caterpillar setae) should be referred to ophthalmology as these are associated with a higher risk of infection and complications.
      • Foreign bodies in or near the centre of the cornea are associated with an increased risk of permanent visual loss.
    • Any of the following red flag clinical features are present:
      • Severe pain.
      • Irregular, dilated or non-reactive pupils.
      • Significant reduction in visual acuity.
      • Hyphema (blood in the anterior chamber) or hypopyon (pus in the anterior chamber).
      • Large or deep abrasions.
      • Corneal opacity.
    • Infection or corneal ulcer is suspected.
    • They are unable to tolerate examination or foreign body removal in primary care.
      • Have a low threshold for referral of young children who may not be able to explain symptoms or are reluctant open their eye for examination.
  • Discuss with ophthalmology or refer (with urgency depending on clinical judgement) if the person is suspected of having:
    • Recurrent erosion syndrome.
    • A superficial corneal injury associated with contact lens use.
      • Antibiotics should not be initiated in primary care as this may affect microbiological specimens taken in secondary care.
    • An abrasion that is not improving or worsening 24 hours after initiation of treatment in primary care.
    • A rust ring.
      • Rust rings should be removed within 1–2 days of appearance by ophthalmology.

Basis for recommendation

The recommendations on when to refer a person to ophthalmology are based on the clinical guidelines Corneal (or other superficial ocular) foreign body [College of Optometrists, 2022], Sub-tarsal foreign body [College of Optometrists, 2021], and Commissioning guidance: Emergency eye care [RCO, 2020], expert opinion in review articles [Gelston, 2013; Hamill, 2015; Wipperman, 2013; Ahmed, 2015; Kuffova, 2015]  [Fraenkel, 2017; Root, 2017; BMJ Best Practice, 2021], and on what CKS feels to be good clinical practice.

Low threshold for referral if penetrating injury suspected
  • Expert opinion in a review article is that globe ruptures may be subtle — the eyeball does not deflate with small lacerations and the normal contour is often maintained. A low threshold for referral is essential to minimize compilations [Root, 2017].
  • Guidelines from the Royal College of Ophthalmologists recommend penetrating ocular injuries to be immediately referred [RCO, 2020].
Chemical burns
  • The recommendation on copious ocular irrigation prior to emergency referral of chemical injuries to ophthalmology is based on expert opinion in review articles [Gelston, 2013; Hamill, 2015; Wipperman, 2013; Root, 2017].
  • Delays in irrigation can lead to more severe injury and permanent visual loss [Root, 2017].
  • Guidelines from the Royal College of Ophthalmologists recommend ocular chemical injuries to be irrigated then immediately referred [RCO, 2020].
Refer if a foreign body cannot be safely removed in primary care
  • Expert opinion in a review article [Fraenkel, 2017] is that removal of a corneal foreign body without the aid of a slit-lamp can be difficult and if a GP does not feel safe to proceed, referral to ophthalmology is required.
  • Removal of corneal foreign bodies (in particular from the central and paracentral corneal areas) can lead to visually significant corneal scarring.
Contact lens wear
  • Contact lens wearers are at risk of Pseudomonas infection which can be sight threatening and requires appropriate diagnosis and treatment [Browner, 2012; Wipperman, 2013; BMJ Best Practice, 2021; College of Optometrists, 2022].
  • The recommendation that antibiotics should not be initiated in primary care for people who wear contact lenses is based on what CKS considers to be good clinical practice. Contact lens wearers may require ophthalmology referral, and prophylactic antibiotic use could affect microbiological specimens taken in secondary care.
Rust rings
  • Iron or metal-containing foreign bodies may leave a rust ring after removal [BMJ Best Practice, 2021].
  • Rust rings should be referred for removal as they increase the risk of infection and recurrent erosion [Fraenkel, 2017].
  • Follow-up appointments should be within 24 to 48 hours after foreign body removal [BMJ Best Practice, 2021].
Visual acuity
  • Minor alterations in acuity can be caused by defects in the visual axis. More significant changes can occur when there are defects in the visual axis that are accompanied by corneal oedema [BMJ Best Practice, 2021].
  • Significant reductions in visual acuity are an indicator for ophthalmology referral [BMJ Best Practice, 2021].

How should I manage a superficial corneal injury that is not referred?

If referral to ophthalmology is not indicated:

  • Remove loose superficial foreign bodies (FB), if the expertise and equipment are available:
    • Ensure that visual acuity is checked before and after attempting foreign body removal.
    • Irrigate the eye with normal saline to wash out the foreign body.
    • If saline irrigation fails, apply a topical ocular anaesthetic, and sweep a sterile cotton-tipped applicator gently over the cornea. 
      • If the FB is subtarsal, evert the eye lid to access it.
      • Following removal of a FB, the person should be advised to protect the anaesthetised eye from injury, dust and bacterial contamination.
      • Repeat doses should be avoided as they can cause corneal epithelium toxicity and impair healing.
    • Metallic foreign bodies may leave a rust ring which requires follow up and removal by ophthalmology within 1-2 days.
    • If swabbing is unsuccessful, FB removal with other disposable instruments, such as a hypodermic needle, should only be carried out in primary care by appropriately trained and experienced clinicians.
    • Refer immediately to ophthalmology if there is diagnostic uncertainty or the expertise or equipment for FB removal is not available in primary care.
  • Consider the need for analgesia or ocular lubricants:
    • Advise the person if they are experiencing discomfort that simple oral analgesia such as paracetamol can be taken – for further information, see the section on Prescribing information.
    • Non-prescription lubricating eye drops/ointment may provide additional pain relief to oral analgesics.
      • Eye ointments can blur vision, and therefore eye drops may be preferred in the day, with ointments used at night.
    • Do not prescribe topical analgesia.
    • Do not prescribe cycloplegics.
  • Consider prescription of topical antibiotics:
    • If there is a risk of infection, prescription of a broad spectrum topical antibiotic such as chloramphenicol (prescribed for at least 5 days) is appropriate. For further information on prescribing chloramphenicol, see the CKS topic on Conjunctivitis - infective.
      • Corneal epithelial defects, in particular those contaminated with foreign matter, increase the risk of corneal infection which can be sight threatening.
  • Arrange follow up in 24 hours:
    • Advise the person to seek urgent medical review if symptoms worsen in the interim.
    • Refer to ophthalmology if:
      • Vision worsens.
      • Symptoms (such as pain, photophobia, foreign body sensation or redness) are not improving.
      • The abrasion has increased in size.
      • A corneal infiltrate, ulcer or infection has developed.
      • A rust ring is present.
      • The abrasion does not resolve completely within 3–4 days.
  • Advice for people with superficial corneal injuries:
    • Wearing sunglasses or staying out of areas of bright light may help with symptoms of light sensitivity.
    • Advise the person on suitable eye protection to prevent injury in the future and provide patient information.
    • The eye should not be touched or rubbed and contact lenses should be avoided while the eye recovers.
    • Patient information on Eye injuries is available from NHS Choices at www.nhs.uk.

Basis for recommendation

The recommendations on how to manage a superficial corneal injury in primary care are based on the clinical guidelines, Corneal (or other superficial ocular) foreign body [College of Optometrists, 2022], Sub-tarsal foreign body [College of Optometrists, 2021], and Common eye conditions management [Moorfields Eye Hospital, 2017] systematic reviews [Thiel, 2017] and meta-analyses [Wakai, 2017; Lim, 2016], and expert opinion in review articles [Gelston, 2013; Hamill, 2015; Wipperman, 2013; Ahmed, 2015; Kuffova, 2015; Fraenkel, 2017; Root, 2017; BMJ Best Practice, 2021; Ambikkumar, 2022].

Remove foreign bodies
Subtarsal foreign body removal
  • Vertical scratch marks that stain with fluorescein suggest a foreign body under the upper lid [Ambikkumar, 2022].
  • Recommendations on subtarsal foreign body removal are based on clinical guidelines from the College of Optometrists [College of Optometrists, 2021], Moorfields Eye Hospital [Moorfields Eye Hospital, 2017], and expert opinion in a review article [BMJ Best Practice, 2021].
  • To evert the eye lid, ask the person to look down, firmly grasp the central lashes or lid margin between thumb and forefinger. Pull the eyelid down and out (away from the globe). Place a cotton-tipped applicator at the superior margin of the tarsal plate on top of the eyelid and apply slight downward pressure whilst rotating the lid margin upwards. Once everted, use thumb to hold the lashes against the superior orbital margin whilst examining the eye lid. To invert the tarsal plate, release the lashes and ask the person to look up [BMJ Best Practice, 2021].
Topical anaesthetic to aid foreign body removal
  • Foreign bodies should be removed under topical anaesthesia [College of Optometrists, 2021].
  • One drop of topical anaesthetic should provide pain relief for 10 to 20 minutes [BMJ Best Practice, 2021].
  • Guidelines from Moorfields Eye Hospital and the College of Optometrists both suggest the use of one drop of proxymetacaine 0.5% w/v [Moorfields Eye Hospital, 2017; College of Optometrists, 2021]
  • Repeat doses should be avoided as they can cause corneal epithelium toxicity and impair corneal healing [Fraser, 2019].
  • If a topical ocular anaesthetic is used to aid examination of the eye, the person should be advised to protect the anaesthetised eye from injury, dust and bacterial contamination for the likely duration of the anaesthetic action [ABPI, 2016].
Symptom relief

Oral analgesia

Ocular lubricants

Topical analgesia

  • Prescription of topical analgesics is not recommended.
  • A 2017 Cochrane review indicated that the use of topical NSAIDs may reduce the need for oral analgesia (low certainty evidence), but there was no evidence to demonstrate that topical NSAIDs improve healing times, and no studies had assessed whether these treatments considerably reduce self-reported pain intensity scores. The authors of the study concluded that given the higher cost of topical NSAIDs compared with oral analgesics, the evidence does not support the use of topical NSAID use in the management of traumatic corneal abrasions [Wakai, 2017].

Topical anaesthetics

  • A systematic review and meta-analysis [Puls, 2015] of effectiveness and complications associated with the short-term use of topical anaesthetics (≤72 hours) in the management of corneal abrasions in an accident and emergency department (n = 140) found no differences in pain, persistent symptoms, or corneal healing with short-term use of topical anaesthetics compared to placebo. The authors concluded that data on safety was sparse, and that treatment was not supported by evidence to date.
  • A 2017 systematic review found no evidence to suggest that use of topical anaesthetics improved healing or pain management in people with corneal abrasions [Thiel, 2017].
  • Expert opinion in one review article [Ahmed, 2015] is that repeated administration of topical anaesthetic is absolutely contraindicated with any corneal injury as this has been shown to delay corneal wound healing, mask worsening symptoms and can be toxic to corneal epithelium.

Cycloplegics

  • Cycloplegic agents dilate the pupil and paralyse the ciliary muscle thereby inactivating the accommodation reflex [BNF, 2022].
  • As a result, use of cycloplegics can worsen glare and make reading difficult. The pharmacodynamic effect is also prolonged, with even short-acting agents producing pupil dilation for 24 to 36 hours. This is longer than some small defects take to heal [BMJ Best Practice, 2021].
  • A 2017 systematic review found no evidence to suggest that use of cycloplegics improved healing or pain management in people with corneal abrasions [Thiel, 2017].
  • Prescription of cycloplegics (for example, cyclopentolate) is not recommended [BMJ Best Practice, 2021].
Consider topical broad spectrum antibiotics
  • The recommendation on use of topical chloramphenicol is based on clinical guidelines from the College of Optometrists [College of Optometrists, 2022; College of Optometrists, 2021] and expert opinion in a review article [Fraenkel, 2017].
  • Guidelines state that risk of infection following mild trauma is low.
  • Expert opinion in a review article is that topical antibiotics are commonly prescribed to prevent bacterial superinfection despite evidence being lacking [Wipperman, 2013].
  • No studies investigating the optimal length of therapy have been identified in the literature. Expert opinion in a review article is that therapy can be continued until 24 hours after the patient has become symptom-free [BMJ Best Practice, 2021].
Eye patches
  • Although some sources recommend the use of eye patches for 24 hours for superficial corneal injuries [Moorfields Eye Hospital, 2017], the evidence from clinical trials does not support routine use. 
  • Findings from a 2016 Cochrane systematic review suggested that treating simple corneal abrasions with a patch does not improve healing or reduce pain. However, it was noted that there were limited data on the effect of patch use in people with large abrasions (>10 mm2 in size) [Lim, 2016].
  • Patients may find some relief in keeping the eye shut and wearing sunglasses or staying in low light to avoid light sensitivity [BMJ Best Practice, 2021].
Arrange follow up and provide patient information
  • The recommendation on arranging follow up in 24 hours is based on expert opinion in review articles [Wipperman, 2013; Ahmed, 2015; Fraenkel, 2017; BMJ Best Practice, 2021].
  • An observation prospective cohort study (n = 60 eyes) looking at corneal foreign bodies in non-contact lens wearers [Brissette, 2014] found that few non-complicated injuries develop infectious keratitis. However, the authors recommend advising all patients of red flag symptoms for urgent review including worsening in eye pain, irritation, redness, and decrease in their visual acuity.
  • The recommendation on provision of patient information (including advice on prevention of future injury) is based on clinical guidelines from the College of Optometrists [College of Optometrists, 2022; College of Optometrists, 2021], the commissioning guidance Urgent eye care from The College of Optometrists and The Royal College of Ophthalmologists [College of Optometrists and the Royal College of Ophthalmologists, 2013] and expert opinion in review articles [Ahmed, 2015; Fraenkel, 2017; BMJ Best Practice, 2021].
  • The recommendation to use suitable eye protection to prevent injury in the future is supported by a retrospective observational study which identified lower rates of eye injury among eye protection users in comparison with non-users [Sun, 2021].
Refer to ophthalmology if symptoms do not improve within 24 hours
  • Expert opinion in a review article is that if foreign body sensation persists overnight but no foreign body can be identified in primary care, referral to ophthalmology is required for full assessment including slit lamp [Fraenkel, 2017].
  • A study looking at people presenting to a UK emergency department with ocular foreign body sensation (n = 1,155) found that 67.8% had a corneal foreign body and 13.6% had a corneal abrasion without foreign body [Jayamanne, 1995].
Refer to ophthalmology if examination cannot be tolerated, for example in children
  • Expert opinion in a review article is that children unable to tolerate eye examination should be referred to secondary care for examination and treatment under general anaesthesia if necessary [Fraenkel, 2017].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical antibiotics

Which topical antibiotic should I prescribe?

Oral analgesia (short-term use)

What should I consider before prescribing paracetamol?

For information on the prescription of paracetamol, see the Management section in the CKS topic on Analgesia - mild-to-moderate pain.

Supporting evidence

This CKS topic is largely based on clinical guidelines from the College of Optometrists Corneal (or other superficial ocular) foreign body [College of Optometrists, 2022], Sub-tarsal foreign body [College of Optometrists, 2022], from the Royal College of Ophthalmologists Commissioning guidance: Emergency eye care [RCO, 2020], and from Moorfield Eye Hospital Common Eye conditions management [Moorfields Eye Hospital, 2017]. Evidence is also provided by Cochrane [Wakai, 2017; Lim, 2016; Algarni, 2022] and other systematic reviews [Thiel, 2017], expert opinion in review articles, and on what CKS considers to be good clinical practice.

A brief summary of the available evidence is given in the relevant basis for recommendation sections.

CKS has not summarized the evidence for secondary care treatment as this is outside the scope of this topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of corneal superficial injury.

Search dates

August 2017 - May 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • corneal injur$.tw., corneal abrasion$.tw., ocular injur$.tw., (corneal and (foreign adj body)).tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Bausch & Lomb U.K. Limited (2016) Minims Proxymetacaine Hydrochloride 0.5% w/v, Eye drops solution. ABPI. http://www.medicines.org.uk [Free Full-text]
  • Ahmed F, House RJ, Feldman BH (2015) Corneal Abrasions and Corneal Foreign Bodies. Prim Care 42(3), 363-375.
  • Algarni, A., Guyatt, G.H. and Turner, A. and Alamri, S. (2022) Cochrane Review: Antibiotic prophylaxis for corneal abrasion. 5. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Ambikkumar, A. and Arthurs, B. and El-Hadad, C. (2022) Corneal foreign bodies. CMAJ 194(11). [Abstract] [Free Full-text]
  • Woreta, F. (2019) Eye trauma. BMJ Best Practice. https://bestpractice.bmj.com [Free Full-text]
  • McStay, C. (2021) Corneal abrasions. BMJ Best Practice. https://bestpractice.bmj.com [Free Full-text]
  • BMJ Group and Pharmaceutical Press (2022) British National Formulary; Mydriatics and cycloplegics. National Institute for Health and Care Excellence. https://bnf.nice.org.uk [Free Full-text]
  • Brissette A, Mednick Z, Baxter S. (2014) Evaluating the need for close follow-up after removal of a noncomplicated corneal foreign body. Cornea 33(11), 1193-1196.
  • Browner, EA (2012) Corneal abrasions. Pediatr Rev. 33(6), 285-286.
  • Chiapella AP, Rosenthal AR (1985) One year in an eye casualty clinic. Br J Ophthalmol 69(11), 865-870.
  • College of Optometrists and the Royal College of Ophthalmologists (2013) Commissioning better eye care. Urgent eye care. College of Optometrists and the Royal College of Ophthalmologists. [Free Full-text]
  • College of Optometrists (2021) Sub-tarsal foreign body (STFB). College of Optometrists. http://www.college-optometrists.org [Free Full-text]
  • College of Optometrists (2022) Corneal (or other superficial ocular) foreign body. College of Optometrists. http://www.college-optometrists.org [Free Full-text]
  • Fraenkel A, Lee LR, Lee GA (2017) Managing corneal foreign bodies in office-based general practice. Aust Fam Physician. 46(3), 89-93.
  • Fraser, R., Walland, M. and Chan, E. and Crock, C. (2019) Topical anaesthetic in the treatment of corneal epithelial defects: What are the risks? Aust J Gen Pract 48(8), 504-506. [Abstract] [Free Full-text]
  • Gelston, C.D. (2013) Common eye emergencies. American Family Physician. 88(8), 515-519. [Abstract]
  • Hamill CE, Bozorg S, Peggy Chang HY, Lee H, Sayegh RR, Shukla AN, Chodosh J (2015) Corneal alkali burns: a review of the literature and proposed protocol for evaluation and treatment. Int Ophthalmol Clin. 53(4), 185-194.
  • Jayamanne DG (1995) Do patients presenting to accident and emergency departments with the sensation of a foreign body in the eye (gritty eye) have significant ocular disease? J Accid Emerg Med. 12(4), 286-287.
  • Kuffova L, Forrester JV, Dick A. (2015) Assessing the painful, uninflamed eye in primary care. BMJ 351, h3216. [Abstract]
  • Lim, C.H.L. and Turner, A. and Lim, B.X. (2016) Cochrane Review: Patching for corneal abrasion. Issue 7. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • McGwin G, Xie A, Owsley C (2015) Rate of eye injury in the United States. Acta Ophthalmol 123(7), 970-976.
  • Moorfields Eye Hospital (2017) GP Handbook Common eye conditions. Moorfields Eye Hospital NHS Foundation Trust. http://www.moorfields.nhs.uk [Free Full-text]
  • Moorfields Eye Hospital (2021) Lubricants/artifical tears. Moorfields Eye Hospital NHS Foundation Trust. https://www.moorfields.nhs.uk [Free Full-text]
  • Pflipsen M., Massaquoi M. and Wolf S. (2016) Evaluation of the painful eye. American Family Physician 93(12), 991-998. [Abstract]
  • Puls HA, Cabrera D, Murad MH, Erwin PJ, Bellolio MF (2015) Safety and Effectiveness of Topical Anesthetics in Corneal Abrasions: Systematic Review and Meta-Analysis. J Emerg Med 49(5), 816-824.
  • Royal College of Ophthalmologists (2020) Commissioning guidance: Emergency eye care. Royal College of Ophthalmologists. http://www.rcophth.ac.uk [Free Full-text]
  • Jeremy M. Root, Shipra Gupta, Nazreen Jamal (2017) Nonpenetrating eye injuries in children. Clinical Pediatric Emergency Medicine, 18(1), 74-86.
  • Royal College of General Practitioners, Royal College of Ophthalmologists (2001) Ophthalmology for general practice trainees.. London: Medical Protection Society..
  • Saccomano SJ, Ferrara LR (2014) Managing corneal abrasions in primary care. Nurse Pract. 39(9), 1-6.
  • Shields, T. and and Sloane, P.D. (1991) A comparison of eye problems in primary care and ophthalmology practices. Fam Med 23(7), 544-546. [Abstract]
  • Sun, F., Zhou, Y. and Dong, L and Qin, H. (2021) Relationship between the use and type of eye protection and work-related corneal and conjunctival foreign body injuries. Inj Prev 27(6), 521-526. [Abstract]
  • Thiel, B. and Muacevic, A. and Adler, J.R. (2017) Efficacy of topical analgesics in pain control for corneal abrasions: A systematic review. Cureus 9(3), e1121. [Free Full-text]
  • Wakai, A., Lawrenson, J.G., Lawrenson, A.L., et al. (2017) Cochrane Review: Topical non‐steroidal anti‐inflammatory drugs for analgesia in traumatic corneal abrasions. Cochrane Database of Systematic. Issue 5. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Willman, D., Fu L. and and Melanson, S.W. (2022) Corneal injury. StatPearls. NIH National Library of Medicine. http://www.ncbi.nlm.nih.gov [Free Full-text]
  • Wipperman JL, Dorsch JN (2013) Evaluation and management of corneal abrasions. Am Fam Physician 87(2), 114-120.
  • Wong TY, Lincoln A, Tielsch JM, Baker SP (1998) The epidemiology of ocular injury in a major US automobile corporation. Eye (London) 12(Pt 5), 870-874.
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