To Patch or Not to Patch, That is the Question

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Patient Presentation
An 18-month-old female came to clinic after a few hours of crying and refusing to open her right eye. The symptoms began after she was fighting with her sister over a toy. The sister reports that the toy hit the toddler in her eye.
The past medical history reveals that she is otherwise well.
The pertinent physical exam shows her right eye to be generally pink and watering and she refused to open it for examination. After a topical anesthetic and fluorescein was applied, the Wood’s lamp evaluation found a 3 mm corneal abrasion at 3 o’clock lateral to the pupil. The rest of the ophthalmologic examination was normal including eversion of the eyelid.
The diagnosis of corneal abrasion was made. She was treated with Erythromycin opthalmic ointment and covered with a pressure patch to prevent further rubbing of her eye, although she removed it later that evening. One day later the child had no pain and repeat examination showed complete healing of the abrasion.

Discussion
Corneal abrasions are a loss of corneal epithelium that exposes the corneal nerves. It is caused by physical or chemical trauma and can often be missed. It is the most common corneal eye injury. Symptoms include pain, tearing, redness, photophobia, foreign body sensation and blepharospasm. The diagnosis is made with history, eye examination and fluorescein staining of the eye with Wood’s lamp or slit lamp visualization. The fluorescein dye stains areas of removed epithelium and fluoresces a greenish-white color under blue light. It is important to remember to examine the underside of the eyelid to rule out a retained foreign body.
Most corneal abrasions heal in 24-48 hours but corneal scarring, ulcerations or infections of the cornea and iris do occur. If the eye still has an abrasion after 48 hours, has increased pain, pain with no obvious defect, or a clouded cornea, an ophthalmologic evaluation is needed.

Other common causes of a painful eye related to the eye itself include:

  • Corneal abrasion
  • Conjunctivitis
  • Foreign body
  • Chelazion
  • Blepharitis
  • Keratitis – bacterial, Herpes simplex
  • Uveitis/iritis
  • Intraocular infection
  • Glaucoma (acute)

Learning Point
Treatment for corneal abrasion includes:

  • Patching of the eye – Theoretically patching may decrease friction of the eyelid on the cornea, improving comfort and accelerating healing. The theoretical disadvantages include decreased oxygen delivery to the cornea which is needed for healing, increased moisture which may result in increased infection, and if the patch is applied inappropriately it may cause corneal abrasions. Patching is not recommended in contact lens wearers because of the risk of incubating infectious organisms.

    Although patching is recommended by many standard textbooks, there are several newer studies which find that the benefit of patching is questionable and may itself cause other problems.

    • A meta-analysis found no improvement in healing rate or pain and 48% complained of the patch causing pain itself (see Flynn, 1998 in To Learn More below).
    • One randomized controlled trial found no improvement in healing rate or pain. (see Le Sage, 2001 in To Learn More below).
    • Another randomized controlled trial found no improvement in healing rate but more problems with difficulty walking (see Michael, 2002 in To Learn More below)

    The child in this case was patched because the physicians felt that she would continue to rub her eye and risk further damage.

  • Topical analgesics – Theoretically these may decrease the pain but they can be toxic to keratocytes and may delay healing. They should be used in the evaluation process only. Ice may help to relieve some pain caused by eyelid swelling.
  • Topical antibiotics – The goal is to prevent infection in the abraded areas. Ointment also helps to lubricate the eye better than drops but can make the vision blurry. Bacitracin, Polymyxin/bacitracin, Erythromycin, and Ciprofloxacin are often used. People who wear contact lenses should have coverage for Pseudomonas.
  • Mydriatics – They may relieve ciliary muscle spasm if present. If they are used, they should be used with caution as they may mask another cause of a painful eye.
  • Follow-up at 24-48 hours is recommended to determine healing.

Questions for Further Discussion
1. Besides corneal abrasion, what are other causes of crying that are often hidden?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Flynn CA, D’Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis.
J Fam Pract. 1998 Oct;47(4):264-70. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9789511

Le Sage N, Verreault R, Rochette L.
Efficacy of eye patching for traumatic corneal abrasions: a controlled clinical trial.
Ann Emerg Med. 2001 Aug;38(2):129-34. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11468606

Michael JG, Hug D, Dowd MD.
Management of corneal abrasion in children: a randomized clinical trial.
Ann Emerg Med. 2002 Jul;40(1):67-72. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12085075

Verma, A. Corneal Abrasion. eMedicine.
Available from the Internet at http://www.emedicine.com/oph/topic247.htm (rev. 10/19/04, cited 1/26/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
February 21, 2005

Published