ARTICLE Are Associated With Persistent Corneal Abrasions in Children?

Kristine K. Rittichier, MD; Mark G. Roback, MD; Kathlene E. Bassett, MD

Background: Corneal abrasions are common inju- ties, specificities, positive predictive values, and nega- ries in children. Most are treated with drops tive predictive values of selective signs and symptoms for or ointment, patching of the affected eye, and follow-up persistent abrasions were as follows: for pain, 53%, 93%, within 24 hours to confirm resolution by fluorescein 80%, and 80%; for , 57%, 100%, 100%, and examination. 80%; for redness, 100%, 46%, 44%, and 100%; for pain and redness, 40%, 96%, 80%, and 80%; and for at least 1 Objective: To determine if signs and symptoms at fol- sign or symptom, 95%, 48%, 47%, and 95%. Twenty-six low-up were associated with the presence of a persistent patients had persistent corneal abrasions at follow-up. corneal abrasion or abnormal visual acuity. Six of these 26 patients were symptom free at follow-up, and 15 patients had only redness as a persistent sign. Five Design: Retrospective case series. patients had abnormal visual acuity, one of whom was asymptomatic. All 3 patients with complications were Setting: A children’s hospital. symptomatic.

Patients: Children who were aged 4 years or older with Conclusions: Signs and symptoms are inconsistently as- the diagnosis of corneal abrasion between May 1992 and sociated with persistent corneal abrasions. Asymptom- December 1996 and who had a follow-up examination. atic patients may have persistent corneal abrasions, sug- gesting the need for selective follow-ups. Results: Seventy-seven patients (57% male) were en- rolled (median age, 7 years). The respective sensitivi- Arch Pediatr Adolesc Med. 2000;154:370-374

be present as well.11 If the abrasion is near Editor’s Note: It looks like we can’t depend on obvious signs or the visual axis of the eye, visual acuity may symptoms to determine the persistence of corneal abrasions. Eye, be affected. The epithelial lining of the is Eye, Eye! Catherine D. DeAngelis, MD the eye’s protective barrier to infection. Al- though rare, patients with an unhealed cor- nea may develop bacterial infections, ul- YE INJURIES account for many cerations, iritis, or chronic erosion visits annually to emer- syndrome.6,8-10 These complications may gency departments and phy- require long-term medical management or sicians’ offices. Corneal even surgery.6,8-10 An unhealed corneal de- abrasions, or epithelial de- fect, especially if linear in shape, may also fects,E are the most common injuries.1 In suggest a retained . the pediatric age group, corneal abra- Treatment of corneal abrasions is di- sions are frequently caused by foreign bod- rected at relieving pain, preventing infec- ies in the eye or direct trauma to the eye. tion, and promoting reepithelialization of Nonverbal patients often present with the cornea. For patients who do not wear From the Primary Children’s fussiness alone2,3 or in combination with contact lenses, therapy often includes ap- Medical Center, University a painful, watery, red eye. Older patients plication of a broad-spectrum topical an- of Utah, Salt Lake City (Drs Rittichier and Bassett), usually complain of severe pain and pho- tibiotic, with or without a cycloplegic, fol- and the University of Colorado tophobia secondary to exposure of the cor- lowed by a unilateral pressure eye patch 3-10 4-8 Health Sciences Center, nea’s sensitive nerve endings. Tearing, for at least 24 hours. The Children’s Hospital, Denver redness, blurred vision, and foreign body Reevaluations after 24 to 48 hours of (Dr Roback). sensation are signs and symptoms that can treatment are considered routine to con-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 1. Demographics of the 77 Patients PATIENTS AND METHODS Characteristic No. (% of Total) Sex A retrospective review of the medical records of chil- Male 44 (57) dren with the diagnosis of corneal abrasions be- Female 33 (43) tween May 1992 and December 1996 at The Chil- Location of initial visit dren’s Hospital (TCH), Denver, Colo, was performed. Emergency department 66 (86) Inclusion criteria were the discharge diagnosis clinic 10 (13) of a corneal abrasion and documentation of a fol- Primary care clinic 1 (1) low-up visit at 24 to 48 hours after the initial visit. Location of follow-up visit Patients were excluded if they were younger than 4 Emergency department 47 (61) years, sustained other ocular trauma (eg, corneal lac- Ophthalmology clinic 15 (20) eration or hyphema), had preexisting Primary care clinic 15 (20) or other disease in the affected eye, were wearers (placing them at risk for Pseudomonas infec- tion), had received prior medical treatment for the corneal abrasion, or had follow-up at a facility other Table 2. Cause of Corneal Abrasion in the 77 Patients than the TCH system. Medical records were reviewed for demo- Cause No. (%) graphic information, as well as signs and symptoms, Minor trauma 61 (79) during the initial visit. These included pain, photo- Branch 12 (16) phobia, blurred vision, foreign body sensation, tear- Toy 12 (16) ing, and redness. Visual acuity and treatment ren- Dust/sand 11 (14) dered at the initial visit were also reviewed and noted. Finger 9 (12) Similar information, including evidence of any signs Bottle rocket 3 (4) and symptoms, was then evaluated at the follow-up Cigarette 3 (4) visit. Treatment rendered and disposition were also Dog/cat scratch 3 (4) documented for this second visit. Miscellaneous 8 (10) Fluorescein evaluations are performed at our in- Foreign body 9 (12) stitution with a dry paper strip impregnated with fluo- Wood 3 (4) rescein wetted with sterile isotonic sodium chloride Dust/sand 2 (2) solution. A drop of the solution or the strip itself is Metal 2 (2) gently introduced into the patient’s bulbar conjunc- Toy piece 1 (1) tiva in the lower . The are then evaluated Cigarette ash 1 (1) with a handheld cobalt light with magnification or a Unknown 7 (9) Woods lamp, for evaluation of fluorescein uptake on the cornea. 5,12 Sensitivity, specificity, positive predictive value, or recur, therefore saving patient time and expense of and negative predictive value were calculated for all a return visit. signs and symptoms at the follow-up visit. ␹2 Analy- The purpose of this study was to determine if signs sis was performed on all independent variables. Only and symptoms commonly associated with corneal abra- documented presence or absence of signs and symp- sions are predictive of fluorescein examination findings toms extracted from medical records was used for sta- after 24 hours of treatment. We hypothesized that if ver- tistical analysis. bal patients (4 years or older) were symptom free, they would no longer have uptake of fluorescein indicating an unhealed cornea or have abnormal visual acuities.

firm healing of the epithelium, to rule out infection, and RESULTS to check for retained foreign bodies.3,6-9 These follow- ups are believed to be important as some patients may Two hundred fifty-nine patients were identified who had feel relief when their eye is patched despite develop- initial visits at TCH and were discharged with the diag- ment of infection, ulcerations, or retained foreign body. nosis of corneal abrasion. One hundred twenty-six pa- At the follow-up visit, patients are routinely questioned tients had follow-up visits in the TCH system. Thirty- about persistence of symptoms, and the eye is reexam- four patients were excluded because they were younger ined with fluorescein. If the abrasion is still present, the than 4 years, and an additional 15 were excluded sec- patient is either repatched for an additional 24 hours or ondary to having other ocular injuries at the time of pre- referred to an ophthalmologist. sentation (hyphema, traumatic iritis, etc). The traditional 24- to 48-hour follow-up visit, how- Seventy-seven patients met the inclusion criteria for ever, is controversial in practice. Although little has been this study. The age range of these patients was 4 to 21 written on this subject, some physicians believe that the years (median age, 7 years), and the majority of patients follow-up visit is unnecessary if patients are free of signs (57%) were male. Demographics are listed in Table 1. and symptoms suggesting persistence.5,12 They typically The majority of patients (79%) sustained their cor- instruct patients and parents to remove the eye patch at neal abrasion as a result of minor trauma from their own 24 hours and return only if symptoms and signs persist finger, a tree branch, or from a toy (Table 2). Nine pa-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 3. Signs and Symptoms at Initial Visit by Age Table 4. Analysis of Signs and Symptoms at Follow-up* in the 77 Patients Sign/Symptom Sensitivity Specificity PPV NPV P (␹2) No. (%) of Patients, by Age Pain 53 93 80 80 .002 4-6 y 7-9 y 10-12 y Ͼ12 y Blurred vision 33 100 100 85 .09 Sign/Symptom (n = 35) (n = 18) (n = 12) (n = 12) Photophobia 57 100 100 80 .01 Redness 100 46 44 100 .003 Pain 27 (77) 17 (94) 11 (92) 11 (92) Tearing 57 84 57 78 .26 Blurred vision 6 (17) 9 (50) 5 (42) 8 (66) Foreign body sensation NA 100 NA 1 .06 Photophobia 11 (32) 7 (39) 5 (42) 2 (16) Pain and photophobia 33 100 100 78 .004 Redness 26 (74) 18 (100) 11 (92) 12 (100) Pain and redness 40 96 80 80 .003 Foreign body sensation 7 (20) 4 (22) 0 5 (40) Pain, redness, and 22 100 100 82 .003 Tearing 14 (40) 10 (55) 6 (50) 6 (50) photophobia Other Any sign or symptom 95 48 47 95 .002 Eyelid swelling 4 (11) 2 (11) 3 (25) 3 (25) Discharge 1 (3) 1 (5) 1 (8) 1 (8) *Data are given as percentage. PPV indicates positive predictive value; NPV, negative predictive value; and NA, not enough patients to give a number.

tients (12%) had a foreign body removed at their initial a foreign body removed, and 3 failed to return for a third visit. visit. All remaining patients had resolution of their abra- Pain and redness in the affected eye were the most sion at a third visit. No patients at the follow-up visit or common presenting complaints in all ages (Table 3). subsequent visits had evidence of infection, ulceration Reports of blurred vision and foreign body sensation were of the cornea, or chronic erosion syndrome. more common in the older age groups. Overall, the young- Treatment during the initial visit did not differ be- est age group (4-6 years old) had fewer reported symp- tween the patients who had resolution of their abrasion toms. Visual acuity was checked in 44 patients (53%) at and those with persistence. One patient who was asymp- the initial visit. Treatment rendered at the initial visit was tomatic with persistence and 2 patients who were symp- cycloplegic agents in 12 patients (15%), antibiotic oint- tomatic had been treated with a cycloplegic. This com- ment or drops in 67 patients (87%), and an eye patch in pares with 9 patients who had resolution of their abrasions 73 patients (95%). who had been treated with a cycloplegic (P = .71, ␹2). The The median time from the initial visit to the fol- follow-up period for asymptomatic vs symptomatic pa- low-up visit was 22 hours (range, 12-46 hours). Docu- tients with persistence also did not differ (median time mentation of signs and symptoms at follow-up and per- of 22 hours for both). centage extracted from charts are listed below. Visual acuity was evaluated in only 44 (57%) of the initial patient visits, and 26 (34%) of the follow-up vis- Sign/Symptom No. Documented (% of Charts) Pain 46 (60) its. In patients who had visual acuity tested at follow- Blurred vision 15 (19) up, 5 had abnormal acuities (Ͼ20/50 in the affected eye). Photophobia 19 (25) Four of the patients were symptomatic with pain and Redness 56 (72) blurred vision, and at a later follow-up showed resolu- Foreign body sensation 11 (14) tion of their corneal abrasion and exhibited normal vi- Tearing 21 (27) sual acuity. The other remaining patient with abnormal Fifty-one patients (66%) showed resolution of the cor- visual acuity had persistence of the abrasion at fol- neal abrasions by fluorescein examination at the time of low-up and was free of symptoms. This patient was lost follow-up. The remaining 26 patients (34%) had persis- to a third or subsequent follow-up. tent corneal abrasions. Six (23%) of the 26 patients with persistent corneal abrasions had no sign or symptom at COMMENT follow-up. Fifteen patients (58%) had only redness as a sign of persistence, and 5 patients (19%) were symptom- Corneal abrasions are common pediatric eye injuries. A atic with other or a combination of signs and symptoms. 1-year survey of all children admitted to the emergency Sensitivities, specificities, positive predictive val- department at Wills Eye Hospital, Philadelphia, Pa, in ues, and negative predictive values of signs and symp- 1986 revealed that 446 (55%) of 810 patients presented toms individually and in combination are listed in with corneal abrasions.1 Table 4. All combinations of signs and symptoms not Most corneal abrasions in children are caused by a listed (including combinations of 3 or more signs and foreign body in the eye, minor trauma, or self-infliction symptoms) were found to not be significant. with a finger. Our study showed that 79% of the abra- Five of the 6 patients who were asymptomatic with a sions were caused by minor injuries. Nine (12%) of the persistent corneal abrasion had eventual resolution of their corneal abrasions were caused by a foreign body irritat- abrasion, and 1 patient was lost to further follow-up. ing the eye, which was removed at the initial visit. These The remaining 20 patients with persistent abra- results are slightly different from those of adult studies sions who were symptomatic at follow-up included the of corneal abrasions that revealed that 48% were caused 15 who had redness only as a sign of persistence. At follow- by minor trauma and 40% were caused by a known for- up, 2 of these 20 patients had rust rings removed, 1 had eign body that was removed at the initial visit.11 This dif-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 ference possibly reflects differing environmental expo- even combinations of signs and symptoms were roughly sures of children vs adults. Children may be more 80%. Sensitivities, other than for redness at 100%, were susceptible to sustaining injuries during play activity on poor overall with a range of 33% to 57%. the playground, whereas adults are more likely to have None of the patients in this study, including those occupational exposures to metal and wood particles at who had multiple follow-up visits, showed signs of cor- their jobs. neal infection or chronic corneal erosions. The risk of Signs and symptoms at presentation of corneal abra- these complications, along with removal of a retained for- sions have traditionally been noted to include pain, pho- eign body, has been used to justify early repeated exami- tophobia, foreign body sensation, and redness of the con- nation and fluorescein staining. In one adult study of 99 junctiva.3,4,6,10 We found that almost all children, even the patients with corneal abrasions, 4 developed corneal in- younger age groups, had pain and redness. Few chil- fections.12 In another adult study of 201 patients, 1 de- dren, however, reported foreign body sensation or pho- veloped chronic recurrent erosion syndrome and 2 sub- tophobia. This is similar to the findings of Poole2 in pa- sequently developed conjunctivitis.11 The 2 patients with tients older than 1 year. In that study, 95% of patients conjunctivitis were deemed by the authors “not to be as- presented with pain, 76% presented with redness, and sociated with the original corneal abrasion.”11 In one adult 76% presented with photophobia. Some symptoms not study of patching, half of the complications occurred in typically associated with corneal abrasions, such as swell- the group that was not patched.12 In our study, 2 pa- ing of the and discharge from the affected eye, tients had rust rings removed and 1 had an unidentified were also seen in our study. They most likely are mani- foreign body removed at the time of follow-up. The true festations of local irritation and rubbing a painful eye. incidence of complications from persistent abrasions in In our study, the majority of patients were tradi- the pediatric population, although commented on in most tionally treated with an eye patch and at textbooks of pediatric ophthalmology,8,9 is unknown. their initial visit. Only 15% had a cycloplegic installed Visual acuity, a critical part of any evaluation for in the eye to help eliminate pain by decreasing ciliary eye trauma, was tested very infrequently in our patients’ spasm. This small number was also noted in an adult initial and follow-up visits. Some of the reasons sur- study of the management of corneal abrasions in which rounding this low number may be related to poor docu- only 6% of patients were treated with a cycloplegic, mentation of the actual testing in the medical record or even when it was thought to be common practice at the the inability to test it acutely secondary to patient’s age study facility.12 This treatment, although considered in or pain at presentation. This low rate would be consid- some practices to be standard care, clearly varies across ered below what is acceptable in most ophthalmologic the nation. practices. Recently in the adult literature, the traditional use Visual acuity was abnormal in 5 patients at follow- of the unilateral eye patch for treatment of corneal abra- up. One patient reported being asymptomatic with an ab- sions has been challenged.11-14 Studies in adults have normal acuity and he did not have a previously reported shown a decreased healing time, decreased perception visual acuity recorded to determine whether this was his of pain, and better patient compliance with treatment not baseline value. Furthermore, he was eventually lost to involving an eye patch.11-14 No published study to date follow-up. All other patients within a week had resolu- addresses this issue in pediatric populations. The major- tion of their symptoms and abnormal acuities. Because ity of the patients in this study were treated with an eye of the small number of patients who had visual acuity patch. evaluations, no comments can be made on the effect of In our study, one third of patients had persistence persistent abrasions and abnormal visual acuities. of their abrasion at follow-up. In one adult study of cor- Limitations to this study result largely from its ret- neal abrasions, 18% of patched patients and 31% of un- rospective design. The evaluation and documentation of patched patients had incomplete “24-hour healing.”13 This important signs and symptoms were poor in some in- high percentage of persistence, both in our study and in stances (ie, visual acuity). the adult study, may be related to the timing of fol- Large numbers of patients eligible for the study were low-up as the mean time of follow-up was approxi- excluded due to follow-up outside the TCH system. Fur- mately 24 hours in both studies. In 2 other adult studies ther patients who did have a follow-up and had persis- related to patching, healing times for the corneal abra- tent corneal abrasions were subsequently lost to follow- sions were 2.60 ± 0.77 (mean ± SD) days for patched and up. Also, the number of patients in this study was not 2.33 ± 0.66 for unpatched patients and 2.00 ± 0.71 days large enough to comment on risk of infrequent corneal for patched and 1.55 ± 0.61 days for unpatched, respec- complications (infections, corneal ulcerations, or chronic tively.11,14 Since these studies showed a healing rate of erosion syndrome) from persistent abrasions in the pe- about 48 hours, a higher healing rate may have been found diatric population. if our patients’ follow-ups had been at a later time. In conclusion, patients with persistent corneal abra- Signs and symptoms at the follow-up visit, in our sions, despite traditional antibiotic and eye patch therapy, study, were poorly associated with the persistence of a can be asymptomatic at follow-up. These asymptomatic corneal abrasion. In fact, 23% of the patients who had patients, however, had no complications or morbidity re- persistent abrasions were asymptomatic. The majority of lated to the persistent abrasion in our small study popu- those that were symptomatic (58%) had redness of the lation. Patients who had complications, including rust conjunctiva only as an indication that the epithelial de- rings and retained foreign body, continued to be symp- fect persisted. The negative predictive values of all and tomatic at follow-up.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Therefore, our results suggest that patients who con- REFERENCES tinue to be symptomatic after 24 hours of treatment should be reevaluated to assess for complications, persistent for- 1. Nelson LB, Wilson JW, Jeffers JB. Eye injuries in childhood: demographics, eti- eign bodies, and persistence of abrasion. Selective fol- ology, and prevention. Pediatrics. 1989;84:438-441. low-up for asymptomatic patients may then be enter- 2. Poole SR. Corneal abrasion in infants. Pediatr Emerg Care. 1995;11:25-26. 3. Harkness MJ. Corneal abrasion in infancy as a cause of inconsolable crying. Pe- tained with the knowledge that some of these patients diatr Emerg Care. 1989;5:242-244. will have persistent but probably clinically uncompli- 4. Friedberg MA, Rapuano CT. Willis Eye Hospital: Office and Emergency Room Di- cated abrasions. The incidence of corneal infection, cor- agnosis and Treatment of . Philadelphia, Pa: JB Lippincott; 1990: chap 3. neal ulceration, and chronic erosion syndrome, result- 5. Levin AV. Eye trauma. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emer- ing from persistent unhealed epithelial defects, is gency Medicine. Baltimore, Md: William & Wilkins; 1993:1200-1209. unknown and cannot be further commented on from this 6. Butler HB, Reisdorff EJ. The red eye: a systematic approach to differential diag- nosis and therapy. Emerg Med Rep. 1994;15:43-52. study. 7. Janda AM. Ocular trauma: triage and treatment. Postgrad Med. 1991;90:51-58. Further studies are warranted to prospectively de- 8. Hersh PS, Shingleton BJ, Kenyon KR. Anterior segment trauma. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology: Clinical Practice. termine the association of signs and symptoms with per- Philadelphia, Pa: WB Saunders Co; 1994:3383-3403. sistence of corneal abrasions and to determine the clini- 9. Hiatt RL. Corneal abrasions, contusions, lacerations, and perforations. In: Fraum- cal relevance of the persistent abrasions in the pediatric felden F, Roy FH, Meyer SM, eds. Current Ocular Therapy 3. Philadelphia, Pa: WB Saunders Co; 1990:343-344. patient. 10. Ervin-Mulvey CD, Nelson LB, Freely DA. Pediatric eye trauma. Pediatr Clin North Am. 1983;30:1167-1183. 11. Kaiser PK, and the Corneal Abrasion Patching Study Group. A comparison of pres- Accepted for publication October 14, 1999. sure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Ophthalmology. 1995;102:1936-1942. Presented at the Regional Ambulatory Pediatric Asso- 12. Hart A, White S, Conboy P, Quinton D. The management of corneal abrasions in ciation Meeting, Carmel, Calif, February 8, 1997. accident and emergency. Injury. 1997;28:527-529. Corresponding author: Kristine K. Rittichier, MD, 13. Patterson J, Fetzer D, Krall J, Wright E, Heller M. Eye patch treatment for the pain of corneal abrasion. South Med J. 1996;89:227-229. Emergency Department, Primary Children’s Medical Cen- 14. Kirkpatrick JN, Hoh HB, Cook SD. No eye pad for corneal abrasion. Eye. 1993; ter, 100 N Medical Dr, Salt Lake City, UT 84113. 7:468-471.

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