ARTICLE Are Signs and Symptoms Associated With Persistent Corneal Abrasions in Children? Kristine K. Rittichier, MD; Mark G. Roback, MD; Kathlene E. Bassett, MD Background: Corneal abrasions are common eye inju- ties, specificities, positive predictive values, and nega- ries in children. Most are treated with antibiotic 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 photophobia, 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 cornea 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 Efects, are the most common injuries.1 In suggest a retained foreign body. 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- ARCH PEDIATR ADOLESC MED/ VOL 154, APR 2000 WWW.ARCHPEDIATRICS.COM 370 ©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 Ophthalmology 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 conjunctivitis Primary care clinic 15 (20) or other disease in the affected eye, were contact lens 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 eyelid. The eyes 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. x2 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- ARCH PEDIATR ADOLESC MED/ VOL 154, APR 2000 WWW.ARCHPEDIATRICS.COM 371 ©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 (x2) No. (%) of Patients, by Age Pain 53 93 80 80 .002 4-6 y 7-9 y 10-12 y .12 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.