CONJUNCTIVAL ABRASION AND LACERATION

Signs and Symptoms

While corneal abrasions are among the most common presenting problems in the practice of primary eye care, conjunctival lacerations are uncommon.1-13 Conjunctival abrasions and lacerations result secondary to mechanical rupture of the continuity of the tissue.11-13 Patients almost always present with a history of external (sporting accident, assault, fall, poke, automobile crash, bungee cord injury) or self-induced trauma (rubbing, contact lens insertion or removal).

Symptoms include variable levels of blepharospasm and discomfort depending upon where the conjunctival injury has occurred, foreign body sensation, tearing, photophobia in cases that trigger substantial ocular inflammation and lacrimation.11-13 If a concurrent uveitis is significant, the patient will be symptomatic for pain upon ocular movement.11-13 Vision is typically only affected when the sclera is breached.14 Signs include sectoral conjunctival injection, subconjunctival hemorrhage and a visible conjunctival defect with retracted conjunctival edges and bare sclera that stains with sodium fluorescein dye.11-13

Since both entities are the result of inadvertent trauma, they have no formal racial or gender predilection. With that said, workplace injuries affect males to a much greater degree, especially those between the ages of 17 and 30.15-19

Common sources of superficial household-associated eye injuries include chemicals, housewares, storage and organization paraphernalia and bed and bath items.20 The garage, bathroom and laundry room are common sites of household misfortune.21,22 Eye injuries occurring outside the house are usually associated with landscaping activities and involve foreign debris stirred up by wind or motorized equipment.8,9 Eye injuries at work typically involve manufacturing or construction.16,18 Most superficial eye injuries both in the home and at work occur in the absence of proper eye protection.21-23 The sporting activities commonly related to superficial eye injuries include boxing, hockey and racquet sports (tennis, racquetball, squash).17

Pathophysiology

The conjunctiva is an exposed mucous membrane covering the globe and the inner surface of the eyelid. The palpebral portion of the conjunctiva is tightly adherent to the eyelid.24 The bulbar portion is loosely adherent so that the globe has mobility. The conjunctiva is reflected upon itself so that it has the ability to stretch with ocular excursion.24 The conjunctiva is composed of nonkeratinized stratified squamous epithelium overlying stromal tissue.24 Because the conjunctiva is far less innervated than the cornea, conjunctival abrasions and lacerations are less symptomatic than corneal abrasions of the same severity. Given its position, the bulbar conjunctiva has the greatest chance of sustaining injury.24-27

In a conjunctival abrasion, the surface epithelial cells are physically “rubbed off.” In a conjunctival laceration, the tissue will stretch and wrinkle to its physical capacity, beyond which a full-thickness section of tissue will be torn out to reveal bare sclera beneath. In these cases, the trauma itself acts as an antigen and sets off an inflammatory cascade resulting in vasodilation and edema of the involved and surrounding tissues.24,28,29

Management

Treatment for conjunctival laceration and/or abrasion begins with history. The time, place and activity surrounding the injury should be recorded. Visual acuity (VA) should be recorded before any procedures or drops are given. If the blepharospasm is sufficiently intense, a drop of topical anesthetic can be administered to lessen it. The eye examination should proceed in a logical fashion from external adenexa to fundus. The eyelids should be everted and fornicies scrutinized for foreign material. Fluorescein dye (preferably without anesthetic) should be instilled to assist in identifying defects.

The lesion should be photographed, if possible, and measured using the height and width of the biomicroscope beam. The Seidel test (painting of the wound with fluorescein dye observing for aqueous leakage) should be performed if a full-thickness corneal or globe perforation is suspected.30 The lesion should be cleaned. The anterior chamber should be observed for any evidence of inflammation. Topical anesthesia will permit the clinician to use a forceps or moistened cotton-tipped applicators to manipulate the ragged areas of conjunctiva back into position. Bleeding can be arrested with direct pressure. A dilated examination should be completed (either at time of initial evaluation or at follow-up) to rule out any posterior effects from the trauma.

If the eye is not to be patched, treatment includes topical antibiotics QID, topical cycloplegia applied in the office or prescribed QD-BID depending upon the severity of the injury and may include topical nonsteroidal anti-inflammatory medication QD-QID for local analgesia.31-34 Topical antibiotic ointments can be used for increased contact time and extra lesional cushioning but are often not tolerated well, as they blur vision. Topical steroids have the potential to retard healing and in the setting of trauma, may be postponed until initial tissue knitting takes place.35

Topical antibiotic/steroid combination drops and/or ointments are a reasonable alternative in the event it is determined that inflammation must be addressed on the day of the injury. Another benefit of combination medications is that they simplify the regimen. The smallest lacerations (<1cm) will heal within a week without special attention. Larger lacerations, after appositional placement of the tissue edges, can be remediated with antibiotic ointment and pressure patching for 24 hours. Repair with either sutures or tissue glue are reserved for only the largest lesions (>2cm).36

Bed rest, limited activity, cold compresses, artificial tear drops and over-the-counter analgesics such as acetaminophen or ibuprofen can be used to relieve acute pain. Acetaminophen can be recommended in cases where there is bleeding as it does not encourage antiplatelet effects.

Clinical Pearls

Conjunctival lacerations are minor problems that typically resolve with minimal intervention, yet patients often present with great anxiety. The eye is very red and often hemorrhaging, which may be cause for great concern on the patient’s part, even though there is little pain or other symptoms. While it’s important to rule out a penetrating injury, you can safely reassure most patients that they have a simple “cut” on their eye, and that it will heal in a few days.

While internal inflammation is typically minimal in these cases, any trauma with sufficient force so as to be capable of producing an abraded or lacerated conjunctiva deserves the consideration for cycloplegia.

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