ophtho.corneal-abrasion.core.v1PRODUCTION

ophtho.corneal-abrasion.core.v1

Corneal abrasion & ocular-surface foreign body

general_internal_medicineacutesubacuteadultpediatric

Hard-required inputs

0 / 8

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a SIMPLE epithelial defect that must FIRST survive a dangerous-look-alike screen (penetrating injury/globe rupture, intraocular/retained FB, microbial keratitis/ulcer, herpetic dendrite). Open-globe, IOFB and microbial-keratitis management are recognised then routed OUT by engine_id, not authored here.

Inputs

Actions

Advance rule

Set

Advance when

simple-abrasion scope confirmed; not-this-engine concerns flagged for routing

Patient inputs (15)

contact_lens_use*history • CONTEXT

not present

Contact-lens wear is THE single finding that converts a "simple abrasion" into a microbial-keratitis-until-proven-otherwise pathway — never patch, low ulcer threshold, antipseudomonal cover (Linaburg IDCNA 2024)

visual_acuity*symptom • CONTEXT

Documented visual acuity in EACH eye is the mandatory medico-legal and triage baseline; a central/large defect or media opacity dropping acuity escalates urgency (Cronau AFP 2010)

mechanism_of_injury*symptom • ENTRY

Mechanism sets the pre-test prior: high-velocity grinding/hammering → IOFB/penetration; organic → fungal/erosion; contact lens → microbial keratitis; trivial scratch → simple abrasion (Sindal IJO 2017; Linaburg IDCNA 2024)

fluorescein_staining_pattern*symptom • INITIAL_WORKUP

Slit-lamp fluorescein under cobalt blue defines the epithelial defect; vertical linear "ice-rink" tracks → retained subtarsal FB; dendrite → herpetic; geographic with infiltrate → ulcer (Cronau AFP 2010)

lid_eversion_and_subtarsal_sweep*symptom • INITIAL_WORKUP

Upper-lid eversion + fornix sweep is mandatory whenever an FB is suspected; a retained subtarsal FB causes vertical linear abrasions and non-healing (Cronau AFP 2010)

seidel_sign*symptom • RED_FLAGS

Seidel test (fluorescein stream from a leaking wound) = full-thickness penetration / globe rupture — NEVER pad or pressure, shield + emergency, route OUT (AAO Eye Trauma; Cronau AFP 2010)

corneal_infiltrate_or_hypopyon*symptom • RED_FLAGS

A white/grey stromal infiltrate, anterior-chamber cell or hypopyon means microbial keratitis / ulcer, NOT a simple abrasion — culture, intensive topical, never patch, route OUT (Linaburg IDCNA 2024)

pupil_shape_and_anterior_chamber*symptom • RED_FLAGS

A peaked/teardrop pupil, shallow chamber, or iris/uveal prolapse signals occult open globe — shield, no pressure, route OUT (AAO Eye Trauma)

pediatric_uncooperative_examsymptom • BRANCHING_WORKUP

A child who cannot cooperate with slit-lamp may need exam under sedation/anaesthesia; consider non-accidental injury where the history is inconsistent (Cronau AFP 2010)

occupation_eye_protection_usehistory • CONTEXT

not present

Grinding/welding/hammering occupation without eye protection raises IOFB prior AND drives the prevention/return-to-work counselling (AAO Eye Trauma)

immunocompromisehistory • CONTEXT

not present

Immunosuppression / diabetes lowers the threshold for treating any defect as a developing ulcer and for ophthalmology referral (Linaburg IDCNA 2024)

prior_corneal_abrasion_or_erosionhistory • FOLLOWUP

not present

A history of prior abrasion + recurrent waking eye pain defines recurrent corneal erosion syndrome — lubricant/hypertonic ointment, debridement (Ross Can J Ophthalmol 2017)

symptom_resolution_at_24_48hsymptom • MONITORING

A simple abrasion should be symptomatically and objectively healing by 24-48 h; non-healing pivots to retained FB / ulcer / erosion (Ross Can J Ophthalmol 2017; Lim Cochrane 2016)

tetanus_immunisation_statushistory • TREATMENT

Tetanus prophylaxis is indicated for contaminated / penetrating ocular wounds; status is captured even for the simple abrasion pathway (CDC; AAO Eye Trauma)

pregnancyhistory • TREATMENT

not present

Antibiotic / analgesic safety gating — fluoroquinolone, oral NSAID and systemic-analgesic choices change in pregnancy (Cronau AFP 2010)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement

informationallife_threateningglobe_rupture_penetrating_injury_seidel_route_out
Seidel-positive fluorescein stream, peaked/teardrop pupil, shallow/flat anterior chamber, uveal prolapse, or low acuity after a sharp/high-velocity mechanism — full-thickness penetration / globe rupture (AAO Eye Trauma; Cronau AFP 2010)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningintraocular_retained_fb_high_velocity_route_out
High-velocity mechanism (grinding, hammering metal-on-metal, drilling, strimmer) with an entry wound, occult low acuity, or vitreous/retinal signs — suspected intraocular/retained foreign body (Sindal IJO 2017)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverecontact_lens_or_organic_abrasion_microbial_keratitis_risk
Contact-lens-related or organic/vegetative-matter abrasion, OR any abrasion with a stromal infiltrate, anterior-chamber reaction or hypopyon — microbial (esp. Pseudomonas) keratitis risk (Linaburg IDCNA 2024)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereherpetic_dendritic_keratitis_no_steroid
Branching dendritic fluorescein staining with terminal end-bulbs, reduced corneal sensation, or recurrent unilateral keratitis — herpes simplex / zoster keratitis, NOT a traumatic abrasion (Cronau AFP 2010)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveretopical_anaesthetic_abuse_harm
Persistent/escalating pain with a non-healing ring-shaped stromal infiltrate, especially after access to or self-use of a topical anaesthetic — anaesthetic-abuse toxic keratopathy (Tok Int J Ophthalmol 2015; Shen Indian J Ophthalmol 2020)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatelarge_central_or_non_healing_abrasion
Large (>10 mm²) or visual-axis-central abrasion, OR an abrasion not healing on fluorescein at the 24-48 h recheck (Lim Cochrane 2016; Ross Can J Ophthalmol 2017)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatepediatric_uncooperative_or_non_accidental_injury
Child unable to cooperate with slit-lamp examination, OR an injury history that is inconsistent / changing / developmentally implausible (Cronau AFP 2010)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildrecurrent_corneal_erosion_syndrome
Recurrent sharp pain on waking / eye-opening weeks-to-months after a prior (esp. organic / fingernail) abrasion, with a loose/heaped epithelium or map-dot-fingerprint pattern (Ross Can J Ophthalmol 2017; Wang Eye Contact Lens 2022)
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RED_FLAGSoptionalDrives screening

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Recommended regimen

Confirmed simple corneal abrasion — prophylaxis + analgesia ladder (NOT for ulcer / penetrating injury / IOFB)

axis: corneal_abrasion_simple_pathwaystep 1 - Step 1 — Confirm it is a SIMPLE abrasion before any abrasion-pathway treatment

Selected step "Step 1 — Confirm it is a SIMPLE abrasion before any abrasion-pathway treatment" — Epithelial defect on fluorescein with NO infiltrate, NO hypopyon, NO Seidel leak, NO peaked pupil, acuity explained by the surface defect; subtarsal/embedded FB removed

dangerous_lookalike_exclusion_gate
first line
decision_gate
triggers: seidel_positive, stromal_infiltrate_or_hypopyon, peaked_pupil_or_shallow_AC, high_velocity_mechanism
Globe rupture/penetrating injury → SHIELD, never pad/pressure, emergency, route ophtho.ocular-trauma.core.v1. Infiltrate/hypopyon → microbial keratitis, culture, intensive topical, NEVER patch, route ophtho.microbial-keratitis.core.v1. High-velocity → CT orbit (NEVER MRI if metallic) for IOFB. These are NOT treated on the abrasion ladder (AAO Eye Trauma; Linaburg IDCNA 2024).
foreign_body_removal_and_lid_eversion
first line
procedure
triggers: embedded_corneal_fb, suspected_subtarsal_fb
Slit-lamp FB removal (cotton bud / 25-30G needle bevel-up at slit-lamp), upper-lid eversion + fornix sweep, rust-ring burr for residual metallic ring; a retained FB is the dominant non-healing cause (Cronau AFP 2010).

outpatient playbook — drug actions (3)

1. erythromycin ophthalmic ointment
rxcui 4053
0.5% ribbon • ophthalmic • QID
trigger: Confirmed simple non-lens abrasion (Cronau AFP 2010)
Prophylaxis + lubrication
2. acetaminophen / ibuprofen PO
rxcui 161
650-1000 mg / 400 mg • PO • q6-8h PRN
trigger: Abrasion pain (Cronau AFP 2010)
Oral analgesia backbone; acetaminophen if pregnant/NSAID-contraindicated
3. nocturnal hypertonic-saline / lubricant ointment
5% NaCl ointment / preservative-free gel • ophthalmic • nightly, prolonged
trigger: Recurrent corneal erosion risk — organic/fingernail/large abrasion or recurrent waking pain (Ross Can J Ophthalmol 2017)
Erosion prophylaxis; prolonged course

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute unilateral sharp eye pain, foreign-body sensation, tearing and photophobia after trauma/FB (classic simple corneal abrasion — Cronau AFP 2010; Lim Cochrane 2016); Contact-lens wearer with a painful red eye — ALWAYS treat as possible contact-lens microbial keratitis until excluded (Linaburg IDCNA 2024 — Pseudomonas-skewed; never patch); High-velocity mechanism — grinding, hammering metal-on-metal, drilling, lawn-strimmer — intraocular/retained-FB & globe-penetration prior is high (Sindal IJO 2017; AAO Eye Trauma).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Corneal abrasion & ocular-surface foreign body** (ophtho.corneal-abrasion.core.v1).
Phenotype framing: Terminal differential with explicit pivots: simple corneal abrasion vs microbial keratitis/ulcer (infiltrate + AC reaction + contact-lens pivot) vs penetrating injury/globe rupture (Seidel + peaked pupil + low acuity pivot) vs retained intraocular FB (high-velocity mechanism + occult entry pivot) vs herpetic dendritic keratitis (branching dendrite + reduced sensation pivot) vs UV/chemical photokeratitis (bilateral + welding/snow + diffuse punctate pivot) vs recurrent corneal erosion (waking pain + prior-abrasion pivot).
Scope: Frame as a SIMPLE epithelial defect that must FIRST survive a dangerous-look-alike screen (penetrating injury/globe rupture, intraocular/retained FB, microbial keratitis/ulcer, herpetic dendrite). Open-globe, IOFB and microbial-keratitis management are recognised then routed OUT by engine_id, not authored here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Confirmed simple corneal abrasion — prophylaxis + analgesia ladder (NOT for ulcer / penetrating injury / IOFB)** — step "Step 1 — Confirm it is a SIMPLE abrasion before any abrasion-pathway treatment".
1. dangerous_lookalike_exclusion_gate (decision_gate, first line) — Globe rupture/penetrating injury → SHIELD, never pad/pressure, emergency, route ophtho.ocular-trauma.core.v1. Infiltrate/hypopyon → microbial keratitis, culture, intensive topical, NEVER patch, route ophtho.microbial-keratitis.core.v1. High-velocity → CT orbit (NEVER MRI if metallic) for IOFB. These are NOT treated on the abrasion ladder (AAO Eye Trauma; Linaburg IDCNA 2024).
2. foreign_body_removal_and_lid_eversion (procedure, first line) — Slit-lamp FB removal (cotton bud / 25-30G needle bevel-up at slit-lamp), upper-lid eversion + fornix sweep, rust-ring burr for residual metallic ring; a retained FB is the dominant non-healing cause (Cronau AFP 2010).

Setting playbook (outpatient) — Primary-care / clinic confirmation of a simple abrasion, prophylaxis + analgesia, recurrent-corneal-erosion prevention and contact-lens / eye-protection counselling; refer dangerous look-alikes (Cronau AFP 2010; Ross Can J Ophthalmol 2017)
3. erythromycin ophthalmic ointment 0.5% ribbon ophthalmic QID — Confirmed simple non-lens abrasion (Cronau AFP 2010) (Prophylaxis + lubrication)
4. acetaminophen / ibuprofen PO 650-1000 mg / 400 mg PO q6-8h PRN — Abrasion pain (Cronau AFP 2010) (Oral analgesia backbone; acetaminophen if pregnant/NSAID-contraindicated)
5. nocturnal hypertonic-saline / lubricant ointment 5% NaCl ointment / preservative-free gel ophthalmic nightly, prolonged — Recurrent corneal erosion risk — organic/fingernail/large abrasion or recurrent waking pain (Ross Can J Ophthalmol 2017) (Erosion prophylaxis; prolonged course)

Non-pharmacologic actions:
- Contact-lens holiday + hygiene counselling; safe re-wear only after full healing and clearance (Linaburg IDCNA 2024)
- Occupational eye-protection counselling for grinding/hammering/welding (AAO Eye Trauma)
- Refer (not patch) contact-lens / non-healing / recurrent-erosion cases to ophthalmology (Ross Can J Ophthalmol 2017)
- Do NOT dispense a take-home topical anaesthetic (Cronau AFP 2010; Tok Int J Ophthalmol 2015)

AVOID / contraindication checks:
- Do NOT dispense topical anaesthetic for home use (Tok Int J Ophthalmol 2015 / Shen Indian J Ophthalmol 2020 — epithelial toxicity, ring keratitis, corneal melt)
- Do NOT routinely patch corneal abrasion (Lim Cochrane 2016 — no healing benefit, RR 0.89 healed at 24 h, may be slower)
- NEVER patch a contact lens or organic or infected abrasion (Linaburg IDCNA 2024 — traps Pseudomonas, accelerates microbial keratitis)
- NEVER pad or pressure a Seidel positive or suspected ruptured globe use rigid shield (AAO Eye Trauma)
- Contact lens and organic abrasion require antipseudomonal cover not erythromycin (Linaburg IDCNA 2024)
- Avoid prolonged topical NSAID in compromised epithelium corneal melt risk (Wakai Cochrane 2017)
- No topical steroid if herpetic dendrite suspected (Cronau AFP 2010 — geographic ulcer / perforation risk)
- Oral NSAID avoid pregnancy ≥20wk and renal disease use acetaminophen (Cronau AFP 2010)

Monitoring

Regimen monitoring:
- fluorescein recheck at 24-48h should show healing (Lim Cochrane 2016 — most heal 24-72 h)
- non healing at 48h triggers re-exam for retained FB ulcer erosion (Ross Can J Ophthalmol 2017)
- contact lens abrasion low threshold to treat as microbial keratitis (Linaburg IDCNA 2024)
- watch for topical anaesthetic abuse ring keratitis if pain persists unusually (Tok Int J Ophthalmol 2015)

Setting (outpatient) monitoring:
- Recheck at 24-48 h; non-healing → ophthalmology (retained FB / ulcer / erosion) (Ross Can J Ophthalmol 2017)
- Recurrent waking pain over weeks-months → recurrent corneal erosion management (Wang Eye Contact Lens 2022)

Follow-up plan: Recurrent corneal erosion prevention & counselling (the long-tail deliverable): for organic / fingernail / large abrasions or recurrent waking pain → prolonged lubrication, nocturnal hypertonic-saline ointment, consider epithelial debridement / bandage lens / referral (Ross Can J Ophthalmol 2017; Wang Eye Contact Lens 2022). Contact-lens hygiene + lens holiday; occupational eye-protection counselling for grinding/hammering; safe lens re-wear timing.
- Close-out criterion: erosion-prevention + lens-hygiene + eye-protection counselling documented; ophthalmology referral made if criteria met

Monitoring phase: A simple abrasion should improve symptomatically and on fluorescein by 24-48 h (most heal in 24-72 h — Lim Cochrane 2016). Non-healing or worsening at the 24-48 h recheck mandates re-exam for retained FB, evolving microbial keratitis/ulcer, herpetic disease or recurrent erosion BEFORE simply continuing — do not silently extend.

Disposition

Current setting: outpatient — Primary-care / clinic confirmation of a simple abrasion, prophylaxis + analgesia, recurrent-corneal-erosion prevention and contact-lens / eye-protection counselling; refer dangerous look-alikes (Cronau AFP 2010; Ross Can J Ophthalmol 2017)

Disposition criteria:
- Continue topical antibiotic + analgesia + erosion prophylaxis if healing (Ross Can J Ophthalmol 2017)
- Refer contact-lens / non-healing / recurrent-erosion / atypical to ophthalmology (Linaburg IDCNA 2024)

Escalation triggers (move to higher acuity):
- Any red flag (Seidel, infiltrate, peaked pupil, low acuity, contact-lens worsening) → same-day/emergent ophthalmology, route OUT by engine_id (AAO Eye Trauma; Linaburg IDCNA 2024)
- Non-healing at 48-72 h → ophthalmology for retained FB / ulcer / erosion (Ross Can J Ophthalmol 2017)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Seidel-positive fluorescein stream, peaked/teardrop pupil, shallow/flat anterior chamber, uveal prolapse, or low acuity after a sharp/high-velocity mechanism — full-thickness penetration / globe rupture (AAO Eye Trauma; Cronau AFP 2010)
- [LIFE_THREATENING] High-velocity mechanism (grinding, hammering metal-on-metal, drilling, strimmer) with an entry wound, occult low acuity, or vitreous/retinal signs — suspected intraocular/retained foreign body (Sindal IJO 2017)
- [SEVERE] Contact-lens-related or organic/vegetative-matter abrasion, OR any abrasion with a stromal infiltrate, anterior-chamber reaction or hypopyon — microbial (esp. Pseudomonas) keratitis risk (Linaburg IDCNA 2024)

Citations

- AAO Preferred Practice Pattern — Corneal/External Disease & Ocular Trauma + Lim, Patching for corneal abrasion, Cochrane 2016 + Wakai, Topical NSAID for traumatic corneal abrasion, Cochrane 2017 + Sulewski, Topical ophthalmic anaesthetics for corneal abrasions, Cochrane 2023 + Linaburg, Contact lens-related corneal infections, Infect Dis Clin North Am 2024 + Cronau, Diagnosis and management of red eye in primary care, Am Fam Physician 2010 + Ross, Practice patterns in interdisciplinary management of corneal abrasions, Can J Ophthalmol 2017 [PMID:27457359](https://pubmed.ncbi.nlm.nih.gov/27457359/)
- Cited evidence (PMID 28516471) [PMID:28516471](https://pubmed.ncbi.nlm.nih.gov/28516471/)
- Cited evidence (PMID 37555621) [PMID:37555621](https://pubmed.ncbi.nlm.nih.gov/37555621/)
- Cited evidence (PMID 26558205) [PMID:26558205](https://pubmed.ncbi.nlm.nih.gov/26558205/)
- Cited evidence (PMID 32317478) [PMID:32317478](https://pubmed.ncbi.nlm.nih.gov/32317478/)

Last reconciled with current guidelines: 2026-05-17.

References

AAO Preferred Practice Pattern — Corneal/External Disease & Ocular Trauma + Lim, Patching for corneal abrasion, Cochrane 2016 + Wakai, Topical NSAID for traumatic corneal abrasion, Cochrane 2017 + Sulewski, Topical ophthalmic anaesthetics for corneal abrasions, Cochrane 2023 + Linaburg, Contact lens-related corneal infections, Infect Dis Clin North Am 2024 + Cronau, Diagnosis and management of red eye in primary care, Am Fam Physician 2010 + Ross, Practice patterns in interdisciplinary management of corneal abrasions, Can J Ophthalmol 2017 — PMID:27457359
Cited evidence (PMID 28516471) — PMID:28516471
Cited evidence (PMID 37555621) — PMID:37555621
Cited evidence (PMID 26558205) — PMID:26558205
Cited evidence (PMID 32317478) — PMID:32317478