PDF| Related Article: Managing Postoperative Corneal Abrasions: A Protocol for Anesthesiology Teams |
TO THE EDITOR
Perioperative corneal abrasion (PCA) is the most common ocular complication associated with nonocular surgery under anesthesia. While distressing to patients, the vast majority of PCAs are superficial epithelial injuries that predictably heal within 48–72 hours without permanent sequelae.1 From a patient safety and systems perspective, routine ophthalmology consultation for uncomplicated PCAs is generally unnecessary and may introduce avoidable delays, excess cost, and inefficient use of specialty resources without improving outcomes.
A systems-based, anesthesia-led triage and management pathway allows timely recognition, appropriate treatment, and reliable escalation of care when indicated. For uncomplicated cases—characterized by intact globe, absence of red flags, and expected clinical improvement—management can be safely standardized using a streamlined, ophthalmic antibiotic–based protocol with supportive lubrication and symptom monitoring. Such protocolization aligns directly with the Anesthesia Patient Safety Foundation’s mission to promote evidence-informed, high-value perioperative care.
Importantly, anesthesia professionals are well positioned to both prevent and manage PCA. Awareness of established perioperative risk factors—including lagophthalmos (the inability to close the eyelid completely), prolonged anesthesia duration, dependent eye positioning, and ocular surface disease—supports proactive prevention and early identification (Table 1).1 Once injury is suspected, a focused assessment and protocol-driven response minimizes patient discomfort while preserving safety.
Table 1: Perioperative Corneal Abrasion (PCA): Key Risk Factors for Anesthesiology‑Led Triage
| Domain | Risk Factors |
| Patient | Advanced age; dry eye disease; recurrent corneal erosion; prior ocular trauma; contact lens use; prominent eyes/proptosis |
| Anesthesia | General anesthesia; prolonged duration (>60–90 min); reduced tear production; loss of corneal reflex |
| Positioning | Prone, lateral, or Trendelenburg positions; dependent eye exposure; external globe pressure |
| Surgical | Head and neck surgery; prolonged procedures |
| Perioperative Care | Inadequate eyelid closure; lack of eye protection; oxygen mask trauma; postoperative eye rubbing |
Clear escalation criteria are essential. Ophthalmologic consultation remains critical for patients with atypical features, concerning examination findings, or deviation from the expected healing course. Indicators such as persistent or worsening pain beyond 24–48 hours, visual acuity changes, corneal infiltrate, or signs of infection mandate prompt specialty evaluation (Table 2).1 Embedding these criteria within standardized perioperative pathways ensures that patients who require ophthalmologic expertise receive it without delay.
Table 2: Findings That Warrant Ophthalmologic Consultation (Safety Escalation Criteria)
| Escalation Trigger | |
| 👁 Significantly reduced visual acuity or persistent visual disturbance | |
| 👁 Worsening or non-improving pain after 24 hours, especially in a contact lens wearer | |
| 👁 Persistent pain beyond 48 hours | |
| 👁 Failure of epithelial healing by 72 hours | |
| 👁 Corneal infiltrate, ulceration, or suspected infection | |
| 👁 Fixed, irregular, or dilated pupil | |
| 👁 Hyphema or hypopyon | |
| 👁 Suspected penetrating injury or foreign body | |
| 👁 Corneal defect involving stroma | |
| 👁 Dendritic fluorescein staining (possible herpetic keratitis) |
Caution is warranted regarding routine use of topical anesthetics or topical nonsteroidal anti-inflammatory agents for pain control, and these agents should generally be avoided. Although studies exist in the literature supporting short-term efficacy,1 these agents carry recognized risks, including corneal toxicity, delayed healing, and masking of clinical deterioration.2,3 In most uncomplicated cases, oral analgesics combined with lubrication and reassurance provide adequate symptom control without introducing additional ocular risk. Caution should also be taken with contact lens wearers. Instead of erythromycin, fluoroquinolone coverage should be strongly considered in contact lens wearers given common colonization with pseudomonas aeruginosa.4,5
In summary, uncomplicated perioperative corneal abrasions can be safely managed without routine ophthalmology consultation using an anesthesia-led, antibiotic-based protocol with explicit safety escalation pathways. Such an approach improves efficiency, reduces unnecessary resource utilization, and—most importantly—maintains patient safety through structured triage and timely referral when indicated.
Dmitry Pyatetsky, MD, is an associate professor of Oophthalmology and medical education at Northwestern University Feinberg School of Medicine, Chicago IL
Jeanine Baqai, MD, is an associate professor of ophthalmology at Northwestern University Feinberg School of Medicine, Chicago, IL
The authors report no conflicts of interest.
REFERENCES
- Malafa MM, Coleman JE, Bowman RW, Rohrich RJ. Perioperative corneal abrasion: updated guidelines for prevention and management. Plast Reconstr Surg. 2016;137:790e–797e. PMID: 27119941.
- Guidera AC, Luchs JI, Udell IJ. Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs. Ophthalmology. 2001;108:936-944. PMID: 11320025.
- Yagci A, Bozkurt B, Egrilmez S, et al. Topical anesthetic abuse keratopathy: a commonly overlooked health care problem. Cornea. 2011;30:571–575. PMID: 21598429.
- Pinna A, Usai D, Sechi LA, et al. Detection of virulence factors in Pseudomonas aeruginosa strains isolated from contact lens-associated corneal ulcers. Cornea. 2008;27: 320–326. PMID: 18362661.
- Mah-Sadorra JH, Yavuz SG, Najjar DM, et al. Trends in contact lens–related corneal ulcers. Cornea. 2005;24:, 51–58. PMID: 15604867.
