NIHR Signal Wearing a patch after a scratch to the eye probably makes no difference to healing

Published on 21 December 2016

After a scratch or minor damage to the outer layer of the eye (corneal abrasion), wearing an eye patch is unlikely to reduce pain at 24 hours and might not lead to quicker healing after 24 hours. Patching the eye was compared to leaving the eye uncovered. Eye patches did not significantly affect symptoms such as eye watering, irritation, sensitivity to light or blurred vision.

Corneal abrasion is usually treated using ointments or drops to reduce irritation, pain killers, and antibiotic eye drops if there is a risk of infection. Eye patches are sometimes also used for short periods.

This Cochrane review found no compelling evidence that there was a difference in symptoms if patients used an eye patch or not. Because of the imprecision in the results it is not clear if more research would help settle the issue.

Patient preference and symptom relief remain important considerations when deciding whether or not to use an eye patch.

Share your views on the research.

Why was this study needed?

Scratches to the surface of the eye – corneal abrasions – can occur due to fingernail scratches, contact lenses, branches or dirt getting caught under the eyelid and rubbing against the cornea. Corneal abrasions are a common reason for accident and emergencies departments visits, including specialist eye departments. Contusions or abrasions are found in about 44% of people presenting to emergency departments with painful eyes.

Treatment usually involves ointments or drops to relieve discomfort, painkillers such as paracetamol or ibuprofen to reduce pain, and antibiotic eye drops where there is a risk of infection. Often people are also given or ask for eye patches or a pad taped across their eye.

Despite being widely used, the evidence for the effectiveness of eye patches is less clear. Therefore this Cochrane review investigated whether eye patches were more effective than leaving the eye uncovered in terms of pain or the time it took to heal completely.

What did this study do?

This systematic review and meta-analysis compared the findings of 12 trials, including a total of 1,080 people, from North America, Europe and South America.

Most of the trials randomly allocated people to have an eye patch or not. Three studies used “quasi randomisation” where people were allocated based on either the order they arrived at the department or allocated differently on alternating days. This approach is not ideal as it can introduce a bias in the way people are randomised to a treatment.

Only one study was judged as having a low risk of bias in all aspects of study design. The other 11 studies had a mixed risk of bias, which affects our confidence in the combined findings.

What did it find?

  • After 24 hours people wearing an eye patch had the same chance of a healed cornea as people with no eye patch (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.79 to 1.00, 531 people in 7 studies, graded low quality). At 48 and 72 hours there was no significant difference either.
  • There was no significant difference in the number of days until the abrasion was healed or how quickly the abrasion reduced in size between people wearing a patch or not.
  • No difference in pain was found at 24 hours, but the results were too imprecise for us to have confidence in this result.
  • There was little difference in symptoms such as watering eyes, sensitivity to light, irritation or blurred vision.

What does current guidance say on this issue?

The NICE Clinical Knowledge Summary recommends treating corneal abrasions using paracetamol or ibuprofen to relieve pain, or a single dose of a cycloplegic eye drop – a drug that stops eye spasms and resultant pain. Antibiotic eye drops can also be used to prevent infection. Eye patches are not mentioned in this guidance.

The College of Optometrists recommends not using eye patches for corneal abrasions (published 2015). This recommendation is based on the previous version of this Cochrane Review, published in 2006.

What are the implications?

This review suggests that patching the eye is probably not useful following a simple, traumatic corneal abrasion.

This review identified variations in the way that corneal abrasions are treated, and the imprecision in the results suggest we can’t be certain if future trials might overturn these findings.

Given that the clinical outcomes were similar, doctors treating corneal abrasion may want to incorporate patient preference and symptom relief into their decision-making. It is worth noting that there may be other reasons to patch an eye. Sometimes they are used following analgesic eye drops for example, when the blink reflex may be compromised.

Citation and Funding

Lim CH, Turner A, Lim BX. Patching for corneal abrasion. Cochrane Database Syst Rev. 2016;(7):CD004764.

Cochrane UK and the Eyes and vision Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

CKS. Corneal superficial injury. London: Clinical Knowledge Summaries; 2012.

Turner A, M Rabiu. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;(2): CD004764.

Moorfields Eye Hospital NHS Foundation Trust. Patient information – accident and emergency service: corneal abrasion. London: Moorfields Eye Hospital NHS Foundation Trust; 2014.

NHS Choices. Eye injuries. London: Department of Health; 2016.

The College of Optometrists. Corneal abrasion. London: The College of Optometrists; 2015.

Why was this study needed?

Scratches to the surface of the eye – corneal abrasions – can occur due to fingernail scratches, contact lenses, branches or dirt getting caught under the eyelid and rubbing against the cornea. Corneal abrasions are a common reason for accident and emergencies departments visits, including specialist eye departments. Contusions or abrasions are found in about 44% of people presenting to emergency departments with painful eyes.

Treatment usually involves ointments or drops to relieve discomfort, painkillers such as paracetamol or ibuprofen to reduce pain, and antibiotic eye drops where there is a risk of infection. Often people are also given or ask for eye patches or a pad taped across their eye.

Despite being widely used, the evidence for the effectiveness of eye patches is less clear. Therefore this Cochrane review investigated whether eye patches were more effective than leaving the eye uncovered in terms of pain or the time it took to heal completely.

What did this study do?

This systematic review and meta-analysis compared the findings of 12 trials, including a total of 1,080 people, from North America, Europe and South America.

Most of the trials randomly allocated people to have an eye patch or not. Three studies used “quasi randomisation” where people were allocated based on either the order they arrived at the department or allocated differently on alternating days. This approach is not ideal as it can introduce a bias in the way people are randomised to a treatment.

Only one study was judged as having a low risk of bias in all aspects of study design. The other 11 studies had a mixed risk of bias, which affects our confidence in the combined findings.

What did it find?

  • After 24 hours people wearing an eye patch had the same chance of a healed cornea as people with no eye patch (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.79 to 1.00, 531 people in 7 studies, graded low quality). At 48 and 72 hours there was no significant difference either.
  • There was no significant difference in the number of days until the abrasion was healed or how quickly the abrasion reduced in size between people wearing a patch or not.
  • No difference in pain was found at 24 hours, but the results were too imprecise for us to have confidence in this result.
  • There was little difference in symptoms such as watering eyes, sensitivity to light, irritation or blurred vision.

What does current guidance say on this issue?

The NICE Clinical Knowledge Summary recommends treating corneal abrasions using paracetamol or ibuprofen to relieve pain, or a single dose of a cycloplegic eye drop – a drug that stops eye spasms and resultant pain. Antibiotic eye drops can also be used to prevent infection. Eye patches are not mentioned in this guidance.

The College of Optometrists recommends not using eye patches for corneal abrasions (published 2015). This recommendation is based on the previous version of this Cochrane Review, published in 2006.

What are the implications?

This review suggests that patching the eye is probably not useful following a simple, traumatic corneal abrasion.

This review identified variations in the way that corneal abrasions are treated, and the imprecision in the results suggest we can’t be certain if future trials might overturn these findings.

Given that the clinical outcomes were similar, doctors treating corneal abrasion may want to incorporate patient preference and symptom relief into their decision-making. It is worth noting that there may be other reasons to patch an eye. Sometimes they are used following analgesic eye drops for example, when the blink reflex may be compromised.

Citation and Funding

Lim CH, Turner A, Lim BX. Patching for corneal abrasion. Cochrane Database Syst Rev. 2016;(7):CD004764.

Cochrane UK and the Eyes and vision Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

CKS. Corneal superficial injury. London: Clinical Knowledge Summaries; 2012.

Turner A, M Rabiu. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;(2): CD004764.

Moorfields Eye Hospital NHS Foundation Trust. Patient information – accident and emergency service: corneal abrasion. London: Moorfields Eye Hospital NHS Foundation Trust; 2014.

NHS Choices. Eye injuries. London: Department of Health; 2016.

The College of Optometrists. Corneal abrasion. London: The College of Optometrists; 2015.

Patching for corneal abrasion

Published on 28 July 2016

Lim, C. H.,Turner, A.,Lim, B. X.

Cochrane Database Syst Rev Volume 7 , 2016

BACKGROUND: Published audits have demonstrated that corneal abrasions are a common presenting eye complaint. Eye patches are often recommended for treating corneal abrasions despite the lack of evidence for their use. This systematic review was conducted to determine the effects of the eye patch when used to treat corneal abrasions. OBJECTIVES: The objective of this review was to assess the effects of patching for corneal abrasion on healing and pain relief. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2016), EMBASE (January 1980 to May 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2016), System for Information on Grey Literature in Europe (OpenGrey) (January 1995 to May 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 9 May 2016. We also searched the reference lists of included studies, unpublished 'grey' literature and conference proceedings and contacted pharmaceutical companies for details of unpublished trials. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials that compared patching the eye with no patching to treat simple corneal abrasions. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the risk of bias and extracted data. Investigators were contacted for further information regarding the quality of trials. The primary outcome was healing at 24, 48 and 72 hours while secondary outcomes included measures of pain, quality of life and adverse effects. We graded the certainty of the evidence using GRADE. MAIN RESULTS: We included 12 trials which randomised a total of 1080 participants in the review. Four trials were conducted in the United Kingdom, another four in the United States of America, two in Canada, one in Brazil and one in Switzerland. Seven trials were at high risk of bias in one or more domains and one trial was judged to be low risk of bias in all domains. The rest were a combination of low risk or unclear.People receiving a patch may be less likely to have a healed corneal abrasion after 24 hours compared to those not receiving a patch (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.79 to 1.00, 7 trials, 531 participants, low certainty evidence). Similar numbers of people in the patch and no-patch groups were healed by 48 hours (RR 0.97, 95% CI 0.91 to 1.02, 6 trials, 497 participants, moderate certainty evidence) and 72 hours (RR 1.01, 95% CI 0.97 to 1.05, 4 trials, 430 participants, moderate certainty evidence). Participants receiving a patch took slightly longer to heal but the difference was small and probably unimportant (mean difference (MD) 0.14 days longer, 95% CI 0 to 0.27 days longer, 6 trials, 642 participants, moderate certainty evidence).Ten trials reported pain scores. Most studies reported pain on a visual analogue scale (VAS). It was not possible to pool the data because it was skewed. In general, similar pain ratings were seen between patch and no-patch groups. Data from two trials reporting presence or absence of pain at 24 hours was inconclusive. There was a higher risk of reported pain in the patch group but wide confidence intervals compatible with higher or lower risk of pain (RR 1.51, 95% CI 0.86 to 2.65, 2 trials, 193 participants, low certainty evidence). Five trials compared analgesic use between the patch and no-patch groups. Data from three of these trials could be combined and suggested similar analgesic use in the patch and no-patch groups but with some uncertainty (RR 0.95, 95% CI 0.69 to 1.32, 256 participants, low certainty evidence). Frequently reported symptoms included photophobia, lacrimation, foreign body sensation and blurred vision but there was little evidence to suggest any difference in these symptoms in people with or without a patch.Activities of daily living (ADL) were assessed in one study involving children. There was little difference in ADL with the exception of walking which was reported to be more difficult with a patch on: VAS 1.7 cm (SD 2.1) versus 0.3 cm (SD 0.7).Complication rates were low across studies and there is uncertainty about the relative effects of patching or not patching with respect to these (RR 3.24, 95% CI 0.87 to 12.05, 8 trials, 660 participants, low certainty evidence). Three trials reporting rates of compliance to treatment found that 22% of participants did not have their eye patches during follow-up. No-patch groups generally received more adjuvant treatment with antibiotics or cycloplegics, or both, than the patch group. There were limited data on the effect of patching on abrasions greater than 10mm2 in size. AUTHORS' CONCLUSIONS: Trials included in this review suggest that treating simple corneal abrasions with a patch may not improve healing or reduce pain. It must be noted that, in these trials, participants who did not receive a patch were more likely to receive additional treatment, for example with antibiotics. Overall we judged the certainty of evidence to be moderate to low. Further research should focus on designing and implementing better quality trials and examining the effectiveness of patching for large abrasions.

Expert commentary

Corneal abrasions are very common minor ocular injuries that can be exquisitely painful. Such abrasions may occur through a variety of accidents including in the workplace, sports injuries and daily activities and are common in children and patients within the working age group. Patients with corneal abrasions may present to a variety of health care professionals both in primary and secondary care settings. Health professionals are motivated to minimise pain and there is variation in practice with regards to patching the eye to improve comfort and with the intention to promote healing of the ocular surface.

Patients often request the eye to be padded to help alleviate their pain symptoms. This review should help healthcare professionals and their patients understand the distilled evidence that this practice may not be helpful for pain relief or for healing and minimise the use of unnecessary padding.

Miss Reshma Thampy, Consultant Ophthalmic Surgeon, Manchester Royal Eye Hospital

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