The Daily Differential — Tuesday, May 26, 2026

2 of 4

Corneal Abrasion

Corneal abrasion is common, painful, and usually benign, but missed retained foreign body, contact lens-associated infection, or open globe can lead to vision loss.

At the Bedside

Presentation: Eye pain, foreign body sensation, tearing, photophobia, blepharospasm, worse with blinking. Usually trauma, fingernail, paper, plant material, contact lens use, or foreign body.
Exam priorities:
Visual acuity first when possible.
Inspect lids/lashes/conjunctiva.
Evert upper lid to find retained foreign body, especially vertical linear abrasions.
Slit lamp exam.
Fluorescein staining: abrasion appears as bright epithelial defect.
Look for:
Seidel sign: streaming aqueous = open globe.
Corneal infiltrate/opacity = infectious keratitis.
Dendritic lesions = HSV keratitis.
Hyphema, irregular pupil, shallow anterior chamber = deeper injury.
Management:
Remove superficial foreign body if present; irrigate.
Topical antibiotic prophylaxis.
Pain control with oral NSAIDs/acetaminophen; topical NSAID short course can help.
Cycloplegic may help large abrasions or traumatic iritis symptoms.
Do not patch routine abrasions.
Avoid topical steroids unless ophthalmology directs.
Do not discharge with topical anesthetic for routine board-style management; some EDs have limited protocols, but this remains institution-dependent.
Contact lens wearers need antipseudomonal coverage and must stop lens use until cleared.
Follow-up/disposition:
Small uncomplicated abrasion, normal vision, no contact lenses: follow-up in 24–48h if symptoms persist.
Ophthalmology within 24h for contact lens abrasions, large/central abrasions, decreased visual acuity, corneal infiltrate/ulcer, dendritic lesions, rust ring, or persistent symptoms.
Immediate ophtho for suspected open globe.

A Classic Presentation

A 24-year-old contact lens wearer presents with severe foreign body sensation after sleeping in lenses. Visual acuity is mildly decreased, fluorescein shows a small corneal epithelial defect, and lid eversion finds no foreign body. Because contact lenses increase risk of Pseudomonas keratitis, you prescribe topical fluoroquinolone, instruct no contact lens use, provide pain control, and arrange ophthalmology follow-up within 24 hours.

Study Directive

Practice a complete eye exam sequence: visual acuity → pupils → EOM → lids → slit lamp → fluorescein → IOP if safe.
Memorize antibiotic choices for contact lens vs non-contact lens abrasions.
Review slit lamp images of abrasion, ulcer, dendrite, and Seidel sign.
Simulate counseling: no contacts, return for worsening pain/vision, photophobia, discharge, or persistent symptoms.

Key Medications

Topical anesthetic for exam only:
- Proparacaine 0.5%: 1–2 drops once for exam.
Antibiotic prophylaxis, non-contact lens:
- Erythromycin ophthalmic ointment: 0.5-inch ribbon to affected eye QID x 3–5 days.
- Alternative: polymyxin B/trimethoprim: 1 drop q3h while awake, max 6 doses/day, x 3–5 days.
Contact lens-associated abrasion: antipseudomonal
- Ciprofloxacin 0.3% ophthalmic: commonly 1–2 drops q2h while awake for 1–2 days, then q4h while awake; dosing varies by severity — check local protocol.
- Ofloxacin 0.3% ophthalmic: 1–2 drops QID; may use more frequently if ulcer concern.
- Moxifloxacin 0.5% ophthalmic: 1 drop TID; check institutional preference.
Pain:
- Ibuprofen 400–600 mg PO q6h PRN.
- Acetaminophen 650–1000 mg PO q6h PRN; max generally 3–4 g/day depending risk factors.
- Ketorolac 0.5% ophthalmic: 1 drop QID PRN for 24–48h; avoid prolonged use.
Cycloplegic if significant photophobia/iritis:
- Cyclopentolate 1%: 1 drop, may repeat; sometimes prescribed BID–TID short course.
Tetanus: update if penetrating injury, dirty wound, or associated periocular trauma; simple nonpenetrating corneal abrasion alone generally does not require tetanus.
Pediatric: similar topical antibiotics; weight-dose oral analgesics.

High-Yield Pearls

Vertical linear abrasions suggest a retained foreign body under the upper lid — evert the lid.
Contact lens abrasion = cover Pseudomonas and arrange close follow-up.
Negative Seidel sign helps exclude full-thickness corneal laceration, but clinical suspicion still matters.

Board Question

A patient has eye pain after being scratched by a fingernail. Fluorescein exam shows a small corneal abrasion. There is no contact lens use, normal visual acuity, and negative Seidel sign. Which management is most appropriate?

AEye patch and topical steroid
BErythromycin ointment and oral analgesics
CImmediate lateral canthotomy
DTopical anesthetic prescription for home use

Reveal answer

Correct: B

Uncomplicated corneal abrasions are treated with topical antibiotic prophylaxis and analgesia. Patching and topical steroids are not recommended, and home topical anesthetics are not standard board-style management.

Recent Literature

Review or guideline Corneal wound healing
Exp Eye Res, 2020
Recent clinical Injectable hyaluronic acid hydrogels for the treatment of ocular diseases: A review
Int J Biol Macromol, 2026

3 of 4

Ear Trauma

Ear trauma ranges from simple lacerations to auricular hematoma, tympanic membrane rupture, temporal bone fracture, and CSF leak. Missed auricular hematoma...

At the Bedside

Initial assessment:
Mechanism: blunt trauma, assault, sports, blast/barotrauma, penetrating injury, bite, MVC.
Symptoms: hearing loss, tinnitus, vertigo, otorrhea, bleeding, facial weakness, severe headache.
Examine external ear, canal, TM, mastoid, cranial nerves, and facial nerve function.
Check for Battle sign, raccoon eyes, hemotympanum, CSF otorrhea.
Auricular hematoma:
Fluctuant swelling of pinna after blunt trauma, usually anterior/superior auricle.
Drain urgently via needle aspiration if small/early or incision and drainage if larger/clotted.
Apply compression bolster to prevent reaccumulation.
ENT/plastics follow-up in 24–48h.
Auricular lacerations:
Irrigate thoroughly; remove debris.
Repair cartilage with absorbable sutures if needed; align skin carefully.
Preserve tissue; avulsions or devascularized segments require ENT/plastics.
Consider antibiotics if cartilage exposed, contaminated, bite wound, immunocompromised, or hematoma drainage.
Tympanic membrane perforation:
Sudden pain, hearing loss, tinnitus, vertigo, bloody otorrhea after slap/blast/barotrauma/Q-tip.
Otoscopy: TM defect; avoid pneumatic otoscopy/irrigation.
Keep ear dry; no swimming; cotton ball with petroleum jelly for showering.
Most heal spontaneously.
ENT referral if large perforation, persistent >6–8 weeks, significant hearing loss, vertigo, facial weakness, or recurrent infection.
Temporal bone/basilar skull fracture concern:
Hemotympanum, CSF otorrhea, Battle sign, facial nerve palsy, vertigo, severe mechanism.
CT head/temporal bone as indicated; trauma/neurosurgery/ENT involvement.
Disposition:
Discharge: simple repaired laceration, uncomplicated small TM perforation, drained auricular hematoma with close follow-up.
Consult/admit: avulsion, canal stenosis, facial nerve palsy, CSF leak, severe vertigo, temporal bone fracture, uncontrolled bleeding, complex contaminated wounds.

A Classic Presentation

A 19-year-old wrestler presents after blunt ear trauma with a painful fluctuant swelling of the superior auricle. Hearing is intact and TM is normal. You diagnose auricular hematoma, perform drainage, place a compression bolster, update tetanus as indicated, consider antipseudomonal prophylaxis per local practice, and arrange ENT follow-up within 24–48 hours.

Study Directive

Practice the steps of auricular hematoma drainage and bolster placement.
Memorize red flags requiring ENT/trauma involvement: CSF otorrhea, facial palsy, severe vertigo, hemotympanum, avulsion.
Review otic drop safety with perforated TM: fluoroquinolone drops are preferred; avoid aminoglycosides.
Create a quick discharge script for TM perforation: dry ear precautions, no swimming, return precautions, ENT follow-up.

Key Medications

Local anesthesia:
- Lidocaine 1% without epinephrine or with epinephrine depending wound/location and clinician comfort.
- Max lidocaine without epi: 4.5 mg/kg, usual adult max 300 mg.
- Max lidocaine with epi: 7 mg/kg, usual adult max 500 mg.
Antibiotics — use selectively; practice varies:
- Cartilage exposure/auricular hematoma drainage where Pseudomonas coverage desired:
- Ciprofloxacin 500 mg PO BID x 5–7 days. Risks include tendinopathy, QT prolongation, dysglycemia, CNS effects; check local protocol.
- Simple skin laceration with infection risk but no cartilage/Pseudomonas concern:
- Cephalexin 500 mg PO QID x 5 days.
- Human/animal bite involving ear:
- Amoxicillin-clavulanate 875/125 mg PO BID x 3–5 days prophylaxis, 5–7+ days if infected.
TM perforation with contaminated water exposure or infection:
- Ofloxacin 0.3% otic: commonly 5–10 drops affected ear BID x 5–7 days; dosing varies by indication, check protocol.
- Avoid aminoglycoside-containing drops, e.g., neomycin, when TM is perforated due to ototoxicity risk.
Pain:
- Ibuprofen 400–600 mg PO q6h PRN.
- Acetaminophen 650–1000 mg PO q6h PRN.
Tetanus: update for lacerations/dirty wounds per standard schedule.
Pediatric: avoid routine fluoroquinolones unless benefits outweigh risks; consult references/ENT for cartilage infection prophylaxis.

High-Yield Pearls

Ear cartilage is nourished by the perichondrium; hematoma disrupts this and causes deformity.
TM perforation: keep dry, avoid irrigation, avoid ototoxic drops.
Hemotympanum after trauma is a basilar skull/temporal bone fracture clue until proven otherwise.

Board Question

A boxer presents with a fluctuant swelling of the external ear after blunt trauma. What is the most important ED management step?

AReassurance only because it will self-resolve
BIncision/aspiration drainage with compression dressing
CImmediate CT temporal bone
DTopical antibiotic drops only

Reveal answer

Correct: B

Auricular hematoma separates perichondrium from cartilage, compromising cartilage nutrition. Drainage plus compression prevents reaccumulation and cauliflower ear.

Recent Literature

Review or guideline Mechanisms of Ototoxicity and Otoprotection
Otolaryngol Clin North Am, 2021 · cited 65×

Full text · open access
Recent clinical Transient conductive hearing loss as a notable and rare manifestation of preeclampsia: a case report
J Matern Fetal Neonatal Med, 2026

Full text · open access

4 of 4

Eye Trauma

Eye trauma can hide time-critical diagnoses: open globe, retrobulbar hematoma/orbital compartment syndrome, chemical burns, hyphema, lens dislocation, and...

At the Bedside

Initial approach:
ABCs first in major trauma.
Then eye-specific priorities: visual acuity is the vital sign of the eye.
Mechanism: blunt vs penetrating, high-velocity metal/glass, chemical, contact lens, explosion, assault.
Check pupils/RAPD, EOMs, visual fields, external structures, lids, conjunctiva, cornea, anterior chamber, lens, fundus if possible.
Avoid if open globe suspected:
No tonometry.
No ocular ultrasound.
No pressure on globe.
No lid retraction forcing.
No Morgan lens.
Open globe clues:
Teardrop/irregular pupil, obvious laceration, uveal prolapse, positive Seidel sign, shallow/deep anterior chamber, hyphema, markedly decreased vision, 360° subconjunctival hemorrhage, high-risk mechanism.
Open globe management:
Rigid eye shield, not pressure patch.
NPO.
Antiemetics and analgesia.
Tetanus update.
Broad-spectrum IV antibiotics.
CT orbits with thin cuts for intraocular foreign body.
Emergent ophthalmology; surgical repair.
Chemical eye injury:
Irrigate immediately before full exam; do not wait for ophthalmology.
Remove contacts; sweep fornices for particulate matter.
Use topical anesthetic.
Irrigate with NS/LR until ocular pH 7.0–7.2, then recheck after several minutes.
Alkali burns penetrate deeply and are worse than most acids.
Orbital compartment syndrome / retrobulbar hematoma:
Severe eye pain, proptosis, tight eyelids, decreased vision, RAPD, ophthalmoplegia, elevated IOP.
If vision threatened and IOP high, perform lateral canthotomy/cantholysis immediately; do not delay for CT.
Common threshold: IOP >40 mmHg with concerning signs.
Hyphema:
Blood in anterior chamber after blunt trauma.
Head elevation, eye shield, analgesia, antiemetics.
Avoid NSAIDs/aspirin.
Check IOP if no open globe concern.
Ophthalmology follow-up; admit/urgent consult for large hyphema, elevated IOP, sickle cell disease/trait, anticoagulation, unreliable follow-up, rebleed, or poor vision.
Orbital blowout fracture:
Diplopia, infraorbital numbness, enophthalmos, restricted upgaze, orbital emphysema.
CT maxillofacial/orbits.
No nose blowing.
Entrapment, oculocardiac reflex, pediatric “white-eye” fracture, or vision deficit = urgent ophthalmology/OMFS.
Corneal/conjunctival foreign body:
Remove superficial FB if safe; rust ring may need ophthalmology.
High-velocity metal-on-metal requires CT for intraocular FB.
Disposition:
Emergent ophtho: open globe, chemical burn severe, retrobulbar hematoma/OCS, intraocular FB, severe hyphema, globe-threatening laceration.
Urgent ophtho: corneal ulcer, traumatic iritis, small hyphema, orbital fracture, significant vision changes.
Discharge only after visual acuity documented, dangerous diagnoses excluded, pain controlled, and follow-up arranged.

A Classic Presentation

A 35-year-old man is struck in the eye by a metal fragment while grinding. He has decreased vision, irregular teardrop pupil, and shallow anterior chamber. You avoid tonometry and ultrasound, place a rigid eye shield, give antiemetics/analgesia, update tetanus, start IV broad-spectrum antibiotics, obtain CT orbits for intraocular foreign body, keep him NPO, and call ophthalmology emergently for open globe.

Study Directive

Rehearse the open globe checklist from memory: shield, no pressure, NPO, antiemetic, analgesia, tetanus, IV antibiotics, CT, ophtho.
Watch a procedural video and verbalize the steps of lateral canthotomy/inferior cantholysis.
Practice identifying eye trauma images: hyphema, globe rupture, retrobulbar hematoma, blowout fracture, chemical burn.
Memorize chemical burn endpoint: irrigate until pH 7.0–7.2, then recheck.

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Mechanism Pearl of the Day: The eye and ear are unforgiving because small pressure or barrier disruptions can cause ischemia or infection in specialized sensory tissue: CRVO impairs retinal venous drainage, auricular hematoma separates cartilage from perichondrial blood supply, orbital compartment syndrome compresses optic nerve perfusion, and corneal abrasions remove the epithelial barrier that protects the cornea.

Key Medications

Topical anesthetic for exam/irrigation:
- Proparacaine 0.5%: 1–2 drops; repeat during irrigation as needed in ED.
Open globe antibiotics: regimens vary; check institutional protocol.
- Common adult regimen: Vancomycin 15–20 mg/kg IV plus ceftazidime 2 g IV q8h.
- Alternative in some protocols: fluoroquinolone such as moxifloxacin 400 mg IV/PO daily; confirm locally.
Antiemetic for open globe/hyphema:
- Ondansetron 4 mg IV/PO q6–8h PRN.
Analgesia:
- Fentanyl 0.5–1 mcg/kg IV q30–60 min PRN severe pain.
- Morphine 0.05–0.1 mg/kg IV q2–4h PRN.
- Acetaminophen 650–1000 mg PO q6h PRN.
IOP reduction if no open globe and ophtho agrees/while arranging definitive care:
- Timolol 0.5%: 1 drop affected eye.
- Brimonidine 0.2%: 1 drop affected eye.
- Acetazolamide 500 mg PO/IV once; caution sickle cell disease/trait, sulfa severe allergy, renal/hepatic disease.
- Mannitol 1–2 g/kg IV over 30–60 min for severe acute IOP elevation; avoid in significant CHF/renal failure unless specialist-guided.
Cycloplegic for traumatic iritis/hyphema per ophtho:
- Cyclopentolate 1%: 1 drop BID–TID.
Tetanus: update for open globe, penetrating trauma, contaminated wounds.
Pediatric: dose opioids/acetazolamide/mannitol by weight; urgent specialist involvement for open globe/chemical burns.

High-Yield Pearls

In trauma, visual acuity is the eye’s vital sign — document it early.
Suspected open globe: shield, antiemetics, antibiotics, NPO, ophtho; avoid pressure/tonometry/US.
Chemical burns are one of the few eye complaints where treatment precedes full exam: irrigate immediately.

Board Question

A trauma patient has severe eye pain, proptosis, decreased vision, RAPD, tight eyelids, and IOP of 52 mmHg after blunt orbital trauma. CT is not yet available. What is the next best step?

AWait for CT orbit before intervention
BApply pressure patch
CPerform lateral canthotomy and inferior cantholysis
DDischarge with ophthalmology follow-up

Reveal answer

Correct: C

This is orbital compartment syndrome with threatened optic nerve perfusion. Lateral canthotomy/cantholysis is a vision-saving bedside procedure and should not be delayed for imaging.

Recent Literature

Review or guideline Eye injuries: Understanding ocular trauma
Aust J Gen Pract, 2022 · cited 38×

Full text · open access
Recent clinical Patterns of attentional and cognitive biases in community trauma survivors: an eye tracking study
Eur J Psychotraumatol, 2026

Full text · open access

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