O R I G I N A L A R T I C L E

ANN OPHTHALMOL. 2000;32(4):316–319316

Reprints:Abraham Solomon, MD, Department of Ophthalmology, Hadassah University Hospital,91120 Jerusalem, Israel.

The authors are from the Department of Ophthalmology, Hadassah University Hospi-tal and the Hebrew University-Hadassah Medical School, Jerusalem, Israel.

Mild ocular trauma causing corneal epithelialabrasions is common in general ophthalmic

practice. Most of the patients experience severe acutepain, photophobia, blepharospasm, tearing, and con-junctival hyperemia. Severe complaints are caused byconstant stimulation of the exposed sensory nerveendings. In eyes that are otherwise normal, most ofthe erosions epithelialize within 24 to 48 hours afteradministration of cycloplegics, antibiotics, and semi-pressure eye patching.1 However, eye patching maycause considerable discomfort and pain,2 and inciden-tal epithelial erosions may occur in patients who werenot carefully patched. Furthermore, eyelid closurewith an eye patch is not absolutely necessary for heal-ing of epithelial erosions or following cataract extrac-tion.3,4 We therefore studied the efficacy ofadministration of topical 1% indomethacin withouteye patching in patients with corneal epithelial abra-sions following minor corneal trauma.

Patients & MethodsTwenty-eight consecutive patients with minor oculartrauma associated with corneal abrasion of differentcauses (Table 1) were evaluated in the Department ofOphthalmology, Hadassah University Hospital,Jerusalem, Israel. All patients gave informed consent.At inclusion, each patient was asked about the pres-ence of tearing, pain/discomfort, itching, burning, dis-charge, foreign body sensation, and photophobia.Each symptom was graded on a scale from 0 to 3,except for pain, which was graded on a scale of 0 to 10.Thereafter, biomicroscopic examination of the anteri-

Abraham Solomon, MD, Michael Halpert, MD, &Joseph Frucht-Pery, MD

Comparison of Topical Indomethacin andEye Patching for Minor Corneal Trauma

The effects of administration of topical 1% indomethacin vs semi-

pressure patching were studied in a prospective, randomized,

masked study of 28 patients with symptomatic corneal abrasion of 3

mm or less. One group of 14 patients received topical antibiotic and

administration 4 times daily of topical indomethacin. The other 14

patients were treated with topical antibiotic, and the traumatized

eye was patched. After 6 to 9 hours, indomethacin-treated eyes had

less pain and itching. After 24 hours, there was no difference

between groups except that itching remained significantly greater in

patched eyes.

A B S T R A C T

ANN OPHTHALMOL. 2000;32(4) 317

or segment was performed. Swelling or hyperemia ofthe eyelid and conjunctival hyperemia were evaluatedon a scale of 0 to 3. The sum of the scores of signs andsymptoms for each patient was defined as the totalscore. The area of epithelial damage of the conjuncti-va and cornea was measured in millimeters. Cornealand conjunctival foreign bodies were removed with a25-gauge needle after administration of 2 drops of0.2% benoxinate hydrochloride.

At completion of the eye examination, patientswere randomly assigned into 1 of 2 treatment proto-cols. In group 1 (age range, 18 to 63 years; mean, 32.6years), the traumatized eye received 1% topicalcyclopentolate, 1 drop of 0.3% chloramphenicol, and 1drop of 1% indomethacin (Merck, Sharp, and Dohme).No eye patch was used. Patients were instructed toinstill 1% topical indomethacin 4 times daily and topi-cal chloramphenicol 3 times daily. In group 2 (agerange, 19 to 58 years; mean, 31.3 years), 1% topicalcyclopentolate and 2 drops of 0.3% topical chloram-phenicol were applied to the traumatized eye, followedby a semipressure patching. The eye patch in group 2was applied in a manner that precluded eyelid motili-ty under the patch.

Six to 9 hours after the beginning of treatment pro-tocol, patients were questioned, by telephone, as totheir subjective symptoms. Eighteen to 24 hours afterthe first visit, patients were reevaluated by gradingsigns and symptoms as described above and measur-ing the epithelial defect. The first eye examinationwas always performed by 1 of the authors (M.H.),whereas the follow-up examination was done byanother author (J.F.-P.), who was unaware of the treat-ment used. The scores of the signs and subjectivesymptoms were evaluated using the Wilcoxonmatched-pairs signed rank test.

ResultsAll corneal erosions in this study were of a diameterless than 3 mm (Table 1). In both groups, all the

epithelial defects except 2 (1 in each group) werehealed by the time of the 24-hour examination, andthe other 2 eyes with erosions epithelialized duringthe next 24 hours. Before administration of the treat-ment, there was no difference between the scores ofsigns and symptoms in groups 1 and 2. After 6 to 9hours, we recorded symptoms in 10 of the 14 patientsin group 1 and 11 of the 14 patients in group 2; theother patients were not available.

In group 1, total scores ranged between 3 and 23(mean score, 13.1) before the treatment and between 0and 14.5 (mean score, 3.1) 24 hours after treatment. At9 and 24 hours after administration of topicalindomethacin, the scores of symptoms and signs hadsignificantly decreased (Table 2), compared with pre-treatment scores in pain, foreign body sensation,burning, and tearing. At 24 hours, a significantdecrease was observed in itching, photophobia, andconjunctival hyperemia but not in eyelid swelling(Table 2). The total score significantly decreased at the2 time points (9 hours, P=.005; 24 hours, P=.001). After24 hours, 7 of the 14 participants were free of symp-toms or signs, but 6 patients still maintained somesymptoms. Only 1 patient remained without sympto-matic difference despite healing of the corneal ero-sion. Finally, he too was free of symptoms within thenext 24 hours.

In group 2, total scores ranged from 3 to 23 (meanscore, 14.9) before the treatment and from 0 to 11(mean score, 4.1) after 24 hours. At 9 or 24 hours aftereye patching, the scores of symptoms and signs hadsignificantly decreased, compared with pretreatmentscores, for pain, foreign body sensation, burning, con-junctival hyperemia, tearing, and photophobia. Nosignificant difference was observed in eyelid swelling.The total score significantly decreased at 9 and 24hours (Table 2). The itching significantly increased at9 hours (P=.028) and was of borderline significance at24 hours (P=.054). Of the 14 participants, 5 were free ofsigns and symptoms, while 9 patients remained symp-tomatic after 24 hours of wearing an eye patch.

Comparison between groups of the scores of signsand symptoms revealed greater pain relief in group 1at 6 to 9 hours (P=.032) and a greater increase in itch-ing sensation in group 2 (9 hours, P=.025; 24 hours,P=.017). All of the other studied parameters in bothgroups had no statistically significant differences atany time (Table 2).

DiscussionEye patching is a procedure used daily in eye clinics toimmobilize the eyelids for relief of pain and photo-phobia following trauma to the corneal epithelium,recurrent epithelial erosions, or eye surgery.1 Theneed for eye patching after cataract surgery has beenquestioned because a study showed that patients witheither patched or nonpatched eyes had similar symp-toms.4 Currently, some cataract surgeons do not patchthe eye after surgery, believing that the postoperativecontribution of eye patching is limited. Furthermore,

T A B L E 1Cause and Size of Minor Epithelial Trauma

Group 1

8

4

0

2

7

2

3

2

Cause

Foreign body

Welding

Road accident

Unknown

Size of Epithelial Defect

<1 mm

1–3 mm

Linear

Punctate

Group 2

12

1

1

0

4

5

3

2

No. of Eyes

ANN OPHTHALMOL. 2000;32(4)318

eye closure is associated with subclinical inflammato-ry responses in the eye5 and an increase of the micro-bial population in the conjunctiva.6 On the other hand,nonsteroidal anti-inflammatory agents, includingindomethacin, have some bactericidal activity in addi-tion to their anti-inflammatory effect.7

In the present study, we challenged the need foreye patching in normal eyes that sustained minor ocu-lar trauma with epithelial defects of less than 3 mm. Inall eyes except 2 (1 in each group), epithelialization ofthe corneal surface was complete within 24 hours. Fur-thermore, all the studied symptoms except itching ingroup 2 and eyelid swelling in both groups had signif-icantly decreased after 24 hours. Interestingly,patients who received indomethacin (group 1) had lesspain 6 to 9 hours after the treatment began. After 24hours, 7 of the indomethacin-treated patients (group1) were asymptomatic, compared with 2 patients withan eye patch (group 2), and the mean total score ofsigns and symptoms in the patched eye was 25%greater in group 2 (group 1, 3.1; group 2, 4.1). The factthat patients in both groups were symptomatic,despite the complete epithelialization of corneal abra-sions, is most probably related to the inflammation inthe injured tissues.

The reason for the significant decrease of pain inindomethacin-treated patients (group 1) after 6 to 9hours is not entirely clear. The first post-treatmentocular examination was done after 18 to 24 hours. Wetherefore do not know whether the corneal abrasionswere already epithelialized after 6 to 9 hours. There isno evidence that epithelial abrasion, in an otherwisenormal eye, epithelializes faster in an uncovered eyethan in a patched eye, or that topical indomethacinenhances the epithelialization rate in corneal abra-sion.8 We believe that the greater decrease of pain sen-sation in group 1 might be indomethacin-induced.Topical indomethacin may relieve cornea-related pain9

by decreasing the prostaglandin levels, which causean increase of activation of the pain threshold, result-

ing in increased central nervous system pain percep-tion.10,11 The fact that in group 1 only 4 of 10 patientswere free of pain after 6 to 9 hours and 7 patients pre-sented other symptoms similar to group 2 may sug-gest that the analgesic effect of indomethacin isefficient, despite the persistence of inflammation.However, whether the greater decrease of pain ingroup 1 is purely indomethacin-related or a combina-tion of drug effect in group 1 and patch-induced painin group 2 remains unclear.

Our study indicates that itching is one of the com-mon complaints in patched eyes. While in group 1 thescores of itching decreased during the 24 hours aftertreatment, in group 2 the scores of itching increasedafter 9 and 24 hours and were significantly greaterthan those in group 1. The increased itching in group2 is most probably patch-related. This finding is inagreement with a previous report of itching in normaleyes patched for experimental reasons, most probablybecause the patch material constantly rubs againstthe skin.2

Finally, 4 of 5 patients in group 1 who demonstrat-ed eyelid swelling or edema at the first examinationhad normal eyelids after 24 hours (P=.06). On theother hand, 4 of 5 patients in group 2 had unchangedscores of eyelid swelling after 24 hours. The decreaseof the eyelid scores in group 1 may be related to theanti-inflammatory effect of indomethacin or to thenatural course of mild inflammation in the eyelids. Inthe patched eyes in group 2, the constant rubbing ofthe patch against the eyelids could maintain theinflammatory state.

In the present study, eye patching or alternativeuse of indomethacin (in the nonpatched eye) followingminor ocular trauma and symptomatic corneal abra-sion was effective and led to similar anatomicalresults. However, we dispute the need for eye patchingin these eyes. The eyes with no patch had earlier reliefof pain, decreased itching, and most probably lesserduration of eyelid inflammation. These findings, in

T A B L E 2Changes in Symptoms and Signs Between Pretreatment and Post-treatment Scores and Comparison Between Groups

Group

1

2

2 vs 1

HoursAfter

Treatment

9

24

9

24

9

24

Values are expressed as P values, based on the Wilcoxon signed rank test. ↓ indicates decrease from pretreat-ment score; ↑, increase from pretreatment score; NS, not significant; and ND, not done.

Pain/Discomfort

.008 ↓

.003 ↓

.008 ↓

.003 ↓

.032 ↑NS

ForeignBody

Sensation

.028 ↓

.005 ↓

.018 ↓

.003 ↓

NS

NS

Burning

.028 ↓

.003 ↓

.018 ↓

.005 ↓

NS

NS

Itching

.11 ↓

.043 ↓

.028 ↑

.054 ↑

.025 ↑

.017 ↑

Photo-phobia

NS

.018 ↓

NS

.012 ↓

NS

NS

Tearing

.018 ↓

.005 ↓

NS

.004 ↓

NS

NS

ConjunctivalCongestion

ND

.022 ↓

ND

.008 ↓

ND

NS

EyelidEdema/

Congestion

ND

NS

ND

NS

ND

NS

TotalScore

.005 ↓

.001 ↓

.005 ↓

.001 ↓

NS

NS

ANN OPHTHALMOL. 2000;32(4) 319

addition to the benefit of binocular vision and sparingpatients the possible psychological effects of an eyepatch, make treatment with topical antibiotics andindomethacin preferable over conventional eye patch-ing. We therefore suggest the administration of com-bined topical antibiotics and indomethacin for painfulminor corneal abrasion, in an otherwise normal eye.

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