No, not all patients with corneal abrasions can or should get take-home topical anesthetics; however, a subset of carefully selected adult patients with a simple corneal abrasion can take home a <24-hour supply. When considering dispensing topical anesthetics, the ACEP clinical policy provides additional recommended information to add to patient discharge instructions.⁵ Importantly, these instructions highlight the importance of the <24 hour timeframe and potential adverse consequences. These instructions can be adapted for local use and, in my own practice, serve as a stimulus for shared decision making with the patient.

Many ophthalmologists are unhappy with the ACEP recommendations and anecdotally report an increasing number of patients presenting to clinic with entire bottles of topical anesthetic from the ED.^3,6 The guideline contains a description of the drama that unfolded when the joint ACEP-AAO workgroup submitted their recommendations: The AAO supported the literature review but disagreed with the recommendations and eventually withdrew support.⁵ Although not supported by published evidence to date, the concerns from our ophthalmologic colleagues should not be ignored. In fact, with regard to rare outcome data, the studies are rather small. Additionally, our Achilles’ heel in emergency medicine is the lack of follow-up on downstream outcomes, which can lead to overconfidence in our practice patterns and gestalt. We are unlikely to become aware of our misdiagnoses, such as mistaking microbial keratitis or a corneal ulcer for a corneal abrasion. Emergency physicians are unlikely to see adverse sequelae unless we actively seek follow-up. It is critical to take certain steps when contemplating topical anesthetic for home use.

• Be certain of the diagnosis of a simple corneal abrasion. This means a thorough exam, using the slit lamp, to exclude foreign body/rust ring, ulcer, laceration, infection, or keratitis. Also, be sure to address pertinent features in the history to ensure fewer than two days since onset, no chemical or thermal cause, no history of herpetic eye disease, and similar issues.
• Counsel patients on potential risks.
• Dispense <1.5 to 2 mL (40 drops) of anesthetic and throw away the rest.
• Provide written and verbal instructions to the patient on appropriate use, including duration of use, follow-up, and risks.
• Consider discussing with local ophthalmologists.

Dr. Westafer is assistant professor in the department of emergency medicine at the UMass Chan Medical School–Baystate and co-host of FOAMcast.

References

1. Channa R, Zafar SN, Canner JK, et al. Epidemiology of eye-related emergency department visits. JAMA Ophthalmol. 2016;134(3):312-319.
2. Klauer KM. Science has repeatedly debunked this stubborn ophthalmology myth. ACEP Now. Published September 19, 2018. Accessed September 15, 2024.
3. Weiser P. American Academy of Ophthalmology. Topical anesthetics: The latest on use for corneal abrasions. Published February 1, 2024. Accessed September 15, 2024.
4. Sulewski M, Leslie L, Liu S-H, et al. Topical ophthalmic anesthetics for corneal abrasions. Cochrane Database Syst Rev. 2023;8(8):CD015091.
5. Green SM, Tomaszewski C, Valente JH, et al. Use of topical anesthetics in the management of patients with simple corneal abrasions: consensus guidelines from the American College of Emergency Physicians. Ann Emerg Med. 2024;83(5):477-489.
6. Chuck RS, Jeng BH, Lum F. Consensus guidelines versus evidence-based medicine in the treatment of corneal abrasions. Ophthalmology. 2024;131(5):524–525.