Corneal abrasions are the most commonly encountered emergent ophthalmologic issue in the emergency department (ED) and are generally associated with significant discomfort.¹ Yet, in the ED we often perform a single intervention that appears to instantly cure these patients: instillation of a topical anesthetic (e.g., proparacaine, tetracaine). As a result, emergency physicians have increasingly demonstrated interest in providing patients with take-home relief via topical anesthetics; however, the use of topical anesthetics in patients with corneal abrasions has long stirred up intense debate between emergency phsicians and ophthalmologists.² Ophthalmologists, who are on the receiving end of ophthalmic complications, have opposed topical anesthetics in these patients due to concern regarding potential vision-threatening complications such as toxic keratopathy.³ The concern regarding adverse effects historically stemmed from case reports and series skewed by publication bias and often addressing situations that included welders and those with topical anesthetic abuse.

Now, ACEP has published a consensus guideline that has fueled this controversy. The consensus guideline serves up an interesting read—“spilling the tea” on what went down in this document that began as a joint guideline between ACEP and the American Academy of Ophthalmology (AAO).

First, the guideline gives the following Level B recommendation: “In adult ED patients with simple corneal abrasions as defined in these guidelines, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (i.e., proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours.” This recommendation is a win for emergency physicians who favor doling out topical anesthetics in select patients.

This recommendation was informed by evidence derived from case reports and series, ophthalmology literature after photorefractive keratectomy, four ED-based randomized trials (totaling 307 patients) and two ED-based nonrandomized studies (totaling nearly 2,000 patients). Although the ACEP guideline does not analyze the pooled data, a Cochrane review examining the randomized trials found the relative risk (RR) of incomplete resolution of epithelial defects by 24-72 hours and complications at longest time point not statistically significant in post-trauma corneal abrasions treated with topical anesthetic versus placebo (RR 1.37, 95 percent CI 0.78- 2.42 and RR 1.13, 95 percent CI 0.23-5.46, respectively).⁴

The ACEP guideline gives a smattering of supporting recommendations, including that tetracaine, proparacaine, and oxybuprocaine appear similarly safe, that clinicians should consider patient-specific medical and social factors, and that topical anesthesia appears a more effective analgesic than acetaminophen with or without an opioid. Use in pediatric patients should be avoided due to a lack of studies in these patients.⁵