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Assessment:
The patient presents with eye pain, tearing, and foreign body sensation, consistent with a corneal abrasion. The patient [does/does not] wear contact lenses, which increases the risk of bacterial infection, particularly with Pseudomonas species. No signs of vision loss or hyphema. Fluorescein staining reveals an epithelial defect without evidence of foreign body. Differential diagnosis includes foreign body, corneal ulcer, and infectious keratitis.
Plan:
Recommend antibiotic eye drops (e.g., erythromycin or ciprofloxacin) to prevent infection, especially if the patient wears contact lenses. Instruct the patient to avoid rubbing the eye and to use artificial tears for comfort. If the patient wears contact lenses, advise discontinuation until the abrasion heals and discard old lenses to reduce the risk of infection. Prescribe topical NSAID drops or oral pain relievers as needed for discomfort. Follow up in 24-48 hours to ensure healing and reassess symptoms. Refer to ophthalmology if there is no improvement, worsening pain, or vision changes.
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