What is the recommended treatment for corneal abrasion using topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Topical NSAIDs for Corneal Abrasion Management

Topical NSAIDs are effective for pain management in corneal abrasions and should be used for a short course (typically 24-48 hours) alongside prophylactic topical antibiotics, with close follow-up due to potential risk of corneal melting or perforation. 1

Evidence-Based Treatment Algorithm

First-Line Treatment

1. Prophylactic topical antibiotics

   • Required for all corneal abrasions, especially contact lens-related or traumatic abrasions 1
   • Prevents bacterial keratitis when started within 24 hours of abrasion 1
   • Fluoroquinolones or broad-spectrum antibiotics are preferred options

2. Short course of topical NSAIDs

   • Provides effective pain relief 1, 2
   • Significantly reduces need for oral analgesics 3, 2
   • Common options include diclofenac, ketorolac, and flurbiprofen
   • Requires close monitoring due to potential complications

3. Avoid eye patching

   • Patching is contraindicated, especially in contact lens wearers 1
   • Increases risk of secondary bacterial keratitis

Specific Patient Considerations

Contact Lens Wearers

• Discontinue contact lens use immediately 1
• Mandatory antibiotic prophylaxis 1
• Avoid therapeutic contact lens use due to increased infection risk 1
• More frequent follow-up (within 24 hours)

Non-Contact Lens Traumatic Abrasions

• Topical antibiotics are still required 1
• NSAIDs provide superior pain control compared to oral analgesics alone 3, 2
• Follow-up within 24-48 hours to assess healing

Important Monitoring and Safety Considerations

Potential Complications

• Corneal melting or perforation: Rare but serious complication associated with topical NSAIDs 1, 4
• Delayed healing: Not significantly observed in studies but requires monitoring 4, 2
• Secondary infection: Can occur despite antibiotic prophylaxis 1

Follow-Up Requirements

• All patients: Re-evaluation within 24-48 hours 1, 5
• Higher risk patients (contact lens wearers, large abrasions): More frequent follow-up
• Monitor for signs of infection: Increasing pain, redness, or photophobia 1

Evidence Quality and Considerations

The strongest evidence supports that topical NSAIDs effectively reduce pain and decrease the need for oral analgesics in corneal abrasions 2. A meta-analysis demonstrated significantly reduced pain scores at 24 hours (SMD -0.69) and 48 hours (SMD -0.56) with topical NSAIDs compared to control 2.

While concerns exist about potential complications with topical NSAIDs, studies have not shown significant differences in healing rates or complications when used short-term for simple corneal abrasions 4, 2. However, caution is warranted due to case reports of serious complications in adults 5.

The 2024 Ophthalmology guidelines specifically mention that "a short course of topical nonsteroidal anti-inflammatory (NSAID) drops can help control discomfort" but emphasize the need for "close follow-up due to a concern for corneal melting or perforation associated with topical NSAIDs" 1.

Common Pitfalls to Avoid

• Prolonged NSAID use without monitoring
• Failing to prescribe prophylactic antibiotics
• Using eye patches, especially in contact lens wearers
• Inadequate follow-up within 24-48 hours
• Missing signs of developing infection or complications

By following this evidence-based approach, clinicians can effectively manage pain from corneal abrasions while minimizing risks of complications and promoting proper healing.