What is the management for a corneal abrasion?

Management of Corneal Abrasions

For corneal abrasions, topical antibiotics should be prescribed to prevent acute infection, especially in patients who wear contact lenses or have suffered trauma, while patching should be avoided as it increases the risk of secondary bacterial keratitis. 1

Initial Assessment and Diagnosis

• Confirm diagnosis with fluorescein staining under cobalt-blue filtered light
• Carefully examine for and remove any foreign bodies
• Assess size, depth, and location of the abrasion
• Determine if the patient is a contact lens wearer (highest risk factor for microbial keratitis)

Treatment Algorithm

Immediate Management

1. Antibiotic Prophylaxis:

   • First-line: Fourth-generation fluoroquinolones (moxifloxacin 0.5% or gatifloxacin 0.3%) for better gram-positive coverage 1
   • Alternative: For small, non-central ulcers - ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5% 1
   • For contact lens wearers: Use antipseudomonal coverage due to higher risk of Pseudomonas infection 2

2. Pain Management:

   • Topical NSAIDs (e.g., ketorolac) - reduces pain and decreases need for oral analgesics 3
   • Oral analgesics (NSAIDs or acetaminophen) as needed 1
   • Cycloplegic agents (e.g., cyclopentolate) if significant anterior chamber inflammation present 1
   • Preservative-free ocular lubricants every 2 hours for comfort 1

3. Important Precautions:

   • Do NOT patch the eye - delays healing and increases infection risk, especially in contact lens wearers 2, 1
   • Avoid topical anesthetics for outpatient use - delays healing and can cause complications 1
   • Avoid topical corticosteroids initially - should only be considered after 48 hours of antibiotic therapy and confirmed response 2, 1
   • Avoid bandage contact lenses - increases risk of bacterial keratitis 1

Follow-up Care

• Small (≤4 mm), uncomplicated abrasions with normal vision and resolving symptoms may not require follow-up 4
• All other patients should be reevaluated within 24 hours 1
• Daily follow-up during acute phase for larger or complicated abrasions 1

Indications for Immediate Referral to Ophthalmology

• Symptoms that worsen or do not improve within 24-48 hours
• Development of corneal infiltrate or ulcer
• Significant vision loss
• Suspicion of penetrating eye injury
• Large or central abrasions affecting visual axis

Prevention

• Recommend protective eyewear for sports and high-risk activities 1
• For contact lens wearers:
  • Proper lens hygiene education
  • Avoid overnight wear (major risk factor for infection) 2
  • Reassess lens choice and fitting after healing 2

Special Considerations

• If no improvement after 48 hours, consider antibiotic resistance, incorrect diagnosis, or non-infectious cause 1
• In developing countries, early antibiotic prophylaxis for corneal abrasions has been shown to significantly reduce the incidence of corneal ulcers 2
• The American Academy of Ophthalmology notes that contact lens wear is the number one risk factor for microbial keratitis in the United States, while trauma is the leading risk factor in many other parts of the world 2