Management of Corneal Abrasion After Tetracaine Application
For a patient with a corneal abrasion who has already received tetracaine, immediately prescribe preservative-free artificial tears (hyaluronate or carmellose) every 2 hours and a broad-spectrum topical antibiotic such as moxifloxacin or ofloxacin four times daily. 1, 2, 3
Critical First Step: Stop Topical Anesthetic Use
- Tetracaine must not be given to the patient for home use - the FDA label explicitly states it is "not intended for patient self-administration" and prolonged use causes corneal epithelial toxicity that can progress to permanent corneal damage 4
- Tetracaine's anesthetic effect lasts only 10-20 minutes, so the patient will regain corneal sensation shortly after leaving your care 4
- Warn the patient not to touch or rub the eye for at least 10-20 minutes after the last tetracaine application, as accidental injuries can occur due to insensitivity 4
Essential Therapeutic Regimen
Lubrication (Mandatory)
- Prescribe preservative-free artificial tears (hyaluronate or carmellose) to be applied every 2 hours while awake 1, 2, 5
- Preservative-free formulations are critical - preserved drops worsen epithelial damage in the setting of corneal defects 5
- Consider adding nighttime ointment or moisture chamber for severe abrasions 5
Antibiotic Prophylaxis (Strongly Recommended)
- Prescribe a broad-spectrum topical antibiotic - moxifloxacin or ofloxacin (fluoroquinolones) four times daily 1, 2, 3
- The American Academy of Ophthalmology specifically recommends topical antibiotics for corneal abrasions, particularly following trauma, to prevent acute bacterial keratitis 3
- Prophylactic antibiotics started within 24 hours of abrasion have been shown to prevent ulceration 3
- Continue antibiotics until the epithelial defect heals completely 5
Important Caveat About Antibiotics
- While a 2022 Cochrane review found insufficient evidence to definitively prove benefit of antibiotic prophylaxis for all corneal abrasions 6, guideline-based practice and expert consensus strongly support their use in traumatic abrasions 2, 3
- The risk-benefit ratio favors treatment given the potentially devastating consequences of bacterial keratitis versus minimal antibiotic side effects 2, 3
What NOT to Do
- Do not prescribe tetracaine or any topical anesthetic for home use - this causes severe corneal toxicity with repeated application 4, 7
- Research demonstrates that both regular and diluted proparacaine (similar anesthetic) impede corneal wound healing, with additive negative effects when combined with antibiotics 7
- Do not patch the eye - this increases the risk of secondary bacterial keratitis, especially in contact lens wearers 3
- Do not use therapeutic contact lenses in contact lens-associated abrasions due to infection risk 3
Follow-Up and Monitoring
- Schedule ophthalmologic follow-up within 24-48 hours to assess healing with fluorescein staining 2, 5
- Daily ophthalmologic review is necessary during the acute phase for significant abrasions 1, 2
- Watch for warning signs of infection: increased pain, purulent discharge, worsening symptoms, or lack of improvement within 48 hours 5
Special Considerations for High-Risk Features
If the abrasion has any of the following characteristics, consider more aggressive management:
- Central location threatening the visual axis - may require topical corticosteroids (dexamethasone 0.1% twice daily) after 2-3 days of antibiotic therapy once epithelial healing has begun, but only under ophthalmology supervision 1, 2
- Contact lens-related injury - culture the lens and case; these patients have higher infection risk 1, 3
- Vegetable matter or organic material exposure - higher risk for fungal infection; obtain cultures 1
- Large or deep abrasions - may require more frequent antibiotic dosing and closer monitoring 1