What is the management of symptomatic corneal abrasions?

Management of Symptomatic Corneal Abrasions

Topical broad-spectrum antibiotic drops, preferably fluoroquinolones such as moxifloxacin or gatifloxacin, should be prescribed as first-line treatment for all corneal abrasions to prevent secondary bacterial infection. 1, 2

Initial Assessment and Immediate Care

• Do not rub the eye as this worsens the injury and causes further corneal epithelial damage 1, 2
• Apply a protective hard plastic eye shield, paper cup, or plastic cup over the eye to prevent unintentional touching 3
• Confirm diagnosis with fluorescein staining under cobalt-blue filtered light (abrasion appears green) 4, 5
• Carefully examine for and remove any foreign bodies present 5
• Exclude serious pathology including penetrating injury, infective keratitis, corneal ulcers, or irregular pupil 3, 5

Antibiotic Prophylaxis Algorithm

For Non-Contact Lens Wearers:

• Apply fluoroquinolone drops (moxifloxacin or gatifloxacin) 4 times daily as the preferred antibiotic due to broad-spectrum coverage and FDA approval for bacterial keratitis 1, 2
• Consider antibiotic ointment at bedtime for additional protection and lubrication 1, 2
• Chloramphenicol ointment 1% three times daily for 3 days is effective when started within 48 hours of injury 6, 1

For Contact Lens-Related Abrasions:

• Prescribe antipseudomonal topical antibiotics (fluoroquinolones preferred) to prevent acute bacterial keratitis 3, 5
• Avoid contact lens wear until complete healing is confirmed by healthcare professional 1, 3
• Do not patch the eye in contact lens wearers due to significantly increased risk of bacterial keratitis 1, 3

The evidence supporting antibiotic prophylaxis shows that treatment started within 24 hours prevents ulceration, though a 2022 Cochrane review found only very low certainty evidence for infection prevention overall 1, 7. However, given the potential sight-threatening consequences of bacterial keratitis and the low risk of antibiotic use, prophylaxis remains standard practice 1, 2.

Pain Management

• Prescribe oral acetaminophen or NSAIDs for pain control 1, 3
• Topical NSAIDs (such as diclofenac) provide significant pain relief and allow binocular function 8
• Consider cycloplegic agents only if substantial anterior chamber inflammation is present 3, 5
• Avoid topical steroids initially as they delay healing and increase infection risk 1, 2

What NOT to Do

• Do not patch the eye - multiple well-designed studies demonstrate patching does not improve pain or healing and may actually hinder recovery 1, 2, 4, 5
• Avoid chronic prophylactic antibiotic use as this promotes resistant organisms 1, 2
• Do not use topical mydriatics for uncomplicated abrasions as they are not beneficial 4

Follow-Up Protocol

Patients Who Need 24-Hour Follow-Up:

• Abrasions larger than 4 mm 5
• Any vision loss 5
• Contact lens-related abrasions 5
• Symptoms not resolving 5

Patients Who May Not Need Follow-Up:

• Small abrasions (≤4 mm) 5
• Normal vision 5
• Resolving symptoms 5

Warning Signs Requiring Immediate Ophthalmology Referral

• Increasing pain, purulent discharge, or corneal infiltrate (signs of infection) 1, 3, 2
• High-velocity eye injuries or penetrating trauma 3
• Irregular pupil after trauma 3
• Eye bleeding or significant vision loss 3
• Symptoms worsening or not improving within 24-48 hours 5

Special Considerations for Delayed Healing

• Ensure adequate blinking during waking hours and complete eyelid closure during sleep, as these are critical for healing 2
• Consider temporary tarsorrhaphy with botulinum toxin or suture when blinking or eyelid closure is inadequate 2
• Bandage contact lenses may be helpful for delayed healing but are generally not needed for simple abrasions 2, 8
• For persistent epithelial defects, consider oral doxycycline, autologous serum, or amniotic membrane application 6, 2

Common Pitfalls to Avoid

• Inadequate examination for retained foreign bodies leads to persistent symptoms 5
• Prescribing tetracycline ointment as monotherapy - it lacks corneal penetration for optimal therapeutic benefit 3
• Missing contact lens-related abrasions that require antipseudomonal coverage 5
• Failing to educate patients about infection signs (increasing pain, discharge, vision changes) 3

Most corneal abrasions heal within 24-72 hours with appropriate treatment 4. The key is preventing the rare but serious complication of bacterial keratitis through appropriate antibiotic prophylaxis while avoiding interventions like patching that have been proven ineffective.