What is the treatment for a scratched cornea?

Treatment of Corneal Abrasion (Scratched Cornea)

Topical fluoroquinolone antibiotic drops (moxifloxacin or gatifloxacin) applied 4 times daily are the first-line treatment for corneal abrasions, as they achieve superior corneal penetration compared to ointments and prevent secondary bacterial infection when started within 24 hours of injury. 1, 2

Initial Management Algorithm

Immediate Assessment and Protection

• Do not rub the eye, as this worsens epithelial damage 1
• Apply a hard plastic eye shield or paper cup over the eye to prevent inadvertent touching 1
• Confirm diagnosis with fluorescein staining under cobalt-blue light 3

Antibiotic Selection Based on Risk Stratification

For Simple Traumatic Abrasions (Non-Contact Lens Related):

• Prescribe fluoroquinolone drops (moxifloxacin or gatifloxacin) 4 times daily 1, 2
• These are FDA-approved for bacterial keratitis and provide broad-spectrum coverage 1
• Alternative: Bacitracin ophthalmic ointment for superficial infections, though drops are preferred 4

For Contact Lens-Related Abrasions (High Risk):

• Use more aggressive treatment with frequent antipseudomonal fluoroquinolone drops 2
• Discontinue contact lens wear until complete healing is confirmed by examination 1, 2
• Do not patch the eye or use therapeutic contact lenses in contact lens wearers due to increased risk of secondary bacterial keratitis 1

For Central or Severe Keratitis:

• Initiate hourly fluoroquinolone drops initially 5
• Culture-guided treatment is mandatory if infection is suspected 5

Pain Management

• Use over-the-counter oral acetaminophen or NSAIDs for residual discomfort 1, 2
• Topical NSAIDs (ketorolac tromethamine 0.5%) significantly reduce pain, photophobia, and foreign body sensation within 24 hours without adverse effects 6
• Consider cycloplegic agents only if substantial anterior chamber inflammation is present 1

Critical Timing Considerations

• Prophylactic antibiotics are most effective when started within 24 hours of injury 1, 2, 7
• Most corneal abrasions heal within 24-72 hours 3
• Healing may be delayed 5-7 days in cases with underlying corneal pathology 2

Important Caveats and Warning Signs

When to Avoid Certain Treatments

• Eye patching does not help healing and may hinder it 5, 3
• Tetracycline ointment lacks adequate corneal penetration and should not be used as monotherapy 1, 2
• Tetracycline may be useful only at bedtime as adjunctive therapy in less severe cases 1

Red Flags Requiring Immediate Ophthalmology Referral

• High-velocity eye injuries or penetrating trauma 1
• Irregular pupil after trauma 1
• Eye bleeding or vision loss after trauma 1
• Increasing pain or purulent discharge suggesting infection 2
• Inadequate blinking or incomplete eyelid closure during sleep (may require temporary tarsorrhaphy) 2

Antibiotic Resistance Concerns

• Chronic prophylactic antibiotic use may promote resistant organisms 1, 2
• Regular follow-up is necessary to monitor healing and detect early infection 1

Management of Persistent or Recurrent Defects

For non-healing epithelial defects despite standard treatment:

• Consider bandage contact lens (not in contact lens wearers with active abrasion) 5, 2
• Amniotic membrane application (onlay or inlay) releases anti-inflammatory and pro-healing mediators 5
• Autologous serum drops have demonstrated beneficial effects 5
• Cenegermin (nerve growth factor) 20 μg/ml, 6 drops daily for 8 weeks, for neurotrophic keratopathy 5, 2

Evidence Quality Note

The most recent Cochrane review (2025) found very low certainty evidence regarding antibiotic prophylaxis effectiveness, with one study paradoxically suggesting antibiotics may increase infection risk (RR 1.32) 7. However, the American Academy of Ophthalmology guidelines prioritize fluoroquinolones based on their FDA approval for bacterial keratitis, superior corneal penetration, and clinical consensus 1, 2. In real-world practice, the risk of untreated bacterial keratitis outweighs theoretical concerns, particularly when treatment begins within 24 hours.