What is the management for corneal abrasion?

Management of Corneal Abrasion

Immediate Treatment: Topical Antibiotics Are Essential

All patients with corneal abrasions should receive topical broad-spectrum antibiotic prophylaxis, with fluoroquinolones (moxifloxacin 0.5% or gatifloxacin) as the preferred first-line agents, applied four times daily until complete epithelial healing is confirmed. 1, 2, 3

Treatment must be initiated within 24 hours of injury to effectively prevent progression to bacterial keratitis and corneal ulceration. 1, 2

Treatment Algorithm by Clinical Scenario

Simple Traumatic Abrasions (Non-Contact Lens Related)

• Apply fluoroquinolone drops four times daily as the primary treatment 2, 3
• Add antibiotic ointment at bedtime for additional protection and lubrication 2, 4
• Prescribe oral analgesics (acetaminophen or NSAIDs) for pain control 2
• Chloramphenicol ointment 1% three times daily for 3 days is an alternative when started within 48 hours 2

Contact Lens-Related Abrasions (High-Risk)

• Mandatory topical antibiotic coverage with antipseudomonal activity (fluoroquinolones preferred) 1, 4
• Absolutely no eye patching due to significantly increased risk of bacterial keratitis 1, 2
• Avoid bandage contact lenses in the acute setting for the same reason 1
• Discontinue contact lens wear until complete healing is confirmed by examination 2, 4

Post-Trauma Abrasions

• Broad-spectrum topical antibiotic required to prevent both bacterial and fungal infection 1
• Assess for penetrating injury, foreign body, or irregular pupil requiring immediate ophthalmology referral 4

Critical Management Principles

What NOT to Do

• Do not patch the eye - patching does not improve pain, may delay healing, and increases infection risk in contact lens wearers 1, 2, 3, 5
• Do not use topical steroids initially - they delay healing and increase infection risk 2, 3
• Do not use topical cycloplegics routinely - reserve only for substantial anterior chamber inflammation 1
• Avoid chronic antibiotic use beyond healing period as this promotes resistant organisms 1, 4, 3

Antibiotic Selection Rationale

Fluoroquinolones are superior to ointments alone because ocular ointments lack adequate corneal penetration for optimal therapeutic benefit, though ointments remain useful as bedtime adjunctive therapy. 1, 4

Topical antibiotic drops achieve high corneal tissue levels and are the preferred delivery method. 1

Follow-Up and Warning Signs

Routine Follow-Up

• Small abrasions (≤4 mm) with resolving symptoms may not require follow-up 6
• All other patients require re-evaluation at 24 hours to assess healing and rule out infection 6

Red Flags Requiring Immediate Ophthalmology Referral

• Increasing pain, purulent discharge, or corneal infiltrate 2, 4, 3
• Central or large infiltrate (>2 mm), deep stromal involvement, or hypopyon 1, 4
• Vision loss or irregular pupil 4
• Symptoms worsening or not improving within 24-48 hours 6

Management of Delayed Healing

For persistent epithelial defects beyond expected healing time:

• Consider oral doxycycline, autologous serum, or amniotic membrane application 2, 3
• Ensure adequate blinking and complete eyelid closure - inadequate closure significantly delays healing 3
• Temporary tarsorrhaphy may be needed if eyelid function is compromised 3

Pain Management Strategy

• Oral analgesics (acetaminophen or NSAIDs) are first-line for pain control 2, 4
• Topical NSAIDs may reduce need for oral analgesia but evidence is limited 7
• Protect the eye with a rigid shield (not a patch) to prevent inadvertent rubbing 4

Common Pitfalls to Avoid

• Rubbing the eye worsens injury - educate patients to avoid this and consider protective shielding 2, 3
• Missing foreign bodies - careful examination with eversion of upper lid is essential 6
• Underestimating contact lens-related risk - these require more aggressive antibiotic coverage 1
• Using combination steroid-antibiotic drops initially - steroids should only be added after 2-3 days of antibiotic-only therapy if indicated 4