What is the treatment for corneal abrasions?

Treatment for Corneal Abrasions

Topical broad-spectrum antibiotic drops, preferably fluoroquinolones (moxifloxacin or gatifloxacin), applied four times daily are the first-line treatment for corneal abrasions to prevent bacterial keratitis. 1, 2, 3

Antibiotic Selection and Administration

Standard Cases (Non-Contact Lens Wearers)

• Fluoroquinolones (moxifloxacin 0.5% or gatifloxacin) are the preferred antibiotics due to their broad-spectrum coverage and FDA approval for bacterial keratitis treatment 2, 3
• Alternative options include levofloxacin 1.5%, which provides equivalent efficacy to ofloxacin with higher concentration 1
• For simple abrasions, chloramphenicol ointment 1% three times daily for 3 days is effective when started within 48 hours of injury 2
• Antibiotic drops should be applied four times daily until complete epithelial healing is confirmed 1, 2
• Antibiotic ointment (such as erythromycin or bacitracin) may be added at bedtime for additional protection and lubrication 2, 3, 4

Contact Lens-Related Abrasions

• Prescribe antipseudomonal fluoroquinolones immediately due to high risk of Pseudomonas keratitis 1, 5
• Do NOT patch the eye or use therapeutic contact lenses in contact lens wearers as this increases the risk of secondary bacterial keratitis 1, 2
• Avoid contact lens wear until complete healing is confirmed by a healthcare professional 1, 2

Critical Timing

• Prophylactic antibiotics are most effective when started within 24 hours of the abrasion to prevent ulceration 1, 2, 3
• Treatment should be initiated promptly after diagnosis is confirmed with fluorescein staining 1

Pain Management

• Over-the-counter oral acetaminophen or NSAIDs are reasonable for treating residual discomfort 1, 2
• Topical NSAIDs (such as diclofenac) can provide significant pain relief 6
• Cycloplegic agents are NOT routinely recommended for simple corneal abrasions, but may be considered only if substantial anterior chamber inflammation is present 1, 5

What NOT to Do

Eye Patching

• Eye patching is NOT recommended as multiple studies show it does not improve pain or healing and may actually hinder recovery 2, 3, 7, 5
• Patching specifically increases infection risk in contact lens wearers 1

Topical Steroids

• Avoid topical steroids initially as they delay healing and increase infection risk 2, 3
• Steroids should only be added after 2-3 days of antibiotic-only therapy if needed 1

Treatment Escalation for Severe Cases

Signs Requiring Immediate Escalation

• Central location or infiltrate >2mm 1
• Deep stromal involvement 1
• Presence of hypopyon 1
• Corneal stromal loss 1

Aggressive Treatment Protocol

• Initiate loading dose every 5-15 minutes, then hourly dosing 1
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases 1
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified combination therapy 1

Follow-Up and Warning Signs

Follow-Up Schedule

• Small abrasions (≤4 mm) with normal vision and resolving symptoms may not require follow-up 5
• All other patients should be reevaluated in 24 hours 5
• Regular follow-up is necessary to monitor healing and detect early signs of infection 1

Red Flags Requiring Immediate Ophthalmology Referral

• Increasing pain, purulent discharge, or corneal infiltrate 1, 2, 3
• High-velocity eye injuries or penetrating trauma 1
• Irregular pupil after trauma 1
• Eye bleeding or loss of vision after trauma 1
• Symptoms that worsen or do not improve 5

Special Considerations for Delayed Healing

Persistent Epithelial Defects

• Consider oral doxycycline, autologous serum, or amniotic membrane application 2, 3
• Bandage contact lenses may be helpful in cases of delayed healing but are not needed for simple abrasions 3
• Temporary tarsorrhaphy with botulinum toxin or suture can be helpful when blinking or eyelid closure is inadequate 3
• Nerve growth factor has shown effectiveness for neurotrophic keratopathy 3

Important Caveats

• Chronic use of prophylactic antibiotics may promote growth of resistant organisms 1, 2, 3
• Patients should be educated about signs of infection and instructed to seek prompt care if worsening occurs 1
• Do not rub the eye as this can worsen the injury and cause further corneal epithelial damage 1, 2, 3
• Taping a hard plastic eye shield or cup over the eye can prevent unintentional touching or rubbing 1