What is the treatment for a corneal abrasion?

Treatment of Corneal Abrasion

Prescribe a topical fluoroquinolone antibiotic (moxifloxacin or gatifloxacin) four times daily for 3-5 days, combined with oral NSAIDs for pain control, and avoid eye patching entirely. 1, 2

Antibiotic Prophylaxis

First-Line Antibiotic Selection

• Fluoroquinolones are the preferred topical antibiotics due to their broad-spectrum coverage against both gram-positive and gram-negative organisms, which is critical for preventing bacterial keratitis. 1
• Moxifloxacin 0.5% or gatifloxacin drops should be applied 4 times daily, providing superior gram-positive coverage compared to older fluoroquinolones like ciprofloxacin. 1, 3
• These agents are FDA-approved for bacterial keratitis and address the most common pathogens: Staphylococcus (including methicillin-resistant strains), Streptococcus, and Pseudomonas. 1
• Start antibiotics within 24 hours for maximum prophylactic benefit to prevent ulceration. 1, 3

Alternative Antibiotic Options

• For simple, non-contact lens related abrasions in non-contact lens wearers, chloramphenicol ointment 1% three times daily for 3 days is effective when started within 48 hours. 2
• Antibiotic ointment (such as erythromycin or polymyxin B) may be used at bedtime for additional protection and lubrication as adjunctive therapy to drops. 2, 4
• Tetracycline ointment lacks adequate corneal penetration and should not be used as monotherapy, but may serve as bedtime adjunctive therapy only. 3

Contact Lens-Related Abrasions

• Topical antibiotics with antipseudomonal coverage must be prescribed to prevent acute bacterial keratitis in contact lens wearers. 5, 3, 6
• Fluoroquinolones are particularly important in this population due to Pseudomonas risk. 1
• Do not patch the eye or use therapeutic contact lenses in contact lens wearers due to significantly increased risk of bacterial keratitis. 5, 3, 2

Pain Management Algorithm

First-Line Pain Control

• Oral NSAIDs (ibuprofen) or acetaminophen are the primary pain management strategy and should be prescribed routinely. 1, 2, 6
• Topical NSAIDs (ketorolac tromethamine 0.5%) provide significantly decreased pain, photophobia, and foreign body sensation at 24 hours compared to placebo, with 53% lower oral analgesia use. 4, 7
• Topical NSAIDs reduce pain scores at both 24 hours (SMD -0.69) and 48 hours (SMD -0.56) without causing healing delays or complications. 7

Adjunctive Pain Management

• Consider a cycloplegic agent (cyclopentolate or homatropine) only if substantial anterior chamber inflammation is present to reduce ciliary spasm pain. 5, 1
• Evidence does not support routine use of topical cycloplegics for uncomplicated corneal abrasions. 6, 7

What NOT to Do

Contraindicated Interventions

• Do not patch the eye - patching does not improve pain, may delay healing, and increases infection risk in contact lens wearers. 5, 1, 2, 8, 6, 7
• Avoid topical steroids initially as they delay healing and increase infection risk; steroids should only be considered after 2-3 days of antibiotic-only therapy and only when infection is responding. 5, 1, 2
• Do not use therapeutic contact lenses in the acute phase due to increased bacterial keratitis risk. 1
• Limit prophylactic antibiotics to 3-5 days unless infection develops, as chronic use promotes resistant organisms. 1, 2

Patient Instructions

• Do not rub the eye as this worsens injury and causes further corneal epithelial damage. 1, 2
• Avoid contact lens wear until complete healing is confirmed by a healthcare professional. 1, 2
• Consider taping a hard plastic eye shield or cup over the eye to prevent unintentional touching. 1

Follow-Up and Warning Signs

Routine Follow-Up

• Patients with small (≤4 mm), uncomplicated abrasions, normal vision, and resolving symptoms may not require follow-up. 6
• All other patients should be reevaluated in 24 hours to assess healing and detect early infection. 3, 6

Red Flags Requiring Immediate Return

• Increasing pain after initial improvement suggests developing infection. 1, 2
• Purulent discharge or corneal infiltrate indicates bacterial keratitis. 1, 2
• Vision loss or irregular pupil may indicate penetrating injury or complications. 1
• Persistent foreign-body sensation beyond expected healing time. 1

Escalation Criteria

Indications for Aggressive Treatment

• Central location or infiltrate >2 mm requires immediate escalation with loading doses every 5-15 minutes, then hourly dosing. 3
• Deep stromal involvement, presence of hypopyon, or corneal stromal loss necessitates fortified antibiotics (tobramycin 1.5% + cefazolin 10%). 3
• Large abrasions (>2 mm) or those with significant stromal involvement require more frequent fluoroquinolone dosing initially. 1

Immediate Ophthalmology Referral Required For:

• Symptoms that do not improve or worsen within 48 hours. 1, 6
• Corneal infiltrate or ulcer development. 6
• Significant vision loss. 6
• Any suspicion for penetrating eye injury. 9, 6
• High-velocity eye injuries or eye bleeding after trauma. 1

Common Pitfalls to Avoid

• Missing contact lens history increases Pseudomonas risk - specifically ask about lens wear to guide antibiotic selection. 1
• Inadequate blinking or incomplete eyelid closure delays healing - assess lid function in all patients. 1, 2
• Assuming all abrasions are benign - unknown sources may harbor atypical organisms requiring cultures if not improving by 48 hours. 1
• Failing to remove foreign bodies before treatment - carefully examine and remove if present. 8, 6
• Using combination steroid-antibiotic drops as initial therapy - steroids should never be used initially. 3, 2