Antibiotic Management for Uncomplicated Corneal Abrasion
For uncomplicated corneal abrasions, prescribe topical fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin) four times daily as first-line prophylaxis, as these achieve superior corneal penetration compared to ointments and are FDA-approved for bacterial keratitis. 1, 2
First-Line Antibiotic Selection
Fluoroquinolones are the preferred antibiotic class because they provide broad-spectrum coverage and achieve higher tissue levels in the cornea compared to ointment formulations. 1, 2 The American Academy of Ophthalmology specifically recommends topical antibiotic drops over ointments due to superior corneal penetration. 2
Recommended Regimens:
- Moxifloxacin 0.5% or gatifloxacin drops four times daily until complete epithelial healing is confirmed 1, 2
- Levofloxacin 1.5% provides equivalent efficacy to ofloxacin with higher concentration 1
- Ofloxacin 0.3% is an alternative fluoroquinolone option 1, 3
Critical Timing:
- Initiate antibiotics within 24 hours of injury for maximum effectiveness in preventing bacterial ulceration 4, 1, 2
Alternative Antibiotic Options
Chloramphenicol:
- Chloramphenicol 1% ointment three times daily for 3 days is effective when started within 48 hours in non-contact lens wearers 5
- May be used at bedtime as adjunctive therapy to fluoroquinolone drops in less severe cases 1
Tetracycline Ointment:
Tetracycline ointment should NOT be used as monotherapy because it lacks adequate solubility and cannot penetrate the cornea sufficiently for optimal therapeutic benefit. 1 It may only be considered at bedtime as adjunctive therapy to antibiotic drops in less severe cases. 1
Risk-Stratified Approach
Standard Risk (Non-Contact Lens Wearers):
- Fluoroquinolone drops four times daily 1, 2
- Optional: antibiotic ointment at bedtime for additional lubrication 5
- Oral analgesics (acetaminophen or NSAIDs) for pain control 2, 5
High Risk (Contact Lens Wearers):
Contact lens-related abrasions require aggressive antipseudomonal coverage due to dramatically increased risk of Pseudomonas keratitis. 1, 6
- Fluoroquinolones are mandatory (preferred for antipseudomonal activity) 1
- Never patch the eye in contact lens wearers—this increases bacterial keratitis risk 1, 5
- Discontinue contact lens wear until complete healing confirmed by examination 2, 5
Important Clinical Caveats
What NOT to Do:
- Avoid pressure patching—it does not improve pain and may delay healing 4, 5, 6
- Do not use topical steroids initially—they delay healing and increase infection risk 5
- Avoid chronic prophylactic antibiotic use—this promotes resistant organisms 1, 2, 5
Factors That Delay Healing:
- Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing 4, 2
- Consider temporary tarsorrhaphy with botulinum toxin or suture if eyelid closure is inadequate 4
- Underlying conditions (diabetes, Parkinson's disease) affect healing and antibiotic selection 4
Red Flags Requiring Immediate Escalation
Refer immediately to ophthalmology if:
- Central infiltrate >2mm (requires cultures before antibiotic initiation) 1
- Increasing pain or purulent discharge suggesting infection 2, 5
- Deep stromal involvement or corneal melting 1
- Vision loss 5
- Contact lens wearer with any signs of infection 1
Evidence Quality Note
The Cochrane systematic review found very low certainty evidence regarding antibiotic prophylaxis effectiveness, with one study paradoxically showing increased infection risk with antibiotics versus placebo (RR 1.32). 7, 8 However, guideline recommendations strongly support antibiotic use based on clinical consensus and the serious consequences of untreated bacterial keratitis. 4, 1, 2 The American Academy of Ophthalmology maintains that conventional treatment involves antibiotic drops or ointment to protect against secondary bacterial infection, with antibiotic choice accounting for normal flora, contact lens wear history, and immune status. 4