What is the recommended treatment for a patient with a corneal abrasion, considering potential underlying conditions such as a history of eye problems or immunosuppression?

Corneal Abrasion Treatment

Primary Recommendation

Prescribe topical fluoroquinolone antibiotic drops (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily, initiated within 24 hours of injury, and avoid eye patching. 1, 2, 3

Treatment Algorithm

Standard (Non-Contact Lens) Corneal Abrasion

Antibiotic Selection:

• Fluoroquinolones are the preferred first-line agents due to broad-spectrum coverage and FDA approval for bacterial keratitis treatment 1, 2, 3
• Moxifloxacin 0.5% or gatifloxacin (fourth-generation) are optimal choices 1, 3
• Levofloxacin 1.5% provides equivalent efficacy to ofloxacin with higher concentration 1
• Apply four times daily until complete epithelial healing is confirmed 1, 2
• Consider antibiotic ointment (erythromycin or bacitracin) at bedtime for additional lubrication and protection 2, 3, 4, 5

Pain Management:

• Over-the-counter oral acetaminophen or NSAIDs for residual discomfort 1, 2
• Topical NSAIDs may be considered for pain control 6
• Do not use topical cycloplegics for uncomplicated abrasions (evidence does not support benefit) 6

What NOT to Do:

• Never patch the eye - patching does not improve pain and may delay healing 2, 3, 7
• Avoid topical steroids initially - they delay healing and increase infection risk 2, 3

Contact Lens-Related Corneal Abrasion (HIGH RISK)

This requires more aggressive management due to Pseudomonas risk:

• Mandatory antipseudomonal fluoroquinolone coverage (moxifloxacin, gatifloxacin, or levofloxacin) 1, 6
• Apply more frequently than standard abrasions 1
• Never patch the eye or use therapeutic contact lens - dramatically increases bacterial keratitis risk 1, 2
• Discontinue all contact lens wear until complete healing confirmed 1, 2
• Contact lens wear (especially overnight wear, overwear, inadequate disinfection, or swimming while wearing lenses) dramatically increases infection risk 1

High-Risk Patients Requiring Escalation

Immediate ophthalmology referral and cultures if:

• Central infiltrate >2mm 1
• Deep stromal involvement or corneal melting 1
• Significant anterior chamber inflammation 1
• Immunosuppression (diabetes, prior corneal surgery, refractive surgery) 1, 3
• Signs of bacterial keratitis: purulent discharge, corneal infiltrate with suppuration, necrosis, or feathery margins 1, 2

For severe/central keratitis:

• Initiate loading dose every 5-15 minutes, then hourly dosing 1
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) prepared by FDA-designated compounding pharmacy 1
• Fourth-generation fluoroquinolones have equivalent efficacy to fortified combination therapy 1

Critical Timing

Prophylactic antibiotics prevent ulceration when started within 24 hours of the abrasion - this is the therapeutic window for maximum effectiveness 1, 2

Follow-Up Strategy

• Small abrasions (≤4mm) with normal vision and resolving symptoms may not require follow-up 6
• All other patients require reevaluation in 24 hours to monitor healing and detect early infection 1, 6
• Regular follow-up is necessary to detect early signs of infection 1, 2

Warning Signs Requiring Immediate Return

Educate patients to seek immediate care for:

• Increasing pain 1, 2, 3
• Purulent discharge 1, 2, 3
• Worsening vision 1
• Persistent foreign-body sensation 1
• Development of corneal infiltrate 1, 2, 3

Important Caveats

Protective Measures:

• Do not rub the eye - worsens injury and causes further corneal epithelial damage 1, 2, 3
• Tape a hard plastic eye shield or cup over the eye to prevent unintentional touching 1

Antibiotic Resistance Concerns:

• Chronic prophylactic antibiotic use promotes resistant organisms 1, 2, 3
• MRSA and Pseudomonas show increasing fluoroquinolone resistance 1

Steroid Timing:

• Never use combination steroid-antibiotic drops as initial therapy 1
• Steroids should only be added after 2-3 days of antibiotic-only therapy when organism is identified and infection is responding 1
• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections - they worsen outcomes 1

Healing Factors:

• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing 1, 3
• Underlying conditions (diabetes, Parkinson's disease) affect healing and antibiotic selection 1, 3

Special Populations

Immunosuppressed or Diabetic Patients:

• Consider more aggressive initial treatment 1, 3
• Lower threshold for ophthalmology referral 1
• Account for immune status when selecting antibiotics 3

Patients with Prior Ocular Surgery:

• Prior corneal surgery, refractive surgery, cataract surgery, glaucoma surgery, or keratoplasty significantly increases infection risk 1
• Requires closer monitoring and lower threshold for escalation 1