What is the recommended treatment for a patient with a corneal abrasion?

Corneal Abrasion Treatment

Immediate First-Line Treatment

All patients with corneal abrasions should receive topical broad-spectrum antibiotic drops started within 24 hours of injury to prevent bacterial keratitis and ulceration. 1, 2, 3

Antibiotic Selection Algorithm

For Non-Contact Lens Wearers (Simple Abrasions)

• Fluoroquinolones are the preferred first-line agents due to broad-spectrum coverage and FDA approval for bacterial keratitis treatment 2, 3, 4
  • Moxifloxacin 0.5% or gatifloxacin: Apply 4 times daily 2, 3, 4
  • Alternative: Levofloxacin 1.5% provides equivalent efficacy with higher concentration 4
• Add antibiotic ointment at bedtime for additional protection and lubrication 2, 3
  • Chloramphenicol 1% ointment three times daily for 3 days is effective when started within 48 hours 3
  • Erythromycin ophthalmic ointment is FDA-approved for superficial ocular infections involving the cornea 5
  • Note: Ointments have limited corneal penetration and should not be used as monotherapy for severe cases 1, 4

For Contact Lens-Related Abrasions

• Mandatory antipseudomonal coverage with fluoroquinolones 1, 2, 4
• More aggressive dosing: Apply drops more frequently than standard 4 times daily 2
• Absolutely avoid eye patching or therapeutic contact lenses due to dramatically increased risk of bacterial keratitis 1, 2, 3, 4
• Prohibit contact lens wear until complete epithelial healing is confirmed 2, 3, 4

For Trauma-Related Abrasions

• Broad-spectrum topical antibiotic is mandatory to prevent both bacterial and fungal infection 1
• Fluoroquinolones remain the preferred choice 2, 3

Pain Management

• Oral analgesics are first-line for pain control: Acetaminophen or NSAIDs 2, 3, 6
• Topical NSAIDs may be considered for additional pain relief 6
• Topical anesthetics for home use: Recent consensus guidelines support dispensing commercial topical anesthetics (proparacaine, tetracaine) for simple abrasions only—up to every 30 minutes as needed during the first 24 hours, with maximum 1.5-2 mL total dispensed and remainder discarded after 24 hours 7
• Avoid topical cycloplegics for uncomplicated abrasions as evidence does not support their use 6

Critical Management Principles

What NOT to Do

• Never patch the eye: Patching does not improve pain, may delay healing, and increases infection risk especially in contact lens wearers 1, 2, 3, 4, 6, 8
• Avoid topical steroids initially: They delay healing and increase infection risk 2, 3, 4
• Do not rub the eye: This worsens injury and causes further corneal damage 2, 3, 4

Timing Considerations

• Prophylactic antibiotics are most effective when started within 24 hours of the abrasion 1, 2, 3, 4
• Treatment prevents ulceration specifically when initiated in this timeframe 1, 4

Follow-Up Protocol

Patients Who May Not Need Follow-Up

• Small abrasions (≤4 mm) 6
• Normal vision 6
• Resolving symptoms 6

Mandatory 24-Hour Re-Evaluation Required For

• All other patients not meeting above criteria 6
• Any contact lens-related abrasion 1, 2, 4
• Central or large abrasions 4

Immediate Ophthalmology Referral Indicated For

• Central infiltrate >2 mm: Requires cultures before antibiotic initiation 4
• Deep stromal involvement or corneal melting 4
• Presence of hypopyon 4
• Corneal stromal loss 4
• High-velocity or penetrating trauma 2, 4
• Irregular pupil after trauma 4
• Eye bleeding or vision loss 4
• Increasing pain, purulent discharge, or worsening symptoms despite treatment 2, 3, 4

Special Populations and Risk Factors

High-Risk Patients Requiring Enhanced Vigilance

• Contact lens wearers (especially overnight wear, overwear, inadequate disinfection, swimming/hot tub use with lenses) 4
• Prior corneal or refractive surgery 4
• Chronic ocular surface disease (epithelial defects, severe dry eye, entropion, lagophthalmos) 1
• Immunocompromised patients 4
• Diabetes or Parkinson's disease (impairs healing) 4

Treatment Escalation for Bacterial Keratitis

If the abrasion progresses to bacterial keratitis with concerning features:

• Initiate loading dose every 5-15 minutes, then hourly dosing 4
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases with central location, infiltrate >2mm, deep stromal involvement, or hypopyon 4
• Fourth-generation fluoroquinolones have demonstrated equivalent efficacy to fortified combination therapy 4

Important Caveats

• Chronic prophylactic antibiotic use promotes resistant organisms—use only for finite treatment periods 1, 2, 3, 4
• Inadequate blinking or incomplete eyelid closure delays healing 3, 4
• Patient education is essential: Instruct on infection warning signs (increasing pain, discharge, vision changes) and need for prompt ophthalmologic care if these develop 1, 2, 3, 4
• Protective eye shield (hard plastic, paper cup, or plastic cup taped over eye) prevents unintentional rubbing 4