Corneal Abrasion: Diagnosis and Treatment
Diagnosis
Confirm the diagnosis with fluorescein staining under cobalt-blue filtered light, where the abrasion appears green, and carefully examine for retained foreign bodies that must be removed. 1, 2
Key History Elements
- Mechanism of injury: Contact lens wear (highest risk factor in the U.S.), trauma, or foreign body exposure 3, 2
- Timing: Document when injury occurred—antibiotics are most effective when started within 24 hours 1, 4
- Symptoms: Foreign body sensation, tearing, photophobia, pain worsened by blinking 5, 2
- Risk factors: Contact lens wear (especially overnight), prior corneal surgery, immunosuppression, diabetes 3, 1
Physical Examination Findings
- Fluorescein staining: Epithelial defect appears yellow under normal light, green under cobalt-blue light 5, 2
- Exclude serious pathology: Check for irregular pupil, penetrating injury, corneal infiltrate >2mm, hypopyon, or deep stromal involvement 1, 6
- Foreign body removal: Mandatory if present before initiating treatment 2
Treatment
All patients with corneal abrasions should receive topical fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily, started within 24 hours of injury, to prevent bacterial keratitis and ulceration. 1, 6, 4
First-Line Antibiotic Therapy
Fluoroquinolones are the preferred first-line agents because they achieve superior corneal tissue penetration compared to ointments and provide broad-spectrum coverage against both gram-positive and gram-negative organisms. 1, 6, 4
- Standard regimen: Moxifloxacin 0.5% or gatifloxacin 0.5% four times daily until complete epithelial healing 1, 6
- Avoid tetracycline ointment as monotherapy: Ointments lack adequate corneal penetration for optimal therapeutic benefit 1, 4
- Tetracycline ointment role: May be used at bedtime as adjunctive therapy to drops in less severe cases, but never as sole treatment 1
Risk-Stratified Treatment Algorithm
Low-Risk Abrasions (Non-Contact Lens Related)
- Fluoroquinolone drops four times daily 1, 4
- Oral acetaminophen or NSAIDs for pain 1, 6
- No eye patching: Patching does not improve pain and may delay healing 1, 4, 5
High-Risk Abrasions (Contact Lens Related)
Any contact lens wearer with corneal abrasion requires mandatory antipseudomonal coverage with fluoroquinolones due to dramatically increased risk of Pseudomonas keratitis. 1, 6, 2
- Never patch the eye in contact lens wearers: Patching increases bacterial keratitis risk 1, 6
- Complete contact lens discontinuation until healing confirmed by examination 1, 6
- More aggressive dosing may be needed: Consider more frequent application in high-risk cases 1
Trauma-Related Abrasions
- Broad-spectrum topical antibiotic mandatory to prevent both bacterial and fungal infection 1
- Tetanus prophylaxis if indicated 7
Critical Management Principles
What NOT to Do
Never use topical corticosteroids initially—they delay healing and increase infection risk. 6, 4
- Do NOT use combination steroid-antibiotic drops as initial therapy: Steroids should only be added after 2-3 days of antibiotic-only therapy if bacterial infection is controlled 1, 6
- Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections: They worsen outcomes 1, 6
- Avoid eye patching: Does not improve pain and may delay healing 1, 4, 5, 2
Timing Considerations
Prophylactic antibiotics are most effective when started within 24 hours of the abrasion—this window maximizes prevention of bacterial ulceration. 1, 6, 4
- Most abrasions heal in 24-72 hours 5
- Healing may be delayed 5-7 days with underlying corneal pathology 4
Follow-Up Protocol
Routine Follow-Up
- Small abrasions (≤4mm) with normal vision and resolving symptoms: May not require follow-up 2
- All other patients: Re-evaluate within 24 hours to assess healing and detect early infection 1, 6, 2
Red Flags Requiring Immediate Ophthalmology Referral
- Central infiltrate >2mm: Requires immediate cultures before antibiotic initiation 1
- Increasing pain, purulent discharge, or vision loss 1, 6, 4
- Corneal infiltrate with suppuration, necrosis, or feathery margins 1
- Deep stromal involvement or corneal melting 1
- Irregular pupil or penetrating injury 1, 2
Special Populations and Considerations
High-Risk Patients Requiring Enhanced Vigilance
- Prior corneal surgery (refractive, cataract, glaucoma, keratoplasty): Significantly increases infection risk 1
- Chronic ocular surface disease: Severe dry eye, entropion, lagophthalmos 1
- Immunosuppression or diabetes: Affects healing and antibiotic selection 4
Delayed Healing Management
If inadequate blinking or incomplete eyelid closure during sleep is present, healing will be delayed—consider temporary tarsorrhaphy. 4
- Persistent or recurrent defects: Consider bandage contact lens, amniotic membrane, autologous serum drops, or cenegermin for neurotrophic keratopathy 4
Important Caveats
Antibiotic Resistance Concerns
Chronic prophylactic antibiotic use promotes resistant organisms—limit treatment duration to the healing period only. 1, 6, 4
- Increasing resistance of MRSA and Pseudomonas to fluoroquinolones documented from 2005-2015 3
Patient Education
Instruct patients on infection warning signs (increasing pain, discharge, vision changes) and emphasize the need for prompt ophthalmologic care if these develop. 1, 6