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

Treatment of Corneal Abrasion

Start topical broad-spectrum antibiotic drops within 24 hours of injury—fluoroquinolones (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily are preferred for their superior corneal penetration and antipseudomonal coverage. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, determine the mechanism of injury and risk factors:

• Contact lens-related abrasions require mandatory antipseudomonal coverage with fluoroquinolones due to high risk of Pseudomonas keratitis 1, 2
• Trauma-related abrasions need broad-spectrum coverage to prevent both bacterial and fungal infection 2
• High-risk features requiring immediate escalation: central infiltrate >2mm, deep stromal involvement, hypopyon, contact lens wear, or prior corneal surgery 2

First-Line Antibiotic Therapy

Standard Regimen for Simple Abrasions

• Fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) applied four times daily until complete epithelial healing 1, 2, 3
• These fourth-generation fluoroquinolones provide superior tissue penetration and broad-spectrum coverage including MRSA and Pseudomonas 2
• Alternative option: Chloramphenicol ointment 1% three times daily for 3 days if started within 48 hours in non-contact lens wearers 3

Adjunctive Antibiotic Ointment

• Apply antibiotic ointment at bedtime for additional protection and lubrication in simple, non-contact lens related abrasions 1, 3
• Ointments lack significant corneal penetration and should not be used as monotherapy 2
• FDA-approved options include bacitracin ointment applied 1-3 times daily 4 or erythromycin ointment 5

Contact Lens-Related Abrasions: Critical Differences

Never patch the eye in contact lens wearers—this dramatically increases bacterial keratitis risk. 1, 2, 3

• Prescribe fluoroquinolones with antipseudomonal coverage (mandatory) 2
• Use more aggressive dosing frequency than simple abrasions 1
• Absolutely avoid contact lens wear until complete healing is confirmed by examination 1, 3
• Avoid therapeutic contact lens use due to increased infection risk 1

Pain Management

• Oral acetaminophen or NSAIDs are reasonable first-line options for residual discomfort 1, 3, 6
• Topical NSAIDs (such as diclofenac) provide effective pain relief but require close follow-up within 24-48 hours due to rare serious complications 7
• Avoid topical cycloplegics for uncomplicated corneal abrasions—evidence does not support their use 6

What NOT to Do: Critical Pitfalls

• Do not patch the eye: Patching does not improve pain, may delay healing, and increases infection risk especially in contact lens wearers 1, 2, 3, 6, 8
• Do not use topical steroids initially: They delay healing and increase infection risk 1, 3
• Never use steroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes 2
• Do not rub the eye: This worsens injury and causes further corneal damage 1, 3

Protective Measures

• Tape a hard plastic eye shield, paper cup, or plastic cup over the eye to prevent unintentional rubbing 3
• Clean the affected area and apply an occlusive dressing that keeps the wound moist 1

Follow-Up Strategy

Patients Who May Not Need 24-Hour Follow-Up:

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

Mandatory Follow-Up Within 24 Hours:

• All other patients not meeting above criteria 1, 6
• Any contact lens-related abrasion 2
• Patients using topical NSAIDs (to assess for complications) 7

Red Flags Requiring Immediate Ophthalmology Referral

• Symptoms that worsen or fail to improve 6
• Corneal infiltrate or ulcer development 6
• Significant vision loss 6
• High-velocity eye injuries or penetrating trauma 1, 3
• Irregular pupil after trauma 3
• Eye bleeding after trauma 3
• Increasing pain, purulent discharge, or signs of infection 1, 2, 3

Special Populations Requiring Enhanced Vigilance

• Chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) 2
• Immunosuppression or diabetes (affects healing and antibiotic selection) 2
• Prior corneal surgery (refractive, cataract, glaucoma, or keratoplasty) 2
• Inadequate blinking or incomplete eyelid closure during sleep (significantly impairs healing) 1, 3

Treatment Escalation for Bacterial Keratitis

If the abrasion progresses to bacterial keratitis with central location, infiltrate >2mm, deep stromal involvement, hypopyon, or corneal stromal loss:

• Obtain cultures before antibiotic initiation 2
• Loading dose every 5-15 minutes, then hourly dosing 2
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) prepared by FDA-designated 503A/503B compounding pharmacy 2
• Fourth-generation fluoroquinolones have demonstrated at least equivalent efficacy to fortified combination therapy 2

Important Caveats About Antibiotic Use

• Chronic prophylactic antibiotic use promotes resistant organisms—use only for finite treatment periods 2, 3
• MRSA and Pseudomonas show increasing resistance to fluoroquinolones 2
• Maximum effectiveness requires initiation within 24 hours of injury to prevent bacterial ulceration 1, 2, 3

Patient Education Points

• Instruct patients on infection warning signs: increasing pain, discharge, vision changes 2
• Emphasize the need for prompt ophthalmologic care if symptoms worsen 1, 2, 3
• Educate about proper eye protection to prevent future injuries 8