Treatment Guidelines for Corneal Abrasion
First-Line Treatment: Topical Antibiotics
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
Antibiotic Selection Algorithm
Fluoroquinolones are the preferred first-line agents because they achieve high corneal tissue levels and provide broad-spectrum coverage against both gram-positive and gram-negative organisms. 1, 3
For simple, non-contact lens related abrasions: Use moxifloxacin 0.5% or gatifloxacin 0.5% applied four times daily until complete epithelial healing is confirmed 1, 2, 3
For contact lens-related abrasions: Mandatory antipseudomonal coverage with fluoroquinolones (moxifloxacin 0.5% or gatifloxacin 0.5%) is required due to dramatically increased risk of Pseudomonas keratitis 1, 2, 3
For trauma-related abrasions: Broad-spectrum topical antibiotic is mandatory to prevent both bacterial and fungal infection 2
Why Drops Over Ointments
Topical antibiotic eye drops are preferred over ointments because they achieve high tissue levels in the cornea. 2 Ocular ointments, including tetracycline, lack solubility and cannot penetrate into the cornea significantly for optimum therapeutic benefit. 2 However, antibiotic ointment may be used at bedtime for additional protection and lubrication in simple non-contact lens related abrasions. 1
Pain Management
Over-the-counter oral acetaminophen or NSAIDs are reasonable for treating residual discomfort. 1, 2, 3
- Topical NSAIDs (such as diclofenac) have strong evidence for reducing pain at 24 and 48 hours and decreasing oral analgesia use by 53% 4
- Pain relief is sufficient to allow approximately 80% of patients to return immediately to normal activities 5
Critical Management Principles: What NOT to Do
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, 7
Avoid topical corticosteroids initially as they delay healing and increase infection risk 1, 3
Do not rub the eye as this can worsen the injury and potentially cause further damage 1, 2
Avoid therapeutic contact lens use in contact lens-related abrasions due to increased risk of bacterial keratitis 1
Timing is Critical
Prophylactic antibiotics are most effective when started within 24 hours of the abrasion - treatment prevents ulceration specifically when initiated in this timeframe. 1, 2, 3 This has moderate evidence supporting prevention of corneal ulceration. 8, 1
Follow-Up Protocol
Small, uncomplicated abrasions (≤4 mm) with normal vision and resolving symptoms may not require follow-up 7
All other patients require re-evaluation within 24 hours to assess healing and detect early infection 1, 2, 3, 7
Regular follow-up is necessary to monitor healing and detect early signs of infection 1, 2
Red Flags Requiring Immediate Ophthalmology Referral
- Central infiltrate >2mm 2
- Significant stromal involvement or corneal melting 2
- Corneal infiltrate with suppuration, necrosis, or feathery margins suggesting bacterial keratitis 2
- High-velocity eye injuries or penetrating trauma 1, 2
- Irregular pupil after trauma 2
- Eye bleeding or loss of vision after trauma 2
- Increasing pain, purulent discharge, or vision changes 1, 2, 3
Special Populations Requiring Enhanced Vigilance
Prior corneal surgery (refractive surgery, cataract surgery, glaucoma surgery, or keratoplasty) significantly increases infection risk 2
Chronic ocular surface disease (epithelial defects, severe dry eye, entropion, lagophthalmos) requires enhanced vigilance 2
Immunosuppression or diabetes affects healing and antibiotic selection 2
Important Caveats
Chronic prophylactic antibiotic use promotes resistant organisms and should only be used for finite treatment periods during the healing phase 1, 2, 3
- Increasing resistance of MRSA and Pseudomonas to fluoroquinolones has been documented 2
Patient education is essential - instruct patients on infection warning signs (increasing pain, discharge, vision changes) and the need for prompt ophthalmologic care if these develop 1, 2, 3
Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing 1, 2
Treatment Escalation for Bacterial Keratitis
If the abrasion progresses to bacterial keratitis with central location, infiltrate >2mm, deep stromal involvement, presence of hypopyon, or corneal stromal loss: 2
- Initiate loading dose every 5-15 minutes, then hourly dosing 2
- Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases 2
- Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified combination therapy 2
- Obtain cultures before antibiotic initiation 2