What are the recommended treatment and prevention strategies for a patient with a corneal abrasion?

Corneal Abrasion Management

Immediate First-Line Treatment

All patients with corneal abrasions must 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 with simple abrasions:

• Prescribe fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily until complete epithelial healing 1, 2, 3
• Fluoroquinolones are preferred because they achieve superior corneal tissue penetration and provide broad-spectrum coverage against both gram-positive and gram-negative organisms 2, 3
• Consider adding antibiotic ointment at bedtime for additional lubrication and protection 1

For contact lens-related abrasions:

• Mandatory antipseudomonal fluoroquinolone coverage (moxifloxacin 0.5% or gatifloxacin 0.5%) is required due to dramatically increased Pseudomonas keratitis risk 1, 2, 3
• Use more aggressive treatment with frequent antibiotic drops 1, 3
• Never patch the eye in contact lens wearers—this increases bacterial keratitis risk 1, 2, 3
• Advise complete avoidance of contact lens wear until healing is confirmed by examination 1, 3

The 24-hour window is critical: prophylactic antibiotics prevent ulceration specifically when initiated within this timeframe. 1, 2, 3

Pain Management

• Use over-the-counter oral acetaminophen or NSAIDs for residual discomfort 1, 2, 3
• Topical NSAIDs can also be considered for pain control 4, 5

Critical Management Principles: What NOT to Do

Eye patching is contraindicated:

• Patching does not improve pain, may delay healing, and increases infection risk, especially in contact lens wearers 1, 3, 4, 5

Avoid topical corticosteroids initially:

• Steroids delay healing and increase infection risk 1, 3
• Do NOT use combination steroid-antibiotic drops as initial therapy 2, 3
• Steroids should only be added after 2-3 days of antibiotic-only therapy if bacterial infection is controlled 2, 3
• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes 2, 3

Do not rub the eye:

• This worsens the injury and causes further corneal damage 1, 2

Follow-Up Protocol

• Patients with small (≤4 mm), uncomplicated abrasions, normal vision, and resolving symptoms may not require follow-up 5
• All other patients require re-evaluation within 24 hours to assess healing and detect early infection 2, 3, 5
• Regular follow-up is necessary to monitor healing and detect early signs of infection 1, 2

Red Flags Requiring Immediate Ophthalmology Referral

Obtain emergent ophthalmology consultation for:

• Central infiltrate >2 mm 2, 3
• Significant stromal involvement or corneal melting 2, 3
• Corneal infiltrate with suppuration, necrosis, or feathery margins suggesting bacterial keratitis 2, 3
• High-velocity eye injuries or penetrating trauma 1, 3
• Irregular pupil after trauma 1, 3
• Eye bleeding or loss of vision after trauma 1, 3
• Increasing pain, purulent discharge, or vision changes despite treatment 1, 2, 3

Special Populations Requiring Enhanced Vigilance

High-risk patients include:

• Contact lens wearers (especially overnight wear, overwear, inadequate disinfection, swimming/hot tub use with lenses) 2, 3
• Prior corneal surgery (refractive, cataract, glaucoma surgery, or keratoplasty) 2, 3
• Chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) 2, 3
• Immunosuppression or diabetes 2, 3

Treatment Escalation for Bacterial Keratitis

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

• Obtain cultures before antibiotic initiation 2, 3
• Initiate loading dose every 5-15 minutes, then hourly dosing 2, 3
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases 2, 3
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified combination therapy 2, 3

Important Caveats and Pitfalls

• 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, highlighting the need for judicious use 2, 3
• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing 2, 3
• 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

Prevention in Critical Care Settings

For patients receiving neuromuscular blocking agents or heavily sedated:

• Initiate immediate prophylactic eye care to prevent exposure keratitis 6
• Artificial-tear ointment is more effective than passive eyelid closure in preventing corneal exposure keratitis 6
• A closed-chamber method (swim goggles plus scheduled moistening) is more effective than an open-chamber method (ocular lubricants plus tape) in preventing exposure keratitis 6
• Most corneal lesions develop within the first 48 hours in at-risk patients 6