What is the first‑line treatment for an uncomplicated corneal abrasion?

First-Line Treatment for Corneal Abrasion

Start topical fluoroquinolone antibiotic drops (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily within 24 hours of injury—this is the mandatory first-line treatment for all corneal abrasions to prevent bacterial keratitis and ulceration. 1, 2

Immediate Treatment Protocol

Antibiotic Therapy (Primary Treatment)

• Fluoroquinolones are the preferred first-line antibiotics because they achieve superior corneal tissue penetration and provide broad-spectrum coverage against both gram-positive and gram-negative organisms 1, 2
• Apply moxifloxacin 0.5% or gatifloxacin 0.5% drops four times daily until complete epithelial healing is confirmed 1, 3
• Prophylactic antibiotics prevent ulceration specifically when initiated within 24 hours of the abrasion 1, 2
• Consider adding antibiotic ointment at bedtime for additional lubrication and protection, though drops are superior for achieving therapeutic corneal tissue levels 1, 2

Pain Management (Adjunctive)

• Use over-the-counter oral acetaminophen or NSAIDs for pain control 1, 2
• Topical NSAIDs (if available) significantly reduce pain scores at 24 hours and 48 hours compared to control 4
• Topical anesthetics may be considered for simple abrasions only—dispense no more than 1.5-2 mL for use every 30 minutes as needed during the first 24 hours only, with any remainder discarded after 24 hours 5

Risk-Stratified Antibiotic Selection

Contact Lens-Related Abrasions (High Risk)

• Mandatory antipseudomonal fluoroquinolone coverage (moxifloxacin 0.5% or gatifloxacin 0.5%) is required due to dramatically increased Pseudomonas keratitis risk 1, 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, 3
• Advise complete avoidance of contact lens wear until healing is confirmed by examination 1, 2

Non-Contact Lens Simple Abrasions (Standard Risk)

• Fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily 1, 3
• Treatment duration continues until complete epithelial healing 1, 3

Critical Management Principles: What NOT to Do

Contraindicated Interventions

• Eye patching is contraindicated—it does not improve pain, may delay healing, and increases infection risk, especially in contact lens wearers 1, 6, 4
• Avoid topical corticosteroids initially—they delay healing and increase infection risk 1
• Do NOT use combination steroid-antibiotic drops as initial therapy 1, 3
• Steroids should only be added after 2-3 days of antibiotic-only therapy if bacterial infection is controlled 1, 3
• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes 1, 3
• Do not rub the eye as this worsens the injury and causes further corneal damage 1, 3

Important Caveats

• Tetracycline ointment lacks adequate corneal penetration and should not be used as monotherapy 3, 2
• Topical cycloplegics are not beneficial for uncomplicated corneal abrasions 6, 7
• Chronic prophylactic antibiotic use promotes resistant organisms and should only be used for finite treatment periods during the healing phase 1, 3, 2

Follow-Up Protocol

Routine Follow-Up

• Small 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, 3

Red Flags Requiring Immediate Ophthalmology Referral

• Central infiltrate >2 mm 1, 3
• Significant stromal involvement or corneal melting 1, 3
• Corneal infiltrate with suppuration, necrosis, or feathery margins suggesting bacterial keratitis 1, 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, 3, 2

High-Risk Populations Requiring Enhanced Vigilance

• Contact lens wearers (especially overnight wear, overwear, inadequate disinfection, swimming/hot tub use with lenses) 1, 3
• Prior corneal surgery (refractive, cataract, glaucoma surgery, or keratoplasty) 1, 3
• Chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) 1, 3
• Immunosuppression or diabetes 1, 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 1, 3
• Initiate loading dose every 5-15 minutes, then hourly dosing 1, 3
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases 1, 3
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified combination therapy 1, 3

Special Considerations

• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing—assess this in all patients 8, 2
• Temporary tarsorrhaphy may be helpful when blinking or lid closure is inadequate 8, 2
• For persistent epithelial defects, consider bandage contact lens or amniotic membrane 8, 2
• Increasing resistance of MRSA and Pseudomonas to fluoroquinolones has been documented, highlighting the need for judicious use 1, 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, 3, 2