What is the appropriate management plan for a scleral abrasion?

Management of Scleral Abrasion

Immediate Treatment Protocol

For a scleral scratch or abrasion, initiate topical broad-spectrum antibiotic drops within 24 hours to prevent secondary bacterial infection, with fluoroquinolones (moxifloxacin 0.5% or gatifloxacin 0.5%) as the preferred first-line agents applied four times daily until complete healing is confirmed. 1, 2, 3

The American Academy of Ophthalmology emphasizes that prophylactic antibiotics are most effective when started within this 24-hour window, specifically preventing progression to ulceration and bacterial keratitis. 1, 2, 3

Antibiotic Selection Strategy

• Fluoroquinolones are the preferred choice because they achieve superior tissue penetration in both corneal and scleral tissue and provide broad-spectrum coverage against gram-positive and gram-negative organisms. 2, 4, 3

• The antibiotic selection must account for normal conjunctival and skin flora, the patient's immune status, and underlying conditions such as diabetes or Parkinson's disease that impair healing. 1, 4

• Add antibiotic ointment at bedtime for additional lubrication and sustained antimicrobial coverage during sleep when blinking is absent. 2, 4, 3

Pain Management

• Prescribe oral acetaminophen or NSAIDs for residual discomfort rather than relying on topical anesthetics. 2, 3

• A short course of topical NSAID drops can control discomfort, but close follow-up is mandatory due to risk of corneal melting or perforation with prolonged topical NSAID use. 1

• Consider a cycloplegic agent (such as cyclopentolate or homatropine) if substantial anterior chamber inflammation develops to decrease synechiae formation and reduce pain. 1, 2

Critical Management Principles: What NOT to Do

Never patch the eye - multiple high-quality studies demonstrate that patching does not improve pain or healing speed and may actually delay epithelialization, particularly increasing infection risk in contact lens wearers. 1, 4, 3, 5, 6

Avoid topical corticosteroids initially as they delay healing and increase infection risk. 1, 4, 3 Steroids should only be considered after 2-3 days of antibiotic-only therapy if bacterial infection is controlled, and never in suspected Acanthamoeba, Nocardia, or fungal infections where they worsen outcomes. 2, 3

Do not use combination steroid-antibiotic drops as initial therapy. 2, 3

Instruct the patient not to rub the eye as this worsens the injury and causes further tissue damage. 2, 4

High-Risk Scenarios Requiring Enhanced Vigilance

Contact Lens-Related Injuries

• Mandatory antipseudomonal fluoroquinolone coverage is required due to dramatically increased Pseudomonas keratitis risk. 2, 3
• Never patch the eye in contact lens wearers - this increases bacterial keratitis risk substantially. 1, 2, 3
• Advise complete avoidance of contact lens wear until healing is confirmed by examination. 2, 3

Other High-Risk Populations

• Prior scleral or corneal surgery (refractive, cataract, glaucoma surgery, keratoplasty) significantly increases infection risk. 2, 3
• Chronic ocular surface disease (severe dry eye, lagophthalmos, entropion) requires enhanced monitoring. 2, 3
• Immunosuppression or diabetes impairs healing and increases infection susceptibility. 1, 2, 3

Follow-Up Protocol

• Re-evaluate within 24 hours to assess healing progress and detect early signs of infection. 2, 3

• Regular follow-up is necessary to monitor for complications, particularly in high-risk patients. 2, 3

• Assess adequate blinking during waking hours and complete eyelid closure during sleep, as these are critical for healing. 1, 4, 3

Red Flags Requiring Immediate Ophthalmology Referral

Obtain emergent ophthalmology consultation for:

• Scleral involvement with deep stromal extension or melting 1, 3
• Central infiltrate greater than 2 mm 2, 3
• Corneal or scleral infiltrate with suppuration, necrosis, or feathery margins suggesting bacterial keratitis 2, 3
• High-velocity eye injuries or penetrating trauma 2, 3
• Irregular pupil after trauma 2, 3
• Eye bleeding or acute vision loss 2, 3
• Increasing pain, purulent discharge, or vision changes despite treatment 2, 4, 3
• Impending scleral perforation or descemetocele formation 1

Treatment Escalation for Severe Cases

If the abrasion progresses to bacterial keratitis with scleral extension:

• Obtain cultures before initiating treatment for central infiltrates greater than 2 mm or significant stromal involvement. 1, 2, 3

• Initiate loading dose of antibiotics every 5-15 minutes, then hourly dosing. 1, 2, 3

• Consider fortified antibiotics (tobramycin 1.5% plus cefazolin 10%) prepared by an FDA-designated compounding pharmacy for severe cases with scleral spread. 1, 2, 3

• Subconjunctival antibiotics may be helpful where there is imminent scleral spread or perforation, or when adherence to the treatment regimen is questionable. 1

• Systemic antibiotic therapy is indicated for cases of scleral or intraocular extension of infection. 1

Management of Impaired Healing

Assess Eyelid Function

• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing and must be evaluated in all cases. 1, 4, 3

Interventions for Persistent Defects

• Temporary tarsorrhaphy with botulinum toxin or suture can be employed when blinking or eyelid closure is inadequate. 1, 4, 3

• Bandage contact lens may be helpful in cases of delayed healing but is generally not needed for simple abrasions. 1, 4, 3

• Amniotic membrane (as onlay protective flap or inlay tissue substitute) should be considered for persistent epithelial defects unresponsive to standard treatment. 1, 4, 3

Advanced Therapies for Refractory Cases

• Autologous serum, cord blood tears, or platelet-rich plasma have demonstrated beneficial effects for persistent defects. 1

• Oral doxycycline has been shown to inhibit matrix metalloproteinases and may help manage persistent defects. 1, 4

Structural Support for Scleral Thinning

If progressive scleral thinning or small perforation develops:

• Tissue adhesive (cyanoacrylate) may be applied to a small area of marked thinning, which can remain in place for 6 weeks or longer if applied to a clean and compact base. 1

• The base of the defect needs to be dry for the adhesive to adhere properly. 1

• Apply the least amount of glue that will seal or support the defect. 1

• Bandage contact lenses are applied to prevent dislocation of the glue and provide comfort. 1

• Note that tissue adhesive has not been FDA-approved for ocular use but has been widely used internationally; use a sterile product to reduce infection risk. 1

• Fibrin glue should not be used with scleral perforations because it biodegrades rapidly before healing can occur. 1

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, highlighting the need for judicious antibiotic use. 1, 2

• Patient education is essential: instruct on infection warning signs (increasing pain, discharge, vision changes) and the need for prompt ophthalmologic care if these develop. 1, 2, 3

• Topical corticosteroids may be used to reduce intraocular and scleral inflammation in established cases, but intraocular pressure and cataract formation must be monitored with long-term use. 1