Which lubricating and antibiotic eye drops are appropriate for a corneal abrasion presenting as eye irritation (scratch sensation)?

Eye Drops for Corneal Abrasion (Scratch Sensation)

Start topical fluoroquinolone antibiotic drops (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily within 24 hours of injury to prevent bacterial keratitis, and add preservative-free lubricating drops for symptom relief. 1, 2

Immediate Treatment Algorithm

Step 1: Antibiotic Selection Based on Risk Factors

For simple traumatic abrasions (non-contact lens wearers):

• Prescribe moxifloxacin 0.5% or gatifloxacin 0.5% four times daily until complete epithelial healing 1, 2
• Alternative: levofloxacin 1.5% four times daily 1
• Fluoroquinolones are preferred because they achieve superior corneal tissue penetration and provide broad-spectrum coverage against both gram-positive and gram-negative organisms 1, 3

For contact lens-related abrasions (HIGH RISK):

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

Step 2: Add Lubricating Eye Drops

• Apply preservative-free lubricants (hyaluronate or carmellose drops) 2-4 times daily for symptom relief 4
• Consider adding antibiotic ointment at bedtime for additional lubrication and overnight protection 1
• Lubricants provide comfort but do not replace antibiotic prophylaxis 4

Step 3: Pain Management

• Prescribe over-the-counter oral acetaminophen or NSAIDs for residual discomfort 4, 1, 2
• Topical NSAIDs (ketorolac 0.5%) may reduce pain at 24-48 hours but should be used cautiously with corneal epithelial defects 5, 6

Critical Timing

Prophylactic antibiotics are most effective when started within 24 hours of the abrasion—treatment prevents ulceration specifically when initiated in this timeframe 1, 3, 2

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, 7
• Do NOT use topical corticosteroids initially—they delay healing and increase infection risk 1, 2
• Do NOT use combination steroid-antibiotic drops as initial therapy—steroids should only be added after 2-3 days of antibiotic-only therapy if bacterial infection is controlled 1, 2
• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes 1, 2
• Do NOT rub the eye—this worsens the injury and causes further corneal damage 4, 1

Follow-Up Requirements

• Re-evaluate within 24 hours to assess healing and detect early infection 1, 2
• Regular follow-up is necessary to monitor healing and detect early signs of infection 1, 3, 2

Red Flags Requiring IMMEDIATE Ophthalmology Referral (< 24 hours)

• High-velocity eye injuries (grinding, nailing, machinery) or penetrating trauma 4, 1
• Irregular pupil after trauma 4, 1
• Eye bleeding or loss of vision after trauma 4, 1
• Central infiltrate >2 mm 1, 2
• Significant stromal involvement or corneal melting 1, 2
• Corneal infiltrate with suppuration, necrosis, or feathery margins suggesting bacterial keratitis 1, 2
• Increasing pain, purulent discharge, or vision changes despite treatment 1, 2
• Persistent foreign-body sensation after initial treatment 4, 1

High-Risk Populations Requiring Enhanced Vigilance

• Contact lens wearers (especially overnight wear, overwear, inadequate disinfection, swimming/hot tub use with lenses) 1, 2
• Prior corneal surgery (refractive, cataract, glaucoma surgery, or keratoplasty) 1, 2
• Chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) 1, 2
• Immunosuppression or diabetes 1, 2

Important Caveats

• Chronic prophylactic antibiotic use promotes resistant organisms—use only for finite treatment periods during the healing phase 1, 2
• Increasing resistance of MRSA and Pseudomonas to fluoroquinolones has been documented, but fluoroquinolones remain first-line due to superior tissue penetration 1, 3
• The evidence supporting antibiotic prophylaxis is of very low certainty regarding magnitude of benefit, but antibiotics are strongly recommended because of the potentially severe consequences of untreated bacterial keratitis 3, 8
• 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