What is the appropriate treatment for a corneal abrasion?

Treatment for Corneal Abrasion

Immediate Antibiotic Prophylaxis

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

First-Line Antibiotic Selection

• Fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) are the preferred first-line agents for non-contact lens wearers with simple abrasions, prescribed four times daily until complete epithelial healing is confirmed 1, 2

• Fluoroquinolones are superior because they achieve excellent corneal tissue penetration and provide broad-spectrum coverage against both gram-positive and gram-negative organisms 1

• Consider adding antibiotic ointment (such as tetracycline) at bedtime for additional lubrication and protection, though ointments alone are insufficient as monotherapy due to poor corneal penetration 1, 2

• Levofloxacin 1.5% is an effective alternative, offering equivalent efficacy to other fluoroquinolones with the advantage of higher concentration 1

Contact Lens-Related Abrasions: Mandatory Enhanced Coverage

• Contact lens wearers require mandatory antipseudomonal fluoroquinolone coverage (moxifloxacin 0.5% or gatifloxacin 0.5%) due to dramatically increased Pseudomonas keratitis risk 1, 3

• Use more aggressive treatment with frequent antibiotic drops for contact lens-related abrasions 1

• 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

Pain Management

• Use over-the-counter oral acetaminophen or NSAIDs for residual discomfort 1, 3

• Topical NSAIDs may also be considered for symptomatic relief 4

Critical Management Principles: What NOT to Do

• Eye patching is contraindicated—it does not improve pain, may delay healing, and increases infection risk, especially in contact lens wearers 1, 3, 4, 5

• Avoid topical corticosteroids initially as they delay healing and increase infection risk 1, 3

• Do NOT use combination steroid-antibiotic drops as initial therapy 1

• Steroids should only be added after 2-3 days of antibiotic-only therapy if bacterial infection is controlled 1

• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes 1

• Do not rub the eye as this worsens the injury and causes further corneal damage 1, 3

Follow-Up Protocol

• All patients require re-evaluation within 24 hours to assess healing and detect early infection 1, 6

• Regular follow-up is necessary to monitor healing and detect early signs of infection 1, 2

Red Flags Requiring Immediate Ophthalmology Referral

• Central infiltrate >2 mm 1
• Significant stromal involvement or corneal melting 1
• Corneal infiltrate with suppuration, necrosis, or feathery margins suggesting bacterial keratitis 1
• High-velocity eye injuries or penetrating trauma 1, 3, 6
• 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

High-Risk Populations Requiring Enhanced Vigilance

• Contact lens wearers (especially overnight wear, overwear, inadequate disinfection, swimming/hot tub use with lenses) 1
• Prior corneal surgery (refractive, cataract, glaucoma surgery, or keratoplasty) 1
• Chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) 1, 3
• Immunosuppression or diabetes 1

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
• Initiate loading dose every 5-15 minutes, then hourly dosing 1
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases 1
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified combination therapy 1

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, 3

• Increasing resistance of MRSA and Pseudomonas to fluoroquinolones has been documented, highlighting the need for judicious use 1

• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing 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

Evidence Quality Note

While the 2025 Cochrane review found very low certainty evidence regarding the magnitude of benefit of prophylactic antibiotics 7, 8, the American Academy of Ophthalmology maintains a strong recommendation for antibiotic prophylaxis due to the potentially severe consequences of untreated bacterial keratitis and the low short-term risk of topical therapy 1. In clinical practice, the standard of care remains topical fluoroquinolone prophylaxis initiated within 24 hours of injury.

Management of Delayed Healing

• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs corneal epithelial healing; evaluate eyelid closure in all patients with delayed healing 1, 3

• Temporary tarsorrhaphy can be employed to enhance eyelid closure and promote healing when blinking is insufficient 1, 3

• For corneal abrasions that fail to re-epithelialize, placement of a bandage contact lens or application of an amniotic membrane graft should be considered to support epithelial regeneration 1, 3