What is the recommended treatment for a corneal abrasion?

Treatment for Corneal Abrasion

Start topical fluoroquinolone antibiotic drops (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily within 24 hours of injury to prevent bacterial keratitis and ulceration. 1, 2, 3

Antibiotic Selection and Rationale

Fluoroquinolone drops are the preferred first-line treatment because they achieve superior corneal tissue penetration compared to ointments, which lack adequate solubility to penetrate the cornea effectively. 1, 3 The American Academy of Ophthalmology specifically recommends topical antibiotic drops over ointments for this reason. 1, 3

Standard Dosing Protocol

• Moxifloxacin 0.5% or gatifloxacin 0.5%: one drop four times daily until complete epithelial healing is confirmed 1, 2, 3
• Levofloxacin 1.5%: four times daily (provides equivalent efficacy with higher concentration) 1
• Critical timing: Prophylactic antibiotics prevent ulceration specifically when initiated within 24 hours of the abrasion 1, 2, 3

Role of Tetracycline Ointment

Tetracycline ointment should not be used as monotherapy because it cannot penetrate the cornea significantly for optimal therapeutic benefit. 1, 3 It may be added at bedtime as adjunctive therapy to antibiotic drops for additional lubrication in less severe cases, but drops remain the primary treatment. 1, 2

Risk-Stratified Treatment Algorithm

Simple Non-Contact Lens Abrasions

• Fluoroquinolone drops four times daily 1, 2, 3
• Over-the-counter oral acetaminophen or NSAIDs for pain control 2, 3, 4
• Optional: antibiotic ointment at bedtime for additional lubrication 2

Contact Lens-Related Abrasions (HIGH RISK)

Mandatory antipseudomonal fluoroquinolone coverage is required due to dramatically increased Pseudomonas keratitis risk. 1, 2, 3

• More aggressive treatment with frequent fluoroquinolone drops 1, 2
• Complete avoidance of contact lens wear until healing is confirmed by examination 1, 2, 3
• Never patch the eye in contact lens wearers—this increases bacterial keratitis risk 1, 2, 3
• Never use therapeutic contact lenses on contact lens-related abrasions due to elevated secondary bacterial keratitis risk 1

Critical Management Principles: What NOT to Do

Eye Patching is Contraindicated

Do not patch the eye under any circumstances. Patching does not improve pain, may delay healing, and increases infection risk, especially in contact lens wearers. 1, 2, 5, 4, 6 Multiple well-designed studies demonstrate that patching does not help and may hinder healing. 5

Steroid Use is Dangerous Initially

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

Other Contraindications

• Do not rub the eye—this worsens the injury and causes further corneal damage 1, 2
• Topical cycloplegics are not beneficial for uncomplicated corneal abrasions 5, 6

Pain Management

Topical NSAIDs demonstrate strong evidence for pain reduction, with significantly reduced pain scores at 24 hours and 48 hours, plus 53% lower oral analgesia use compared to control. 4 However, the American Academy of Ophthalmology recommends over-the-counter oral acetaminophen or NSAIDs as reasonable options for treating residual discomfort. 1, 2, 3

Follow-Up Protocol

• Small abrasions (≤4 mm) with normal vision and resolving symptoms may not require follow-up 6
• All other patients require re-evaluation within 24 hours to assess healing and detect early infection 2, 6
• 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: 1, 2

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

High-Risk Populations Requiring Enhanced Vigilance

The following patients have dramatically increased infection risk and require closer monitoring: 1, 2

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

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: 1, 2

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

Management of Delayed Healing

Inadequate blinking or incomplete eyelid closure during sleep significantly impairs corneal epithelial healing. 2, 3 For persistent or recurrent defects, consider: 3

• Temporary tarsorrhaphy to enhance eyelid closure
• Bandage contact lens (only in non-contact lens wearers)
• Amniotic membrane application
• Autologous serum drops
• Cenegermin (nerve growth factor) 20 μg/ml for neurotrophic keratopathy

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 Methicillin-resistant Staphylococcus aureus (MRSA) accounts for roughly 42% of ocular isolates and frequently exhibits concurrent fluoroquinolone resistance, though fluoroquinolones remain first-line due to superior tissue penetration. 1 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