What is the recommended management for a corneal abrasion, including irrigation, prophylactic topical antibiotic drops, oral analgesics, cycloplegic drops, avoidance of patching, follow‑up timing, and criteria for urgent referral?

Corneal Abrasion Management

Immediate First-Line Treatment

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, 2

Standard Antibiotic Regimen for Non-Contact Lens Wearers

• Prescribe fluoroquinolone drops (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily until complete epithelial healing is confirmed. 1, 3, 2
• Fluoroquinolones are preferred because they achieve superior corneal tissue penetration compared to ointments and provide broad-spectrum coverage against both gram-positive and gram-negative organisms. 1, 2
• Consider adding antibiotic ointment at bedtime for additional lubrication and overnight protection, though ointments lack the corneal penetration of drops. 4, 1, 2
• The 24-hour window is critical—prophylactic antibiotics prevent ulceration specifically when initiated within this timeframe. 4, 1

High-Risk Contact Lens Wearers: Mandatory Protocol Changes

Contact lens-related abrasions require mandatory antipseudomonal fluoroquinolone coverage (moxifloxacin 0.5% or gatifloxacin 0.5%) due to dramatically elevated Pseudomonas keratitis risk. 1, 2, 5

• Use more aggressive dosing with fluoroquinolone drops every 2-4 hours while awake for the first 24-48 hours. 2, 5
• Never patch the eye in contact lens wearers—patching increases bacterial keratitis risk and does not improve pain. 4, 1, 2
• Never place a bandage contact lens on contact lens-related abrasions—this elevates secondary bacterial keratitis risk. 4
• Mandate complete avoidance of contact lens wear until healing is confirmed by slit-lamp examination. 1, 2
• Risk factors amplifying infection probability include overnight wear, overwear beyond FDA-approved replacement schedules, inadequate disinfection, contaminated storage cases, and swimming/hot tub use while wearing lenses. 1

Adjunctive Therapies

Pain Management

• Prescribe oral acetaminophen or NSAIDs (ibuprofen 400-600 mg every 6 hours) for residual discomfort. 1, 2
• Topical NSAIDs (e.g., ketorolac 0.5%) significantly reduce pain scores at 24 hours (standardized mean difference -0.69) and 48 hours (standardized mean difference -0.56) and decrease oral analgesia use by 53% compared to placebo. 6
• Topical anesthetics should not be prescribed for home use due to risk of delayed healing and corneal toxicity, though a single dose in the emergency department for examination is acceptable. 6

Cycloplegic Agents

• Consider cycloplegic drops (cyclopentolate 1% or homatropine 5%) if substantial anterior chamber inflammation or photophobia is present to decrease ciliary spasm pain and prevent synechiae formation. 4, 1
• Cycloplegics are indicated when the abrasion is large (>4 mm) or when significant iritis accompanies the injury. 4

Irrigation

• Irrigate the eye with sterile saline or lactated Ringer's solution if foreign body contamination or chemical exposure is suspected before applying fluorescein. 2
• Evert the upper eyelid to identify and remove retained foreign bodies that can perpetuate the abrasion. 7

Critical Management Principles: What NOT to Do

Eye patching is contraindicated—it does not improve pain, may delay healing by 24-48 hours, and increases infection risk, especially in contact lens wearers. 1, 3, 2, 7, 6

• Avoid topical corticosteroids initially—they delay epithelial healing and increase infection risk. 3, 2
• Never use combination steroid-antibiotic drops as initial therapy. 1, 2
• Steroids may only be considered after 2-3 days of antibiotic-only therapy if bacterial infection is controlled and inflammation persists. 1
• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes and can lead to corneal perforation. 1, 2
• Do not rub the eye—this worsens the injury and causes further corneal epithelial damage. 1, 3
• Instruct patients to tape a hard plastic eye shield, paper cup, or protective eyewear over the eye to prevent unintentional touching. 1

Follow-Up Protocol

• Re-evaluate all patients within 24 hours to assess healing progress and detect early signs of infection. 1, 2, 5
• At 24-hour follow-up, perform fluorescein staining to confirm epithelial healing; if the abrasion persists, continue antibiotics and reassess at 48 hours. 5
• Most simple corneal abrasions heal within 24-72 hours. 7, 8
• If healing is incomplete at 48-72 hours, consider underlying conditions impairing epithelial regeneration (diabetes, dry eye, recurrent erosion syndrome). 1, 2

Red Flags Requiring Immediate Ophthalmology Referral

Obtain emergent ophthalmology consultation for any of the following findings: 1, 2

• Central corneal infiltrate >2 mm with or without suppuration, necrosis, or feathery margins suggesting bacterial keratitis 1, 2
• Significant stromal involvement, corneal melting, or stromal loss 1, 2
• Presence of hypopyon (layered white cells in the anterior chamber) 1, 2
• High-velocity eye injuries or penetrating trauma 1, 2, 8
• Irregular pupil after trauma suggesting globe rupture or iris damage 1, 2
• Eye bleeding (hyphema) or acute vision loss after trauma 1, 2
• Increasing pain, purulent discharge, or vision deterioration despite 24 hours of antibiotic therapy 1, 2
• Corneal abrasion in the setting of herpes simplex or varicella-zoster infection (dendritic ulcer pattern on fluorescein staining) 8

Special Populations Requiring Enhanced Vigilance

High-risk patients who warrant closer follow-up and consideration for ophthalmology consultation include: 1, 2

• Contact lens wearers (especially overnight or extended wear) 1, 2
• Patients with prior corneal surgery (LASIK, PRK, cataract surgery, glaucoma surgery, or keratoplasty) 1, 2
• Immunosuppressed patients (HIV, chemotherapy, chronic corticosteroid use) 1, 2
• Diabetic patients (impaired epithelial healing) 1, 2
• Patients with chronic ocular surface disease (severe dry eye, entropion, lagophthalmos, exposure keratopathy) 1, 2
• Contaminated trauma (organic material, soil, vegetable matter suggesting fungal risk) 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: 1, 2

• Obtain corneal cultures and smears before initiating intensive antibiotic therapy. 1, 2
• Initiate loading dose of fluoroquinolone drops every 5-15 minutes for the first hour, then hourly dosing around the clock. 4, 1, 2
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) prepared by an FDA-designated 503A/503B compounding pharmacy for severe cases with hypopyon or large infiltrates. 4, 1
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified combination therapy and offer superior gram-positive coverage. 4, 1

Management of Delayed Healing

If the abrasion fails to heal within 72 hours despite appropriate antibiotic therapy: 3, 2

• Assess for inadequate blinking or incomplete eyelid closure during sleep, which significantly impairs corneal epithelial healing. 3, 2
• Consider temporary tarsorrhaphy (botulinum toxin or suture) to enhance eyelid closure when blinking is insufficient. 3, 2
• For persistent epithelial defects unresponsive to standard treatment, consider oral doxycycline (50-100 mg daily for anti-inflammatory and matrix metalloproteinase inhibition), autologous serum drops (20% concentration), or amniotic membrane application. 3, 2
• Bandage contact lenses may be helpful in cases of delayed healing but are generally not needed for simple abrasions and should never be used in contact lens-related abrasions. 3, 2

Important Caveats and Resistance Patterns

• Chronic prophylactic antibiotic use promotes resistant organisms (particularly MRSA and Pseudomonas) and should only be used for finite treatment periods during the healing phase. 1, 2
• Methicillin-resistant Staphylococcus aureus (MRSA) accounts for approximately 42% of ocular isolates and frequently exhibits concurrent fluoroquinolone resistance; nevertheless, fluoroquinolones remain first-line due to superior tissue penetration and clinical efficacy. 4, 1
• Increasing resistance of MRSA and Pseudomonas to fluoroquinolones has been documented from 2005-2015, highlighting the need for judicious antibiotic use and close follow-up. 1, 2

Evidence Quality and Guideline Strength

• The 2019 American Academy of Ophthalmology Bacterial Keratitis Preferred Practice Pattern provides strong guideline evidence supporting broad-spectrum topical antibiotics for corneal abrasion prophylaxis. 4, 1
• A 2025 Cochrane systematic review reported very low certainty evidence regarding the magnitude of benefit of prophylactic antibiotics in preventing infection or accelerating healing. 9
• Despite low-certainty trial data, the AAO recommends prophylactic antibiotics because of the potentially severe consequences of untreated bacterial keratitis (vision loss, corneal scarring, perforation) and the low short-term risk of topical therapy. 1

Patient Education

Instruct patients on infection warning signs requiring immediate return: 1, 2

• Increasing pain after initial improvement 1, 2
• Purulent discharge (thick yellow or green drainage) 1, 2
• Vision changes or worsening blurriness 1, 2
• Persistent foreign-body sensation beyond 72 hours 1
• Development of white spot on the cornea (infiltrate) 1