Corneal Abrasion Treatment
First-Line Antibiotic Prophylaxis
All patients with corneal abrasions should receive topical broad-spectrum antibiotic drops started within 24 hours of injury to prevent bacterial keratitis and ulceration. 1
Preferred Antibiotic Selection
- Fluoroquinolone eye drops are the preferred first-line treatment due to superior corneal tissue penetration compared to ointments 1, 2
- Recommended agents include:
- Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) provide enhanced gram-positive coverage compared to earlier generations 1
Antibiotic Ointment Role
- Tetracycline or other antibiotic ointments lack adequate corneal penetration and should NOT be used as monotherapy 1
- Ointment may be added at bedtime as adjunctive therapy to drops in less severe cases 1, 2
- Neomycin-containing products inevitably cause epithelial toxicity when used for more than 2 weeks and should be avoided 3
Contact Lens-Related Abrasions (High-Risk)
Contact lens wearers require mandatory antipseudomonal coverage with fluoroquinolones due to dramatically increased risk of Pseudomonas keratitis 1, 2
Critical Management Principles for Contact Lens Wearers
- NEVER patch the eye in contact lens wearers—patching increases bacterial keratitis risk 1, 2
- NEVER place a therapeutic bandage contact lens on contact lens-related abrasions—this elevates secondary infection risk 1
- Prescribe fluoroquinolone drops with antipseudomonal activity (moxifloxacin, levofloxacin, or gatifloxacin) 1
- Instruct complete cessation of contact lens wear until healing is confirmed by ophthalmology 1
Pain Control
Topical NSAIDs provide the most effective pain relief for corneal abrasions 4
Pain Management Algorithm
- Topical NSAIDs: Reduce pain scores at 24 hours (SMD -0.69) and 48 hours (SMD -0.56), and decrease oral analgesic use by 53% compared to control 4
- Oral analgesics: Over-the-counter acetaminophen or NSAIDs are reasonable for residual discomfort 1
- Cycloplegic agents (e.g., cyclopentolate, homatropine): Consider only if substantial anterior chamber inflammation is present 1
- Not routinely indicated for simple abrasions without significant ciliary spasm 1
What NOT to Do for Pain
- Avoid topical anesthetics for ongoing pain management—existing evidence is insufficient to support their use beyond initial examination 4
- Do not use pressure patching—it does not improve pain or healing and may increase complications 1, 2, 4
Tetanus Prophylaxis
Tetanus prophylaxis should be administered according to standard wound management protocols 5
- If the abrasion resulted from contaminated trauma (soil, rust, organic matter), assess tetanus immunization status 5
- Administer tetanus toxoid if last dose was >5 years ago for contaminated wounds, or >10 years for clean wounds 5
Follow-Up Timing
Standard Follow-Up
- Non-contact lens wearers with simple abrasions: Follow up in 24-48 hours to confirm healing 1, 6
- Most uncomplicated abrasions heal within 24-48 hours 6
Accelerated Follow-Up (Next Day)
- Contact lens-related abrasions: Next-day ophthalmology follow-up mandatory 5
- Large or central abrasions (>2mm): Next-day evaluation 1
- Patients with risk factors: Diabetes, immunosuppression, prior corneal surgery, chronic ocular surface disease 1, 2
Warning Signs Requiring Immediate Return
Instruct patients to return immediately if they develop: 1, 2
- Increasing pain (suggests infection)
- Purulent discharge
- Worsening vision
- Persistent foreign-body sensation beyond 48 hours
Urgent Ophthalmology Referral Criteria
Immediate ophthalmology consultation is required for: 1, 5
Absolute Indications
- Hypopyon (layered white cells in anterior chamber)—signals severe infection 1
- Central corneal infiltrate >2mm—requires cultures before antibiotic initiation 1
- Deep stromal involvement or corneal melting 1
- High-velocity injury or suspected penetrating trauma 1, 5
- Irregular pupil after trauma (suggests globe rupture) 5
- Eye bleeding or acute vision loss 5
- Corneal infiltrate with suppuration, necrosis, or feathery margins (bacterial keratitis) 1
High-Risk Features Requiring Ophthalmology Evaluation
- Contact lens-related abrasion with any signs of infection 1
- Prior corneal surgery (refractive, cataract, glaucoma, keratoplasty) 1
- Contaminated trauma (vegetable matter, soil)—risk of fungal keratitis 1
- Immunosuppression or diabetes 1
- Abrasion not healing by 48-72 hours 1
Critical Management Pitfalls to Avoid
Never Patch the Eye
- Eye patching does not improve pain or healing and may delay recovery 1, 2, 4
- Patching in contact lens wearers specifically increases bacterial keratitis risk 1
Never Use Steroids Initially
- Do NOT combine topical corticosteroids with antibiotics as initial therapy—steroids mask infection signs and worsen outcomes in fungal or Acanthamoeba keratitis 1, 2
- Steroids may only be considered after 24-48 hours when the organism is identified and infection is responding 1
Avoid Chronic Antibiotic Use
- Limit prophylactic antibiotics to finite treatment periods (typically 5-7 days) to prevent resistant organism growth 1, 2
- Chronic use promotes MRSA and Pseudomonas resistance 1
Do Not Use Therapeutic Contact Lenses in Contact Lens Wearers
- Bandage contact lenses may be helpful for delayed healing in non-contact lens wearers, but should never be placed on contact lens-related abrasions due to elevated secondary infection risk 1
- If a bandage contact lens is used in appropriate cases, prophylactic broad-spectrum antibiotics are mandatory and the lens should not remain on the eye longer than one month 7
Special Considerations
Resistance Patterns
- MRSA accounts for ~42% of ocular isolates and frequently exhibits fluoroquinolone resistance 1
- Pseudomonas aeruginosa shows increasing fluoroquinolone resistance from 2005-2015 1
- Despite resistance concerns, fluoroquinolones remain first-line due to superior tissue penetration and clinical efficacy 1
Evidence Quality
- The 2024 American Academy of Ophthalmology Bacterial Keratitis Preferred Practice Pattern provides strong guideline evidence supporting broad-spectrum topical antibiotics for corneal abrasion prophylaxis 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 8
- Despite low-certainty trial data, the AAO recommends prophylactic antibiotics because of the potentially severe consequences of untreated bacterial keratitis and the low short-term risk of topical therapy 1