What is the recommended management for a corneal abrasion presenting with ocular pain, tearing, photophobia, and a visible epithelial defect after trauma?

Management of Corneal Abrasions

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

• Fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) are the preferred first-line antibiotics due to superior corneal tissue penetration and broad-spectrum coverage against both gram-positive and gram-negative organisms 1, 2, 3

• Apply fluoroquinolone drops four times daily until complete epithelial healing is confirmed 1, 2

• Antibiotic drops are preferred over ointments because drops achieve higher tissue levels in the cornea 2, 3

• Consider adding antibiotic ointment at bedtime for additional lubrication and protection in less severe cases 1, 3

Risk-Stratified Antibiotic Selection

Contact Lens-Related Abrasions (High Risk)

Contact lens wearers require mandatory antipseudomonal fluoroquinolone coverage due to dramatically increased Pseudomonas keratitis risk 1, 2

• Use more aggressive treatment with frequent fluoroquinolone 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 by examination 1, 2

Simple Non-Contact Lens Abrasions

• Fluoroquinolone drops (moxifloxacin 0.5% or gatifloxacin 0.5%) four times daily are recommended 1, 2

• Prophylactic antibiotics are most effective when started within 24 hours of the abrasion 1, 2

Pain Management

• Use over-the-counter oral acetaminophen or NSAIDs for residual discomfort 1, 2

• Topical NSAIDs (ketorolac tromethamine 0.5%) can provide increased patient comfort without clinical adverse effects when used as adjunctive therapy 4

Critical Management Principles: What NOT to Do

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

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

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

• Steroids should only be added after 48 hours of antibiotic-only therapy if bacterial infection is identified and responding to treatment 6, 1

• Never use corticosteroids in suspected Acanthamoeba, Nocardia, or fungal infections—they worsen outcomes 6, 1

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

Follow-Up Protocol

• All patients require re-evaluation within 24 hours to assess healing and detect early infection 1, 3

• Regular follow-up is necessary to monitor healing and detect early signs of infection 1, 3

Red Flags Requiring Immediate Ophthalmology Referral

Obtain emergent ophthalmology consultation for:

• 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

• Irregular pupil after trauma 1

• Eye bleeding or loss of vision after trauma 1

• Increasing pain, purulent discharge, or vision changes despite treatment 1

Special Populations Requiring Enhanced Vigilance

High-risk patients include:

• Contact lens wearers (especially overnight wear, overwear, inadequate disinfection, swimming/hot tub use with lenses) 1

• Those with prior corneal surgery (refractive, cataract, glaucoma surgery, or keratoplasty) 1

• Those with chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) 1

• Those with 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 from 2005-2015, highlighting the need for judicious use 6, 1

• Inadequate blinking or incomplete eyelid closure during sleep significantly impairs healing 1, 2

• 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

Evidence Quality Considerations

While the 2024 American Academy of Ophthalmology Bacterial Keratitis Preferred Practice Pattern provides strong guideline evidence supporting broad-spectrum topical antibiotics for corneal abrasion prophylaxis 6, 1, a 2025 Cochrane systematic review reported very low certainty evidence regarding the magnitude of benefit in preventing infection or accelerating healing 7. Despite this research uncertainty, the AAO strongly recommends prophylactic antibiotics because of the potentially severe consequences of untreated bacterial keratitis and the low short-term risk of topical therapy 6, 1.