What is the recommended management of an uncomplicated corneal abrasion in a healthy adult?

Management of Uncomplicated Corneal Abrasion in Healthy Adults

For an uncomplicated corneal abrasion in a healthy adult, prescribe topical fluoroquinolone drops (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily until epithelial healing is confirmed, initiated within 24 hours of injury to prevent bacterial keratitis. 1

Immediate Assessment and Diagnosis

• Measure visual acuity with current correction before any other examination 1
• Perform fluorescein staining under cobalt-blue light to confirm the epithelial defect and document size, shape, depth, and location (central versus peripheral) 1, 2
• Examine eyelid margins and lashes for retained foreign bodies, especially under the upper lid; a linear-shaped abrasion suggests a retained foreign body 1
• Avoid contact tonometry when corneal trauma is suspected 1

First-Line Antibiotic Prophylaxis

Antibiotic Selection

• Fluoroquinolone eye drops are strongly preferred over ointments because they achieve superior corneal tissue penetration 1
• Moxifloxacin 0.5% (one drop three times daily for 7 days) or levofloxacin 1.5% (one drop four times daily until healing) are the recommended first-line agents 1
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) provide enhanced gram-positive coverage compared to earlier generations 1

Critical Timing

• Initiate antibiotics within 24 hours of injury for maximum effectiveness in preventing bacterial ulceration 1
• Prophylactic antibiotics prevent ulceration specifically when started in this timeframe 1

Evidence Quality Caveat

While the American Academy of Ophthalmology provides strong guideline recommendations for prophylactic antibiotics, a 2025 Cochrane review found very low certainty evidence regarding the magnitude of benefit in preventing infection or accelerating healing 3. However, the AAO maintains the recommendation due to potentially severe consequences of untreated bacterial keratitis and low short-term risk of topical therapy 1.

Pain Management

• Topical NSAIDs significantly reduce pain at 24 hours and 48 hours and decrease oral analgesia use by 53% compared to control 4
• Over-the-counter oral acetaminophen or NSAIDs are reasonable for residual discomfort 1
• Topical tetracaine for 24 hours is safe and patients perceive it as highly effective, though it does not show significant difference in objective pain scores compared to placebo 5
• Cycloplegic agents may be considered only if substantial anterior chamber inflammation is present 1

Critical Management Principles: What NOT to Do

• Never patch the eye – patching does not improve pain, may delay healing, and increases infection risk, especially in contact lens wearers 1, 2, 4
• Never use combination steroid-antibiotic drops as initial therapy – steroids should only be added after 2-3 days of antibiotic-only therapy if needed 1
• Never use therapeutic contact lenses in contact lens-related abrasions due to elevated secondary bacterial keratitis risk 1
• Avoid rubbing the eye as this worsens injury and causes further corneal epithelial damage 1

High-Risk Populations Requiring Enhanced Vigilance

Contact Lens Wearers (Highest Risk)

• Mandatory antipseudomonal coverage with fluoroquinolones is required 1
• Contact lens wear, especially overnight wear, dramatically increases Pseudomonas infection risk 1
• Never patch the eye in contact lens wearers 1

Other Risk Factors

• Prior corneal surgery (refractive, cataract, glaucoma, keratoplasty) significantly increases infection risk 1
• Chronic ocular surface disease (severe dry eye, entropion, lagophthalmos) requires enhanced vigilance 1
• Immunosuppression and diabetes affect healing and antibiotic selection 1

Red Flags Requiring Immediate Ophthalmology Referral

• Central infiltrate >2mm – requires immediate cultures before antibiotic initiation 1
• Hypopyon (layered white cells in anterior chamber) signals severe infection 1
• Significant stromal involvement or corneal melting warrants cultures and smears 1
• High-velocity eye injuries or penetrating trauma 1, 6
• Irregular pupil after trauma 1
• Eye bleeding or vision loss after trauma 1

Escalation Criteria for Bacterial Keratitis

If the abrasion progresses to bacterial keratitis with any of the following features, escalate immediately: 1

• Central location or infiltrate >2mm
• Deep stromal involvement
• Presence of hypopyon
• Corneal stromal loss

Escalated treatment protocol: 1

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

Resistance Considerations

• MRSA accounts for approximately 42% of ocular isolates and frequently exhibits concurrent fluoroquinolone resistance 1
• Despite increasing resistance patterns documented from 2005-2015, fluoroquinolones remain first-line due to superior tissue penetration and clinical efficacy 1
• Chronic prophylactic antibiotic use promotes resistant organisms and should only be used for finite treatment periods 1

Follow-Up and Patient Education

• Avoid contact lens wear until complete healing is confirmed by a healthcare professional 1
• Instruct patients on infection warning signs: increasing pain, purulent discharge, vision changes, and need for prompt ophthalmologic care if these develop 1
• Regular follow-up is necessary to monitor healing and detect early signs of infection 1
• Patients with persistent foreign-body sensation should seek immediate medical attention as this may indicate complications or incomplete healing 1

Protective Measures During Healing

• Tape a hard plastic eye shield, paper cup, or plastic cup over the eye to prevent unintentional touching or rubbing 1
• Most corneal abrasions heal in 24 to 72 hours and rarely progress to corneal erosion or infection 2