Approach

Practitioners should recognise their limitations, and where necessary, seek further advice or refer the patient to an ophthalmologist, especially for presentations with significant eye injury, eye pain, or periocular trauma.​[11]​​​​ 

New abrasions

Treat simple abrasions with pain relief, infection prophylaxis, and foreign body removal.[12][13][14]​​ Antibiotic ointment, for infection prophylaxis and lubrication, plus an oral analgesic usually suffice.​​​​​[18][19][20][21]​​​​ Contact lens-related abrasions have a higher rate of Pseudomonas infection and may require different antibiotics. Some patients may benefit from other treatments if these initial options do not adequately control symptoms.

Tetanus immunisation is only indicated for penetrating globe injuries and lacerations.[22]

See Eye trauma (Management approach)​.

Remove any retained foreign body

Check for and remove any possible foreign body in the first instance.[11][13][14]​ Rule out multiple foreign bodies in the cornea and conjunctiva by double eversion of the eyelids. Flush out any superficial foreign body not embedded in the conjunctiva or cornea using a sterile saline wash, including the fornices. Particulate matter may be removed with fine-tipped forceps or a blunt spatula. Embedded foreign matter may be removed with a sterile saline-wetted cotton bud or a sterile disposable hypodermic needle. Aggressive attempts to remove deeply embedded foreign bodies may result in corneal perforation (refer or remove any identified or suspected perforation in the operating room). Inert, non-toxic, sterile materials, such as plastic and glass, may be well tolerated within the eye, but metal and vegetable matter must be removed without delay. If present, remove any rust rings secondary to a metal foreign body at a follow-up appointment within 24-48 hours.

Provide adequate analgesia

Oral analgesics (e.g., ibuprofen, paracetamol) may be required for pain relief, especially in the first 24 hours. NSAIDs such as ibuprofen are preferred in patients with significant tissue swelling. Continue treatment until the eye has healed or the symptoms have disappeared.​[23]​​​​

Topical antibiotic therapy

Patients presenting with substantial epithelial loss or contamination, or a contact lens-related corneal abrasion, are prescribed a topical antibiotic.​[24]​​​ Note that the beneficial effect of antibiotic prophylaxis in preventing infection or accelerating healing remains unclear, and it is mostly used to ease discomfort.[21]

Ointments are preferred because they function as lubricants and theoretically aid healing. Given that they blur vision and may be less comfortable than eye drops, consider a combination of eye drops for the day and ointments at night. Therapy is usually continued until 24 hours after the patient has become symptom-free. The preferred antibiotics for traumatic or foreign body-related infection are erythromycin, ciprofloxacin, and ofloxacin.

Contact lens-related abrasions have a higher rate of Pseudomonas infection, requiring treatment with topical fluoroquinolones (e.g., ciprofloxacin, ofloxacin) or aminoglycosides (e.g., gentamicin, tobramycin). Ordinary contact lenses should not be worn while the eye recovers, although a bandage contact lens (also known as a therapeutic contact lens) may help to protect the cornea. Contact lens use may be re-started once approved by an ophthalmologist or, for small defects, once the patient has been symptom-free for 24 hours. Provide ophthalmological follow-up within 24-48 hours.

Consider other agents for symptomatic relief

Despite limited evidence to support or refute the use of topical NSAIDs, topical anaesthetics, cycloplegics, bandage contact lenses, or eye patches, these options are still used.[19][25]​

Topical NSAIDs may have some utility, but they can cause melts (peripheral ulcerative keratitis) in cases with epithelial defects and offer no clear benefits over oral analgesia.[11][19][26]​​[27]​​​​​​​ [ Cochrane Clinical Answers logo ] ​​​​​​

Single-use topical anaesthetics (e.g., proxymetacaine, tetracaine) may provide initial symptom relief and aid examination.[13]​ One Cochrane review concluded that it is uncertain whether topical anaesthetics effectively treat pain associated with corneal abrasions or improve corneal healing.[13] Repeated use of topical anaesthetics is probably toxic to the corneal epithelium and may impair healing (e.g., risks corneal melting, ring infiltrates, and infection).[15][16]​​ Patients should not receive topical anaesthetics for use at home.[15]

Cycloplegics (e.g., cyclopentolate, atropine) are used to reduce pain and photophobia caused by ciliary spasm, and they have a role in patients who experience significant pain from large defects.[19]​ However, they worsen glare and block the accommodation reflex, making it difficult to read, while even short-acting agents can dilate the pupil for longer than some small defects take to heal. Avoid longer-acting agents.

A bandage contact lens may be used after contact lens-related abrasions. Ordinary contact lenses should not be worn while the eye recovers and use should only be restarted once approved by an ophthalmologist or, for small defects, once the patient has been symptom-free for 24 hours.

Eye patching offers no clear benefits for healing and risks causing monocular vision.[28] [ Cochrane Clinical Answers logo ] ​​​​ 

Recurrent erosions or poor healing

These may occur following trauma or in patients with a history of corneal abrasion, and they may only appear some time after the initial traumatic injury.[5] Predisposing factors include corneal dystrophy, dry eye disease, diabetes, and previous refractive surgery (particularly photorefractive keratectomy).[5]

After epithelial healing, patients may benefit from weeks or months of treatment with artificial tears, lubricating ointment, and/or topical hyperosmotic agents. However, no conclusive evidence supports the role of prophylactic medical therapy.[23]​​

Treat recurrent erosions acutely in the same way as new abrasions, with analgesia, antibiotic ointment or drops, and cycloplegics, as needed. After epithelial healing, artificial tears, lubricating ointment, and/or topical hyperosmotic agents can be used for several weeks or months.

Refer patients with multiple recurrences, large defects, or non-healing defects for ophthalmological follow-up. Recurrent or refractory cases may require debridement, stromal micropuncture, phototherapeutic keratectomy, or manual superficial keratectomy to promote proper healing.[23][29][30][31]​​ Patients may also need referral for significant eye injury or pain, periocular trauma, or where the diagnosis is unclear or complicated by comorbidity.​[11]

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