Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute corneal abrasion

Consider – removal of foreign body

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ACUTE
|
acute corneal abrasion
Consider – 

removal of foreign body

Additional treatment recommended for SOME patients in selected patient group

Initial treatment involves the removal of any retained foreign body (where appropriate). Rule out multiple foreign bodies in the cornea and conjunctiva by double eversion of the eyelids.

Flush out any superficial foreign body that is not embedded in the conjunctiva or cornea with 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.

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.

Aggressive attempts to remove deeply embedded foreign bodies may result in corneal perforation. Therefore, if penetration in the anterior chamber is identified or suspected, the foreign body should be removed under the microscope in the operating room.

Contact lenses should not be worn while the eye recovers. Contact lens use may resume once approved by an ophthalmologist or, for small defects, once the patient has been symptom-free for 24 hours.

Plus – analgesia

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ACUTE
|
acute corneal abrasion
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Analgesics may be required for pain relief, especially in the first 24 hours. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are preferred in patients with tissue swelling, reserving paracetamol for use when NSAIDs are contraindicated. Continue treatment until the eye has healed or the symptoms have disappeared.​​​

Topical ophthalmic NSAIDS can cause melts (peripheral ulcerative keratitis) in the setting of epithelial defects and offer no clear benefits over oral analgesia.[26] [ Cochrane Clinical Answers logo ]

Primary options

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 30 mg/kg/day; adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – topical anaesthetic

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ACUTE
|
acute corneal abrasion
Consider – 

topical anaesthetic

Additional treatment recommended for SOME patients in selected patient group

Consider topical ophthalmic anaesthesia as a single dose to provide initial symptom relief and aid examination.[13][15][16]​​​

Topical anesthetics may not effectively treat pain associated with corneal abrasions or improve corneal healing; repeated use may be toxic to the corneal epithelium and impair healing (e.g., risks corneal melting, ring infiltrates, and infection).[13][15]​​[16]

Patients should not receive topical anesthetics for use at home.[15] ​​​

Primary options

proxymetacaine ophthalmic: (0.5% solution) children and adults: 1-2 drops into the affected eye(s) before procedure

OR

tetracaine ophthalmic: (0.5% solution) children ≥2 years of age and adults: 1 drop into the affected eye(s) before procedure

Consider – topical cycloplegic

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ACUTE
|
acute corneal abrasion
Consider – 

topical cycloplegic

Additional treatment recommended for SOME patients in selected patient group

Cycloplegics can reduce pain and photophobia caused by ciliary spasm, but they lack convincing evidence for their use.[19]​ Nevertheless, they may have a role in patients who experience significant pain from large defects, when treatment should continue until the eye has healed or the symptoms have disappeared.

Primary options

cyclopentolate ophthalmic: (0.5%, 1%, 2% solution) children and adults: 1-2 drops into the affected eye(s) once or twice daily

OR

atropine ophthalmic: (1% solution) children: children ≥3 months of age and adults: 1 drop into the affected eye(s) once or twice daily

Plus – topical antibiotics

Back
ACUTE
|
acute corneal abrasion
|
non-contact lens wearers
Plus – 

topical antibiotics

Treatment recommended for ALL patients in selected patient group

Patients presenting with substantial epithelial loss or contamination 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, but they blur vision and may be less comfortable than eye drops (thus, consider a combination of eye drops for the day and ointments at night).

Continue therapy for 24 hours after the patient has become symptom-free.

Primary options

erythromycin ophthalmic: (0.5% ointment) children and adults: apply to the affected eye(s) up to six times daily

OR

ciprofloxacin ophthalmic: (0.3% solution) children and adults: 2 drops into the affected eye(s) every 15 minutes for 6 hours, followed by 2 drops every 30 minutes for 18 hours, then 2 drops every hour for 1 day, then 2 drops every 4 hours thereafter

OR

ofloxacin ophthalmic: (0.3% solution) children ≥1 year of age and adults: 1-2 drops into the affected eye(s) every 30 minutes while awake and every 4-6 hours during sleep hours for 2 days, followed by 1-2 drops every hour while awake for 4-6 days, then 1-2 drops four times daily thereafter

Plus – topical antibiotics

Back
ACUTE
|
acute corneal abrasion
|
contact lens wearers
Plus – 

topical antibiotics

Treatment recommended for ALL patients in selected patient group

Patients presenting with contact lens-related corneal abrasion are prescribed a topical antibiotic.[24]

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), especially if there is substantial epithelial loss or contamination.​[21]​

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, but they blur vision and may be less comfortable than eye drops (thus, consider a combination of eye drops for the day and ointments at night). Continue therapy for 24 hours after the patient has become symptom-free.

Advise the patient to stop wearing contact lenses temporarily. A bandage contact lens (also known as a therapeutic contact lens) may be used to protect the cornea. Contact lens use may be restarted 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.

Primary options

ciprofloxacin ophthalmic: (0.3% solution) children and adults: 2 drops into the affected eye(s) every 15 minutes for 6 hours, followed by 2 drops every 30 minutes for 18 hours, then 2 drops every hour for 1 day, then 2 drops every 4 hours thereafter

OR

ofloxacin ophthalmic: (0.3% solution) children ≥1 year of age and adults: 1-2 drops into the affected eye(s) every 30 minutes while awake and every 4-6 hours during sleep hours for 2 days, followed by 1-2 drops every hour while awake for 4-6 days, then 1-2 drops four times daily thereafter

OR

gentamicin ophthalmic: (0.3% solution) children ≥1 month of age and adults: 1-2 drops into the affected eye(s) every 4 hours (up to 2 drops every hour for severe infections); (0.3% ointment) children ≥1 month of age and adults: apply to the affected eye(s) two to three times daily

OR

tobramycin ophthalmic: (0.3% solution) children ≥2 months of age and adults: 1-2 drops into the affected eye(s) every 4 hours (up to 2 drops every hour for severe infections)

ONGOING

recurrent corneal erosions or poor healing

1st line – analgesia

Back
ONGOING
|
recurrent corneal erosions or poor healing
1st line – 

analgesia

Analgesics may be required for pain relief, especially in the first 24 hours. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are preferred in patients with tissue swelling. Reserve paracetamol for use when NSAIDs are contraindicated. Continue treatment until the eye has healed or the symptoms have disappeared.​[23]

Topical ophthalmic NSAIDs can cause melts (peripheral ulcerative keratitis) in the setting of epithelial defects and offer no clear benefits over oral analgesia.[23][26] [ Cochrane Clinical Answers logo ]

Primary options

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 30 mg/kg/day; adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – topical anesthetic

Back
ONGOING
|
recurrent corneal erosions or poor healing
Consider – 

topical anesthetic

Additional treatment recommended for SOME patients in selected patient group

Consider topical ophthalmic anaesthesia as a single dose to provide initial symptom relief and aid examination.[13][15]​​[16]​​​

Topical anesthetics may not effectively treat pain associated with corneal abrasions or improve corneal healing; repeated use may be toxic to the corneal epithelium and impair healing (e.g., risks corneal melting, ring infiltrates, and infection).[13][15]​​[16]

Patients should not receive topical anesthetics for use at home.[15]

Primary options

proxymetacaine ophthalmic: (0.5% solution) children and adults: 1-2 drops into the affected eye(s) before procedure

OR

tetracaine ophthalmic: (0.5% solution) children ≥2 years of age and adults: 1 drop into the affected eye(s) before procedure

Consider – artificial tears or topical hyperosmotic agent

Back
ONGOING
|
recurrent corneal erosions or poor healing
Consider – 

artificial tears or topical hyperosmotic agent

Additional treatment recommended for SOME patients in selected patient group

After epithelial healing, use artificial tears, lubricating ointment, and/or topical hyperosmotic agents (2.5% or 5% sodium chloride drops and/or ointment) for several weeks or months, as needed.

Consider – topical cycloplegic

Back
ONGOING
|
recurrent corneal erosions or poor healing
Consider – 

topical cycloplegic

Additional treatment recommended for SOME patients in selected patient group

These dilate the eye and can reduce discomfort. In particular, they may have a role in patients who experience significant pain from large defects, when treatment should continue until the eye has healed or the symptoms have disappeared.

Primary options

cyclopentolate ophthalmic: (0.5%, 1%, 2% solution) children and adults: 1-2 drops into the affected eye(s) once or twice daily

OR

atropine ophthalmic: (1% solution) children: children ≥3 months of age and adults: 1 drop into the affected eye(s) once or twice daily

Plus – topical antibiotics

Back
ONGOING
|
recurrent corneal erosions or poor healing
|
non-contact lens wearers
Plus – 

topical antibiotics

Treatment recommended for ALL patients in selected patient group

Patients with substantial epithelial loss or contamination are prescribed a topical antibiotic. 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, but they blur vision and may be less comfortable than eye drops (thus, consider a combination of eye drops for the day and ointments at night).

Continue therapy for 24 hours after the patient has become symptom-free.

Primary options

erythromycin ophthalmic: (0.5% ointment) children and adults: apply to the affected eye(s) up to six times daily

OR

ciprofloxacin ophthalmic: (0.3% solution) children and adults: 2 drops into the affected eye(s) every 15 minutes for 6 hours, followed by 2 drops every 30 minutes for 18 hours, then 2 drops every hour for 1 day, then 2 drops every 4 hours thereafter

OR

ofloxacin ophthalmic: (0.3% solution) children ≥1 year of age and adults: 1-2 drops into the affected eye(s) every 30 minutes while awake and every 4-6 hours during sleep hours for 2 days, followed by 1-2 drops every hour while awake for 4-6 days, then 1-2 drops four times daily thereafter

Plus – topical antibiotics

Back
ONGOING
|
recurrent corneal erosions or poor healing
|
contact lens wearers
Plus – 

topical antibiotics

Treatment recommended for ALL patients in selected patient group

Patients with contact lens-related corneal abrasion are prescribed a topical antibiotic.[24]

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), especially if there is substantial epithelial loss or contamination.​[21]​

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, but they blur vision and may be less comfortable than eye drops (thus, consider a combination of eye drops for the day and ointments at night).

Continue therapy for 24 hours after the patient has become symptom-free.

Advise the patient to stop wearing contact lenses temporarily. A bandage contact lens (also known as a therapeutic contact lens) may be used to protect the cornea. Contact lens use may be restarted 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.

Primary options

ciprofloxacin ophthalmic: (0.3% solution) children and adults: 2 drops into the affected eye(s) every 15 minutes for 6 hours, followed by 2 drops every 30 minutes for 18 hours, then 2 drops every hour for 1 day, then 2 drops every 4 hours thereafter

OR

ofloxacin ophthalmic: (0.3% solution) children ≥1 year of age and adults: 1-2 drops into the affected eye(s) every 30 minutes while awake and every 4-6 hours during sleep hours for 2 days, followed by 1-2 drops every hour while awake for 4-6 days, then 1-2 drops four times daily thereafter

OR

gentamicin ophthalmic: (0.3% solution) children ≥1 month of age and adults: 1-2 drops into the affected eye(s) every 4 hours (up to 2 drops every hour for severe infections); (0.3% ointment) children ≥1 month of age and adults: apply to the affected eye(s) two to three times daily

OR

tobramycin ophthalmic: (0.3% solution) children ≥2 months of age and adults: 1-2 drops into the affected eye(s) every 4 hours (up to 2 drops every hour for severe infections)

Plus – ophthalmology referral and consider surgery

Back
ONGOING
|
recurrent corneal erosions or poor healing
|
no signs of healing after conservative management
Plus – 

ophthalmology referral and consider surgery

Treatment recommended for ALL patients in selected patient group

Practitioners should recognise their limitations, and where necessary, seek further advice or refer the patient to an ophthalmologist. In particular, consider ophthalmology referral for patients with multiple recurrences, large defects, or non-healing defects.

Recurrent or refractory cases may require debridement, stromal micropuncture, phototherapeutic keratectomy, or manual superficial keratectomy to promote proper healing.[29][30][31]

Refer patients with significant eye injury or pain, periocular trauma, or where the diagnosis is unclear or complicated by comorbidity.[32]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer