Scratching the Surface: Corneal vs. Conjunctival Abrasions and Steroids

Should you give steroids to patients with abrasions. Also do you treat conjunctival abrasions differently than corneal abrasions?

Lord of the Rings: The Fellowship of the Ring, Newline Cinema, Peter Jackson, 2001

Recently, a friend of mine asked me whether we should be giving people steroids for corneal abrasions after they were prescribed some. It’s never been a part of my practice, but to be honest—I didn’t have a good answer.

So I went to the library (by which, of course, I mean the internet) to find out. Also, I’ve always wanted to know: what do you do when a patient has fluorescein uptake on the white part of their eye and not the cornea?

What does fluorescein uptake on the white part (scleral conjunctiva) of the eye mean?

It means the same thing as when the fluorescein is taken up on the cornea, there is denuded epithelium in the area of uptake - or in normal person speak - the trauma/chemicals that caused the patient’s injury did a little excavating of the lining of the patient’s eye to get to the creamy center.¹

Do you treat corneal abrasions and conjunctival abrasions differently?

Yep. Supportive care for conjunctival abrasions.

Do your exam like normal and be sure there isn’t an abrasion that goes across both the cornea and conjunctiva. If it’s just the white part (conjunctiva), treat with oral pain meds. No antibiotics needed.²

This is different from corneal abrasions, where you want to prevent bacterial infections with our topical antibiotics (remember to cover for Pseudomonas with fluoroquinolones in contact lens wearers).

How about steroids? Should we give those for these abrasions?

Nope.

Giving topical steroids is something that does seem to happen for abrasions, but the good folks over at the American Academy of Ophthalmology (AAO) give us some great guidance here. The risks of giving topical steroids outweigh the benefits.

What are the risks?

• You’re letting an indolent herpes keratitis (dendritic ulcer) have its way with the eye—gross.

• Delayed healing

• Increased intraocular pressure (glaucoma)

• Cataract formation

Have the patient follow up with ophthalmology and let them make the call on steroids if needed. Otherwise, leave those steroids for your next asthmatic.

Can I do anything other than just oral pain meds?

Give them some topical ketorolac (0.5% 1 drop q8h)

Yu et al. did a wonderful systematic review and meta-analysis that supports topical NSAIDs, showing improved pain scores at 24 and 48 hours for patients with corneal abrasions.³ The Wilderness Medical Society also gives this a strong recommendation.⁴ Best of all: no delay in healing, and no significant increase in rates of complications.

How about topical anesthetics like proparacaine or tetracaine?

Mmmmmmmmaybe.

ACEP supports us giving short-term (<24 hours) topical anesthetics every 30 minutes, provided no more than 1.5–2 mL is dispensed.⁵ However, many ophthalmologists are perturbed by the fact that patients are coming in with whole bottles of topical anesthetics and ultimate alternative diagnoses like microbial keratitis or ulcers instead of our initial diagnosis of corneal abrasions.

You can read about the drama from the incredible host of FOAMCast, Dr. Westafer (who, if she’s reading this, I love your work and will fangirl if I ever meet you): The Corneal Abrasion Treatment Controversy.⁶

The drama comes from the fact that although ACEP initially had the AAO on board, the AAO supporters disagreed on the recommendation of sending people home and withdrew their support. Dr. Westafer wisely points out that this doesn’t mean we can hate on our ophtho colleagues—after all, they gave us the great Dr. Glaucomflecken. But we should pay attention to the concerns they raise since they will ultimately be managing these patients in the clinic setting.

1. So, if you are going to send someone home with topical anesthetics:

2. Make damn sure they have a simple corneal abrasion.

3. Make damn sure you trust this patient to use the medication responsibly.

4. Make damn sure they understand the risk.

5. Provide instructions for how to use the medication (q30 mins for 24 hours max), and who to follow up with.

6. Discuss with your favorite ophthalmology friend.

Use a syringe to get all of the med out of the bottle, and reinject 1.5–2 mL back into the bottle for them to keep. I guess you could prescribe 1.5–2 mLs, but that just seems like extra steps (go to the pharmacy, wait in line, confirm your insurance, etc etc).

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1. Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. American Family Physician. 2013;87(2):114-120. https://pubmed.ncbi.nlm.nih.gov/23317075/

2. Garcia GE. Management of ocular emergencies and urgent eye problems. American family physician. 1996;53(2):565-574. https://pubmed.ncbi.nlm.nih.gov/8629538/

3. Yu CW, Kirubarajan A, Yau M, Armstrong D, Johnson DE. Topical Pain Control for Corneal Abrasions: A Systematic Review and Meta‐Analysis. Academic Emergency Medicine. 2021;28(8). doi:https://doi.org/10.1111/acem.14222

4. Paterson R, Drake B, Tabin G, Butler FK, Cushing T. Wilderness Medical Society Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2014 Update. Wilderness & Environmental Medicine. 2014;25(4):S19-S29. doi:https://doi.org/10.1016/j.wem.2014.08.008

5. Green SM, Tomaszewski C, Valente JH, Lo B, Milne K. Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines from the American College of Emergency Physicians. Annals of emergency medicine. Published online February 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.01.004

6. Westafer, DO, MPH, MS, FACEP L. The Corneal Abrasion Treatment Controversy - Page 2 of 3 - ACEP Now. ACEP Now. Published October 28, 2024. Accessed January 18, 2026. https://www.acepnow.com/article/the-corneal-abrasion-treatment-controversy/2/