In my New York City trauma/cornea referral practice, corneal abrasions are common, arising from mechanisms including post‑procedural defects, organic or traumatic scratches, and adhesion problems like epithelial basement membrane dystrophy (EBMD) and recurrent corneal erosion syndrome (RCES).
Corneal clarity is essential for clear vision. My first goal after any abrasion is to restore the surface quickly and avoid inducing haze or irregularity.
Most simple epithelial abrasions heal within 48 hours.1 However, when an injury violates Bowman’s layer, involves the stroma, does not show signs of healing day‑to‑day, or tips toward infection, I pay particular attention. In general, I follow abrasions closely and escalate early.
Evaluating risks of corneal abrasions
In the case of corneal abrasion, the following steps are critical:
- Take a thorough history
- Document the size and location at the slit lamp
- Consider the mechanism of injury
- Test for corneal sensation
- Set clear patient expectations
Central abrasions, for example, often heal more slowly, and even small epithelial irregularity over the visual axis can affect vision, whereas peripheral abrasions typically close faster and without visual consequences.
Mechanism also matters:
- Dirty material or organic injuries raise infection risk
- Contact lens wear introduces concerns about bacterial biofilms2
- EBMD or RCES signal an adhesion problem with recurrence risk
- High-velocity foreign bodies require inspection and possible imaging, while metallic materials require rust-ring management
- Chemical or thermal injuries demand urgent irrigation and closer monitoring, including pH neutralization.
Figures 1-3: Slit lamp images of a patient with epithelial basement membrane dystrophy.
Figures 1-3: Courtesy of Niraj Desai, MD.
Patient education on corneal abrasions
It is also imperative to counsel patients to practice meticulous hand hygiene, avoid rubbing their eyes, postpone contact lens wear, and to administer prescribed drops correctly. For pain, I recommend oral analgesics as needed and no topical anesthetics at home.1
For large, central, or organic‑mechanism injuries, these cases should be followed daily or near‑daily. It is wise to escalate sooner if corneal sensation is decreased. If pain, blur, or photophobia worsen or if there’s no day‑to‑day improvement, patients are instructed to return to the clinic or emergency room immediately.1
Reassure patients that a faint, regular haze is often less visually significant than an irregular scar. It is often possible to correct a true stromal scar that distorts the corneal shape and causes blur with rigid or scleral lenses. Other cases of corneal scarring may require surgical intervention.
Stepwise medical therapy for corneal abrasions
To start, stabilize the ocular surface with preservative‑free lubrication and a prophylactic topical antibiotic.1 Next, add a bandage contact lens (BCL) for comfort and to protect the epithelium once the surface is clean and infection is not suspected; be cautious about capping fresh organic injuries and wait 24 hours while utilizing antibiotics before placing a lens.
Because BCLs can be associated with microbial keratitis and biofilm formation, make certain to follow-up frequently and emphasize hygiene instructions.2,3 It should be noted that, although some scars may fade with time and not require treatment, in cases requiring treatment topical corticosteroids can be used to help lessen haze.
For early onset haze, intensive steroid therapy may be warranted, while cases of late-onset haze may require a shorter steroid regimen or surgical intervention.4 Losartan eye drops are an emerging, compounded option aimed at TGF‑β–mediated myofibroblast pathways.
In my practice, I consider losartan only after the epithelium has healed and the scar’s potential impact on vision is clear. Early case‑level evidence suggests that losartan may reduce haze and improve visual acuity.5 If a large/central abrasion isn’t improving, or if there is neurotrophic risk or a recurrent‑erosion pattern, I move sooner to my next step: amniotic membrane (AM).
Regenerative healing of the cornea
Self‑retained cryopreserved amniotic membrane (CAM) is my go‑to escalation for non‑healing abrasions, neurotrophic risk, and post‑debridement/recurrent‑erosion cases. CAM acts like a biologically active bandage, quieting inflammation and fibrosis while the surface reorganizes, rather than merely covering the wound.
Mechanistically, the heavy chain–hyaluronan/pentraxin‑3 (HC‑HA/PTX3) matrix within CAM downregulates pro‑inflammatory signaling, promotes clearance of neutrophils, tempers T‑cell activation, and dampens pro‑fibrotic TGF‑β signaling in corneal fibroblasts—biologic actions that reduce the cascade toward fibrosis while supporting orderly epithelial repair.6-10
Prokera (BioTissue Ocular Inc.) is a self‑retained CAM; I find it allows therapeutic drops to reach the cornea while providing a biologically active interface. This is especially useful when infection is a concern or when I’m keeping patients on fortified antibiotics.
CAM 360 AmnioGraft (BioTissue Ocular Inc.) is placed under a collagen shield or BCL and is helpful when I want the added mechanical comfort/protection of a lens and the biologic quieting cryopreserved tissue provides.11
Comparing CAM and dehydrated AMs for corneal abrasions
Dehydrated AM products can serve as scaffolds and are attractive for storage/handling, with in‑vitro and preclinical data suggesting cell‑friendly extracellular matrix features in certain preparations.12 Examples include Biovance 3L Ocular (a decellularized, dehydrated AM; Verséa Ophthalmics) and Ambio2 (Corza Ophthalmology).
While AMs can serve as scaffolds to aid epithelial healing,10,12 multiple analyses indicate dehydration steps may remove PTX3 and alter hyaluronic acid size distribution, changes linked to reduced anti‑inflammatory potency compared with cryopreservation.13-15
Practically, if the goal is maximal biologic anti‑inflammatory/anti‑fibrotic effect in a non‑healing abrasion or neurotrophic surface, utilize CAM first. Consider dehydrated decellularized membranes for scenarios where the scaffold alone may suffice or logistical concerns dominate.
Procedural interventions for corneal abrasions
When the epithelium keeps sloughing after appropriate conservative care, I move from medical to procedural management.
Superficial keratectomy
With the goal of eliminating the unstable epithelial basement membrane and giving new cells a surface to anchor to, perform a superficial keratectomy (SK) with diamond burr polishing of Bowman’s membrane.
This includes:
- Debriding the loose epithelium
- Polishing Bowman’s to remove micro‑erosion tracks
- Creating a uniformly smooth, lightly roughened bed that promotes hemidesmosomal re‑adhesion
Figure 4: Coalesced superficial punctate keratitis with punctate epithelial erosions (top left); same-day s/p SK and diamond burr polish (top right); same-day dehydrated amniotic membrane placement (bottom left); and 1 week later after BCL removal and complete membrane absorption (bottom right).
Figure 4: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Phototherapeutic keratectomy
Phototherapeutic keratectomy (PTK) is reserved for cases with clinically significant EBMD involving the visual axis or when a broader, more uniform smoothing of the optical zone is desired, with the understanding that PTK induces a hyperopic shift. Post-procedure, I cover the surface to support comfortable, orderly re‑epithelialization, and in straightforward cases, I use a BCL.
If the aim is a quieter remodeling or to minimize post-operative inflammation, consider placing CAM 360 AmnioGraft under a BCL. Continue a prophylactic antibiotic and pain control; once the epithelium closes, I may add a short topical steroid taper if inflammation contributes to symptoms. I also reinforce the adhesion cycle with hypertonic ointment at bedtime for 6 to 8 weeks.
If healing lags or infectious signs emerge, I step back to medical therapy and reassess. For small, peripheral lesions away from the visual axis that continue to recur despite these measures, anterior stromal puncture can be a reasonable alternative.16
Key takeaways
- Epithelial‑only abrasions rarely scar; escalate when healing stalls, sensation is reduced, infection is suspected, or stroma is involved.
- Follow closely for large, central, or organic‑mechanism injuries; counsel “come back sooner” red flags.
- Use CAM early for non‑healing or neurotrophic surfaces and after debridement for recurrent erosions; I prioritize cryopreserved membranes to leverage preserved HC‑HA/PTX3 biology.7,8,14,15
- For recurrent erosions, fix adhesion (SK/PTK) and support healing with BCL or CAM.16
- BCLs with low water content and smaller diameter absorb fewer tears and improve oxygen permeability by covering less limbal vessels, allowing extended wear (up to 1 month with good fit and antibiotics). Remove with forceps at the slit lamp, not fingers.
Conclusions
My objective after any abrasion is to close the epithelium quickly and quietly, so vision returns without haze or irregularity. Most epithelial‑only injuries respond to lubrication, antimicrobials, and a BCL; watch closely and escalate when healing stalls, sensation is reduced, or the stroma or infectious involvement appears.
For patients with recurrent epithelial problems, address the adhesion-causing surface instability. SK, with diamond‑burr polishing, (or PTK when indicated), followed by surface protection, lets the epithelium “tack down” and stay put.
Throughout, set expectations, reinforce home care, and communicate with referring doctors.
