Treatment of Red Eye (Conjunctivitis)
The treatment of red eye (conjunctivitis) should be directed at the underlying cause, with indiscriminate use of topical antibiotics or corticosteroids avoided as they can cause toxicity, prolong viral infections, or worsen herpes simplex virus infections. 1
Classification and Diagnosis
Before initiating treatment, it's essential to identify the type of conjunctivitis:
Viral Conjunctivitis:
- Watery discharge
- Burning sensation, gritty feeling
- Preauricular lymphadenopathy
- Most common overall cause
Bacterial Conjunctivitis:
- Mucopurulent discharge
- Eyelids matted shut upon waking
- Lack of itching
- Second most common infectious cause
Allergic Conjunctivitis:
- Bilateral itching
- Watery discharge
- Eyelid edema and chemosis
- Papillary reaction
Treatment Approaches
1. Viral Conjunctivitis
- Supportive care is the mainstay of treatment 2:
- Cold compresses
- Refrigerated artificial tears
- Strict hand hygiene to prevent spread
- Avoid contact lens wear until resolution 1
- Avoid topical antibiotics as they are ineffective against viral causes 1
- For herpes simplex virus conjunctivitis:
2. Bacterial Conjunctivitis
- Most uncomplicated cases are self-limited and resolve within 1-2 weeks 3
- Topical antibiotics decrease duration and allow earlier return to work/school 3:
- Fluoroquinolones (e.g., moxifloxacin 0.5% ophthalmic solution): one drop in affected eye 3 times daily for 7 days 4
- For gonococcal conjunctivitis (hyperacute):
- For chlamydial conjunctivitis:
- Systemic erythromycin plus topical antibiotics 2
3. Allergic Conjunctivitis
- Environmental modifications:
- Avoid allergens
- Wear sunglasses as a barrier
- Hypoallergenic bedding
- Frequent clothes washing 1
- Topical treatments:
- Cold compresses and refrigerated artificial tears 1
- Over-the-counter topical antihistamine/vasoconstrictor agents for mild cases 1
- Second-generation topical histamine H1-receptor antagonists are more effective 1
- Mast cell stabilizers for frequently recurrent or persistent cases 1
- Combination antihistamine/mast cell stabilizer medications for either acute or chronic disease 1
- For severe cases:
Special Considerations
When to Refer to an Ophthalmologist
Immediate referral is necessary for:
- Visual loss
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement
- Lack of response to therapy after 2-3 weeks
- Recurrent episodes
- History of HSV eye disease
- Immunocompromised patients
- Neonatal conjunctivitis 2
Infection Control
- Strict hand hygiene
- Avoid sharing towels and pillows
- Minimize contact with others for 10-14 days for viral conjunctivitis 2
- Proper disinfection of tonometer tips if used 1
Corticosteroid Precautions
- Monitor intraocular pressure regularly
- Watch for glaucoma and cataract development
- Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, loteprednol) to reduce risk of elevated IOP 1
- Taper slowly to minimum effective dose 1
Follow-up
- Patients not treated with topical corticosteroids should return if symptoms persist beyond 2-3 weeks 1
- Patients treated with topical corticosteroids need regular monitoring of IOP and pupillary dilation 1
- Evaluate for corneal subepithelial infiltrates, which typically occur 1+ weeks after onset of viral conjunctivitis 1
Remember that indiscriminate use of topical antibiotics or corticosteroids should be avoided, as antibiotics can cause toxicity and corticosteroids can potentially prolong viral infections or worsen HSV infections 2.