What are the treatment options for red eyes?

Treatment Options for Red Eyes

Treatment of red eyes 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 infections. 1

Classification and Diagnosis

Red eye (conjunctivitis) can be classified into three main types, each requiring different treatment approaches:

1. Viral Conjunctivitis

   • Watery discharge
   • Burning sensation, gritty feeling
   • Preauricular lymphadenopathy
   • Highly contagious

2. Bacterial Conjunctivitis

   • Mucopurulent discharge
   • Eyelids matted shut upon waking
   • More common in children than adults

3. Allergic Conjunctivitis

   • Bilateral itching
   • Watery discharge
   • Eyelid edema and chemosis
   • Papillary reaction

Treatment Algorithm

1. Allergic Conjunctivitis

• First-line treatment:
  • Avoidance of allergens
  • Cold compresses
  • Refrigerated artificial tears (preservative-free)
  • Over-the-counter topical antihistamine/vasoconstrictor agents or second-generation topical histamine H1-receptor antagonists 1
• For persistent symptoms:
  • Mast cell stabilizers or combination antihistamine/mast cell stabilizers 1
• For severe symptoms:
  • Brief course (1-2 weeks) of topical corticosteroids with low side effect profile 1
  • Consider topical cyclosporine or tacrolimus for severe cases 1

2. Viral Conjunctivitis

• Primary treatment:
  • Supportive care (cold compresses, artificial tears)
  • Patient education about proper hygiene to prevent spread
  • Avoid touching eyes and wash hands frequently
  • Avoid sharing towels and pillows
• Important note: Antibiotics are ineffective against viral infections 1, 2

3. Bacterial Conjunctivitis

• Mild cases:
  • Often self-limiting and may resolve without treatment 1
• For moderate to severe cases:
  • Topical antibiotics (no evidence showing superiority of any specific agent) 1
  • For superficial ocular infections: erythromycin ophthalmic ointment applied directly to infected eye(s) up to six times daily 3
• Special cases:
  • Gonococcal conjunctivitis: systemic ceftriaxone plus topical antibiotics 2
  • Chlamydial conjunctivitis: systemic erythromycin plus topical antibiotics 2

Prevention and Infection Control

• For viral conjunctivitis:
  • Strict hand hygiene
  • Disinfect surfaces with EPA-registered hospital disinfectant
  • For healthcare settings: sodium hypochlorite (1:10 dilution) for equipment disinfection 1
  • Consider deferring IOP measurement for patients with acute conjunctivitis 1
  • During epidemics, triage patients and use a dedicated "red-eye room" 1

When to Refer to an Ophthalmologist

Immediate referral is necessary for:

• Visual loss
• Moderate or severe pain (especially if not relieved by topical anesthetics)
• 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, 4

Important Cautions

• Avoid indiscriminate use of:
  • Topical antibiotics (can induce toxicity)
  • Corticosteroids (can prolong viral infections and worsen HSV infections) 1
• When using ketotifen or other antihistamine drops:
  • Remove contact lenses before use
  • Wait at least 10 minutes before reinserting contact lenses
  • Discontinue if eye pain, vision changes, or worsening symptoms occur 5
• For contact lens wearers:
  • Suspend use until conjunctivitis resolves
  • Higher risk for Pseudomonas infection 2

Follow-up

• Uncomplicated cases: return if symptoms persist beyond 2-3 weeks
• Cases treated with corticosteroids: regular monitoring of intraocular pressure and pupillary dilation 2

By identifying the specific type of conjunctivitis and following this treatment algorithm, most cases of red eyes can be effectively managed while avoiding unnecessary medications and preventing complications.