What is the treatment for bilateral injected eyes?

Treatment of Bilateral Injected Eyes

The treatment of bilateral injected eyes depends critically on identifying the underlying cause through clinical examination, with bacterial conjunctivitis requiring topical antibiotics, viral conjunctivitis managed supportively, allergic conjunctivitis treated with antihistamines/mast cell stabilizers, and sight-threatening conditions like gonococcal infection, Stevens-Johnson syndrome, or ocular mucous membrane pemphigoid demanding urgent systemic therapy to prevent permanent vision loss. 1

Initial Clinical Assessment

The first step is determining whether the injection is unilateral or bilateral, as this narrows the differential diagnosis significantly. Key clinical features to identify include:

• Discharge character: Purulent/mucopurulent suggests bacterial; watery suggests viral or allergic; absent discharge with severe injection suggests immune-mediated or systemic disease 1
• Follicles vs papillae: Follicular reaction indicates viral (especially adenovirus), chlamydial, or medication-induced causes; papillary reaction suggests allergic or bacterial etiology 1
• Preauricular lymphadenopathy: Present in viral conjunctivitis (especially adenovirus), gonococcal infection, and Parinaud oculoglandular syndrome 1, 2
• Corneal involvement: Keratitis, infiltrates, or ulceration indicate more serious bacterial (especially gonococcal), viral (HSV, VZV), or immune-mediated disease requiring aggressive treatment 1
• Systemic signs: Fever, rash, lymphadenopathy, or mucous membrane involvement suggests Kawasaki disease, Stevens-Johnson syndrome, or systemic vasculitis 1

Treatment by Etiology

Bacterial Conjunctivitis (Nongonococcal)

Mild cases in adults are self-limited, but treatment accelerates resolution and reduces transmission. 1

• First-line: Topical fluoroquinolone (moxifloxacin 0.5%) three times daily for 4 days achieves 66-69% clinical cure rates and 84-94% microbiological eradication 3
• Alternative agents: Trimethoprim-polymyxin B, azithromycin, or aminoglycosides 1
• Children: Require treatment due to risk of complications including corneal infection, otitis media, and meningitis 1

Gonococcal Conjunctivitis (Medical Emergency)

This requires immediate systemic antibiotics to prevent corneal perforation and systemic dissemination. 1

• Adult treatment: Ceftriaxone 1g IM/IV single dose PLUS azithromycin 1g PO single dose (for concurrent chlamydial coverage) 1
• Neonatal treatment: Ceftriaxone 25-50 mg/kg IV/IM (max 125mg) single dose 1
• Topical therapy: Frequent saline irrigation to remove purulent discharge; topical antibiotics are adjunctive only 1
• Urgent ophthalmology consultation: Monitor for corneal involvement requiring more aggressive intervention 1

Chlamydial Conjunctivitis (Inclusion)

Systemic antibiotics are mandatory as topical therapy alone is insufficient. 1

• Adult treatment: Azithromycin 1g PO single dose OR doxycycline 100mg PO twice daily for 7 days 1
• Neonatal treatment: Erythromycin 50 mg/kg/day PO divided four times daily for 14 days 1
• Partner treatment: Essential to prevent reinfection 1
• Screen for systemic involvement: Up to 50% of neonates have nasopharyngeal, genital, or pulmonary infection 1

Viral Conjunctivitis

Most cases are self-limited and require only supportive care, but patient education about contagion is critical. 1

• Supportive measures: Cool compresses, artificial tears, topical antihistamines for symptom relief 1
• Avoid topical antibiotics: Do not prevent secondary bacterial infection and may cause toxicity 1
• Avoid topical steroids: May prolong viral shedding and cause complications unless severe subepithelial infiltrates develop after acute phase 1
• Infection control: Highly contagious for 10-12 days; strict hand hygiene, avoid eye touching, no shared towels 1

Allergic Conjunctivitis

• First-line: Topical antihistamine/mast cell stabilizer combination (olopatadine, ketotifen) twice daily 1
• Severe cases: Short course of topical corticosteroids (loteprednol, fluorometholone) with close IOP monitoring 1
• Allergen avoidance: Remove triggers, cool compresses 1

Immune-Mediated Conditions (Sight-Threatening)

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Requires immediate hospitalization, systemic immunosuppression, and aggressive ocular surface management to prevent blindness. 1

• Systemic therapy: High-dose IV corticosteroids, IVIG, or cyclosporine in consultation with dermatology/burn unit 1
• Ocular management: Frequent preservative-free lubrication, topical steroids, amniotic membrane transplantation, symblepharon lysis 1
• Stop offending agent: Discontinue all potentially causative medications immediately 1

Ocular Mucous Membrane Pemphigoid

Progressive disease requires systemic immunosuppression to halt cicatricial changes. 1

• Systemic therapy: Dapsone, mycophenolate mofetil, or cyclophosphamide in consultation with rheumatology/immunology 1
• Topical therapy: Preservative-free lubrication, topical steroids for acute flares 1
• Surgical intervention: Only after disease quiescence; premature surgery worsens scarring 1

Kawasaki Disease

Bilateral bulbar conjunctival injection without exudate is a cardinal feature requiring urgent systemic treatment to prevent coronary artery aneurysms. 1

• Diagnostic criteria: Fever ≥5 days plus ≥4 principal features including bilateral bulbar conjunctival injection 1
• Treatment: IVIG 2 g/kg single infusion plus high-dose aspirin 80-100 mg/kg/day divided four times daily 1
• Ophthalmology role: Recognize pattern and facilitate urgent pediatric cardiology referral 1

Common Pitfalls to Avoid

• Do not prescribe topical antibiotics for viral conjunctivitis: This promotes resistance, causes toxicity, and provides false reassurance 1
• Do not miss gonococcal conjunctivitis: Marked eyelid edema with copious purulent discharge requires immediate systemic antibiotics, not just topical therapy 1
• Do not use topical steroids in infectious conjunctivitis: May worsen HSV keratitis, prolong viral shedding, or facilitate bacterial/fungal superinfection 1
• Do not ignore bilateral injection with systemic signs: Consider Kawasaki disease in children, Stevens-Johnson syndrome with medication history, or vasculitis with constitutional symptoms 1
• Do not delay treatment of immune-mediated disease: Cicatricial changes in pemphigoid and SJS are irreversible once established 1

When to Refer Urgently to Ophthalmology

• Suspected gonococcal conjunctivitis (corneal involvement risk) 1
• Any corneal infiltrate, ulcer, or significant keratitis 1
• Severe pain disproportionate to examination findings 1
• Vision loss or photophobia 1
• Suspected Stevens-Johnson syndrome or ocular mucous membrane pemphigoid 1
• Neonatal conjunctivitis (ophthalmia neonatorum) 1
• Failure to improve with appropriate therapy after 3-5 days 1