What is the proper usage and administration of topical antibiotic eye drops and steroid eye drops for conjunctivitis or preseptal cellulitis?

Proper Administration of Topical Antibiotic and Steroid Eye Drops

For bacterial conjunctivitis, use topical antibiotics alone without steroids; for viral conjunctivitis, avoid antibiotics entirely and reserve steroids only for severe cases with marked inflammation; for preseptal cellulitis, systemic antibiotics are the primary treatment, not topical drops.

Bacterial Conjunctivitis

Antibiotic Administration

• Instill one drop every 2 hours while awake (up to 8 times) on Day 1, then reduce to 2-4 times daily on Days 2-7 1
• Continue treatment for the full 7-day course even if symptoms improve earlier 1
• Common agents include gatifloxacin 0.5%, moxifloxacin, or other fluoroquinolones 1

Steroid Use - Generally NOT Recommended

• Avoid topical steroids in routine bacterial conjunctivitis 2
• The American Academy of Ophthalmology explicitly states that "the use of antibiotics in the management of this viral infection should be avoided because of potential adverse treatment effects" when discussing inappropriate antibiotic use, and similarly discourages routine steroid use in simple bacterial cases 2
• Steroids may be considered only in severe bacterial keratitis (corneal involvement) after at least 2-3 days of antibiotic therapy showing improvement, and only after ruling out fungal infection 2

Viral Conjunctivitis (Adenoviral)

Antibiotic Use - AVOID

• Do not prescribe topical antibiotics for viral conjunctivitis 2
• Antibiotics provide no benefit and increase risk of adverse effects and resistance 2

Steroid Administration - Selective Use Only

• Reserve steroids for severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis 2
• Use the minimum effective dose to control inflammation 2
• Consider lower-potency agents (fluorometholone, loteprednol) to minimize IOP elevation and cataract risk 2
• Critical monitoring required: Check IOP and perform pupillary dilation periodically to screen for glaucoma and cataract 2
• Taper slowly once inflammation is controlled 2
• Re-evaluate within 1 week if severe disease present 2

Important Caveat

• Animal studies show topical steroids prolong viral shedding in adenoviral conjunctivitis, though human data are lacking 2
• This theoretical risk must be weighed against benefit in severe cases 2

Preseptal Cellulitis

Primary Treatment - Systemic Antibiotics

• Preseptal cellulitis requires systemic (oral or IV) antibiotics, not topical therapy 3, 4
• Topical drops are insufficient for treating this deeper tissue infection 3, 4
• Common regimen: IV cefotaxime + fosfomycin, or oral amoxicillin-clavulanate 3

Role of Topical Drops

• If associated conjunctivitis is present, topical antibiotics may be added as adjunctive therapy 3
• Topical steroids are NOT indicated for preseptal cellulitis and may worsen bacterial infection 5
• One case report documented bilateral necrotizing fasciitis in an immunosuppressed patient using prescription eye drops, highlighting infection risk 5

Critical Monitoring Parameters

For Any Patient on Topical Steroids

• Measure IOP at baseline and periodically during treatment 2
• Perform pupillary dilation to evaluate for cataract formation 2
• Follow-up within 1-2 days after initiating steroids in severe cases 2
• Counsel patients about risks: glaucoma, cataracts, potential infection prolongation 2

Red Flags Requiring Immediate Re-evaluation

• Worsening pain or vision loss despite treatment 2
• Development of corneal involvement (keratitis) 2
• Signs of orbital (not preseptal) cellulitis: proptosis, ophthalmoplegia, vision loss 3, 4

Common Pitfalls to Avoid

1. Do not prescribe antibiotics for viral conjunctivitis - this is explicitly discouraged and provides no benefit 2

2. Do not use steroids in HSV conjunctivitis - topical corticosteroids potentiate HSV epithelial infections and should be avoided 2

3. Do not rely on topical therapy alone for preseptal cellulitis - systemic antibiotics are required 3, 4

4. Do not use steroids without close follow-up - IOP monitoring is essential to prevent steroid-induced glaucoma 2

5. Do not continue steroids long-term without tapering - use minimum effective dose and taper slowly 2