What are the recommended eye drops for a red eye?

Eye Drop Recommendations for Red Eye

For red eye, the recommended eye drops depend on the underlying cause: use preservative-free artificial tears (hyaluronate or methylcellulose) 2-4 times daily for dry eye-related redness, topical antihistamines (ketotifen or olapatadine) for allergic conjunctivitis, or broad-spectrum antibiotics for suspected bacterial conjunctivitis—but avoid topical corticosteroids and anesthetics in primary care settings. 1, 2

Initial Assessment Framework

Before selecting eye drops, identify warning signs requiring immediate ophthalmology referral 2, 3:

• Severe pain unrelieved by over-the-counter measures 2
• Vision loss or significant visual impairment 2, 3
• Photophobia (light sensitivity) 3
• History of ocular trauma 2, 3
• Corneal involvement or opacity 2, 4
• Unilateral red eye with severe pain and vomiting (suggests acute glaucoma) 5

Treatment Algorithm by Cause

Dry Eye-Related Redness

First-line therapy:

• Preservative-free artificial tears containing hyaluronate or methylcellulose, applied at least 2-4 times daily 1
• Frequency can be increased up to hourly based on symptoms 1
• Use preservative-free formulations when dosing 4+ times daily to avoid toxicity 1, 6

Nighttime management:

• Add ophthalmic ointment at bedtime for overnight symptom control 1, 6
• Follow with morning lid hygiene to prevent blepharitis 1

Moderate-to-severe cases:

• Consider topical cyclosporine 0.05% twice daily for chronic inflammatory dry eye 1
• Lifitegrast 5% twice daily is an alternative anti-inflammatory option 1
• These require 6-12 months for full effect and should be prescribed by ophthalmology 1

Allergic Conjunctivitis

Mild cases:

• Topical antihistamine drops: ketotifen 1 drop twice daily (every 8-12 hours) for ages 3+ years 7
• Alternative: olapatadine 1 drop once daily for ages 2+ years 8
• These provide rapid relief (within minutes) with up to 12-hour duration 7

Adjunctive measures:

• Cold compresses and refrigerated artificial tears 1
• Wearing sunglasses as barrier to airborne allergens 1

Viral or Bacterial Conjunctivitis

Bacterial conjunctivitis:

• Broad-spectrum topical antibiotics (specific agent selection beyond scope, but treatment is standard) 2
• Most cases are self-limiting; serious complications are rare 2

Viral conjunctivitis:

• Supportive care with preservative-free artificial tears 2
• Avoid topical corticosteroids—they can prolong adenoviral infections and worsen HSV infections 1

Important: If no improvement after 10 days, refer to ophthalmology 5

Critical Pitfalls to Avoid

• Never prescribe topical corticosteroids in primary care for red eye 1, 2

  • Can worsen infections (HSV, adenovirus) 1
  • Risk of increased intraocular pressure and cataracts 1
  • May mask serious underlying conditions 2

• Never prescribe topical anesthetics for red eye management 2, 5

  • These are diagnostic tools only, not therapeutic agents 5

• Avoid preservative-containing drops for chronic use 1, 6

  • Can cause toxicity and allergic contact dermatitis 9
  • Switch to preservative-free formulations when using 4+ times daily 1, 6

When to Refer Urgently

Immediate ophthalmology referral is required for 2, 4:

• Chemical burns 4
• Suspected intraocular infection 4
• Globe rupture or penetrating trauma 4
• Acute angle-closure glaucoma 4
• Corneal ulceration or infiltrate 2
• Copious purulent discharge 2
• Distorted pupil 2
• Herpes infection 2