What to do for a painful and swollen eye?

Management of Painful and Swollen Eye

Immediately refer to an ophthalmologist if the patient has visual loss, moderate to severe pain, severe purulent discharge, corneal involvement, or lack of response to initial therapy within 3-4 days. 1, 2, 3

Initial Assessment and Red Flags

The painful, swollen eye requires urgent evaluation to distinguish vision-threatening emergencies from self-limited conditions. 4, 5

Critical conditions requiring immediate ophthalmology referral include: 1, 2, 3

• Visual loss or decreased visual acuity
• Moderate to severe pain unrelieved by simple measures
• Corneal involvement (opacity, infiltrate, or ulceration)
• Severe purulent discharge suggesting bacterial infection
• Conjunctival scarring
• Recurrent episodes

Examine specifically for: 1, 4

• Swollen preauricular or submandibular lymph nodes (indicates bacterial infection)
• Character of discharge (purulent vs watery)
• Degree of conjunctival inflammation and chemosis
• Presence of lid swelling or membranous conjunctivitis

Treatment Algorithm Based on Likely Diagnosis

Moderate to Severe Bacterial Conjunctivitis

If the eye shows copious purulent discharge, marked inflammation, and pain, this represents moderate to severe bacterial conjunctivitis requiring aggressive treatment. 6, 1, 3

Obtain conjunctival cultures and Gram staining immediately before starting antibiotics, especially if gonococcal infection is suspected. 6, 1, 3

Empiric antibiotic treatment: 1, 2, 3

• First-line: Fluoroquinolones (moxifloxacin 0.5% or ofloxacin 0.3%) applied 4 times daily for 5-7 days due to broad-spectrum coverage against Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae
• Alternative: Aminoglycosides (tobramycin or gentamicin) 4 times daily for 5-7 days

Critical pitfall: Methicillin-resistant Staphylococcus aureus (MRSA) has been isolated with increasing frequency (approximately 42% of staphylococcal isolates show methicillin resistance), often with concurrent fluoroquinolone resistance. 6, 2, 3 If MRSA is suspected or confirmed, compounded topical vancomycin may be required. 3

Special Pathogen Considerations

Gonococcal conjunctivitis: 1, 2, 3, 7

• Requires systemic antibiotic therapy—topical treatment alone is insufficient
• Daily follow-up is mandatory until complete resolution
• Hospitalization may be necessary for severe cases

Chlamydial conjunctivitis: 1, 2, 3

• Requires systemic antibiotic therapy (oral azithromycin single dose or tetracycline for 7 days in adults)
• Topical therapy alone is inadequate
• In children, consider the possibility of sexual abuse

Viral Conjunctivitis with Severe Inflammation

If the presentation suggests viral etiology (watery discharge, preauricular lymphadenopathy) but with marked chemosis, lid swelling, or membranous conjunctivitis, consider adenoviral keratoconjunctivitis. 6

Management: 6

• Supportive care with artificial tears, cold compresses, and oral analgesics
• Topical corticosteroids may be helpful to reduce symptoms and prevent scarring in severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis
• Close follow-up is warranted if corticosteroids are prescribed, with periodic measurement of intraocular pressure
• Debridement of membranes can be considered to prevent corneal epithelial abrasions or permanent cicatricial changes

For herpes simplex virus conjunctivitis: 6

• Topical ganciclovir 0.15% gel 3-5 times daily or trifluridine 1% solution 5-8 times daily
• Oral antivirals: acyclovir 200-400 mg five times daily, valacyclovir 1000 mg every 8 hours, or famciclovir 500 mg three times daily for 7 days

For varicella zoster virus conjunctivitis: 6

• Oral antivirals for persistent disease: acyclovir 800 mg five times daily, valacyclovir 1000 mg every 8 hours, or famciclovir 500 mg three times daily for 7 days

Mild Bacterial Conjunctivitis

If inflammation is mild with minimal purulent discharge and no severe pain, a 5-7 day course of broad-spectrum topical antibiotic is appropriate. 6, 1, 2

Options include: 1, 2, 7, 8

• Erythromycin ointment approximately 1 cm applied up to 6 times daily
• Bacitracin ointment applied 1-3 times daily
• Polymyxin B/trimethoprim drops 4 times daily
• Alternative: Povidone-iodine 1.25% ophthalmic solution when access to antibiotics is limited

Follow-Up Protocol

Return for follow-up if no improvement after 3-4 days of treatment. 1, 2, 3 Follow-up should include: 6, 1, 2

• Interval history
• Visual acuity measurement
• Slit-lamp biomicroscopy
• Intraocular pressure measurement if corticosteroids were prescribed

Key Pitfalls to Avoid

Do not use topical corticosteroids without close ophthalmologic supervision as they may prolong bacterial shedding and worsen infection. 1, 3 However, in severe viral conjunctivitis with marked inflammation, corticosteroids under supervision can reduce symptoms and prevent scarring. 6

Avoid prescribing antibiotics for clearly viral conjunctivitis to prevent unnecessary costs and antibiotic resistance. 2

Reserve fluoroquinolones for moderate to severe infections to preserve their effectiveness given increasing bacterial resistance. 2, 3