What is the treatment for conjunctivitis with swelling around the eye?

Treatment of Conjunctivitis with Periocular Swelling

For conjunctivitis with swelling around the eye, determine the etiology first through clinical features, then treat accordingly: viral cases require supportive care only, bacterial cases need topical antibiotics for moderate-to-severe presentations, and severe cases with marked lid swelling may warrant short-term topical corticosteroids under close monitoring. 1, 2

Immediate Assessment and Red Flags

Refer urgently to ophthalmology if any of the following are present:

• Visual loss or decreased vision 1, 2
• Moderate or severe pain 1, 2
• Severe purulent discharge 1, 2
• Corneal involvement 1, 2
• History of herpes simplex virus eye disease 1, 2
• Immunocompromised state 1, 2

Severe eyelid swelling with chemosis can mimic orbital cellulitis in viral conjunctivitis, particularly adenoviral infections, but this is typically self-limited over 5-14 days. 2

Determine Etiology Based on Clinical Features

Viral Conjunctivitis (Most Common Overall)

Key distinguishing features:

• Watery discharge 2, 3
• Follicular reaction on inferior tarsal conjunctiva 2
• Preauricular lymphadenopathy 2
• Often starts unilateral, becomes sequentially bilateral 2
• Chemosis and marked eyelid swelling can occur in severe cases 2
• Concurrent upper respiratory infection common 2

Bacterial Conjunctivitis

Key distinguishing features:

• Mucopurulent discharge with matted eyelids on waking 2, 4, 3
• Papillary (not follicular) reaction 2
• Lack of itching 4
• Preauricular lymphadenopathy less common unless hypervirulent organisms 2

Gonococcal Conjunctivitis (Medical Emergency)

Key distinguishing features:

• Marked eyelid edema 2
• Severe, bilateral purulent discharge 1, 2
• Bulbar conjunctival injection 2
• Risk of corneal perforation 2
• Consider in sexually active adults or neonates 3-5 days postpartum 5

Treatment by Etiology

Viral Conjunctivitis Treatment

Standard supportive care:

• Preservative-free artificial tears applied frequently 6
• Cold compresses for inflammation and symptomatic relief 6
• Oral analgesics (acetaminophen or NSAIDs) for pain 6
• Avoid antibiotics entirely—they provide no benefit and may cause toxicity 2

For severe cases with marked chemosis and lid swelling:

• Consider short course of topical corticosteroids 1, 6
• Use agents with poor ocular penetration: fluorometholone, rimexolone, or loteprednol 1, 6
• Monitor intraocular pressure and perform pupillary dilation periodically 1, 6
• Taper once inflammation is controlled 1
• Caution: Corticosteroids may prolong viral shedding and worsen HSV infections 2

Infection control measures:

• Strict hand hygiene with soap and water 2, 6
• Avoid sharing towels and pillows 2, 6
• Minimize contact with others for 10-14 days from symptom onset 2, 6

Bacterial Conjunctivitis Treatment

For moderate-to-severe presentations:

• 5-7 day course of broad-spectrum topical antibiotic 2
• No specific agent is superior—choose based on convenience or cost 2
• Options include erythromycin ophthalmic ointment 7 or bacitracin 8
• Apply ointment 1-3 times daily directly into conjunctival sac 8

Mild cases:

• Usually self-limited and may resolve without treatment 2, 4
• Topical antibiotics may decrease duration and allow earlier return to work/school 4

Gonococcal Conjunctivitis Treatment (Requires Hospitalization)

• Systemic therapy is mandatory in addition to topical treatment 1, 2
• Hospitalization necessary for parenteral therapy 1
• Daily follow-up until resolution 1
• Treat sexual contacts and screen for concomitant disease 1
• Consider sexual abuse in children 1

Chlamydial Conjunctivitis Treatment

• Systemic therapy required—topical therapy alone is inadequate 1, 2
• Treat sexual contacts simultaneously 1, 2
• Re-evaluate after treatment (failure rate up to 19%) 1
• Consider sexual abuse in children 1

Follow-Up Recommendations

For severe cases with corneal involvement or membranous conjunctivitis:

• Re-evaluate within 1 week 1, 6
• Include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1, 6

For patients not on corticosteroids:

• Return if symptoms of red eye, pain, or decreased vision persist after 2-3 weeks 1, 6

For patients on topical corticosteroids:

• Regular monitoring of intraocular pressure required 1, 6
• Periodic pupillary dilation 1

Critical Pitfalls to Avoid

• Never use antibiotics indiscriminately for viral conjunctivitis—they cause unnecessary toxicity 1, 2
• Never use topical corticosteroids without close ophthalmology follow-up—risk of elevated intraocular pressure, cataract formation, and worsening HSV infections 2
• Never miss gonococcal conjunctivitis—it can cause corneal perforation and requires immediate systemic treatment 1, 2
• Never allow contact lens wear during any infectious conjunctivitis 2
• Chronic or recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma) and requires further evaluation 2