What is the initial management for a patient presenting with pain, watery eye discharge, conjunctival injection, and photophobia in one eye?

Initial Management: Urgent Ophthalmology Referral for Suspected Bacterial Keratitis

This patient requires immediate ophthalmology evaluation and should not be managed as simple conjunctivitis—the combination of unilateral presentation, pain, photophobia, and watery discharge strongly suggests bacterial keratitis (corneal ulcer), which is a sight-threatening emergency. 1

Critical Distinguishing Features

This presentation differs from typical conjunctivitis in several key ways:

• Unilateral involvement with significant pain and photophobia suggests corneal pathology rather than conjunctivitis 1, 2
• True photophobia (light sensitivity causing pain) indicates corneal inflammation or intraocular involvement, not simple conjunctival infection 1
• Severe pain is characteristic of keratitis, whereas conjunctivitis typically causes mild discomfort or foreign body sensation 1, 2

Immediate Actions Before Ophthalmology Evaluation

While arranging urgent referral:

• Do NOT patch the eye as this increases risk of bacterial proliferation 1
• Avoid topical corticosteroids which can worsen infectious keratitis and lead to corneal perforation 1
• Document visual acuity in both eyes 1
• Assess for contact lens use, trauma, or other risk factors for keratitis 1

Why This Cannot Wait

Bacterial keratitis progresses rapidly and can cause:

• Permanent vision loss within 24-48 hours without appropriate treatment 1
• Corneal perforation if untreated or improperly managed 1
• Need for corneal transplantation in severe cases 1

The ophthalmologist will perform slit-lamp examination to identify corneal epithelial defects, stromal infiltrates, or ulceration that cannot be detected without specialized equipment 1.

Definitive Treatment (Ophthalmology-Directed)

Once keratitis is confirmed, management includes:

• Corneal cultures before initiating therapy if the infiltrate is significant 1
• Fortified topical antibiotics (often compounded fluoroquinolones or combination therapy) dosed every 30-60 minutes initially 1
• Close monitoring with daily follow-up until improvement is documented 1

Common Pitfall to Avoid

The most dangerous error is treating this as "pink eye" with routine antibiotic drops. Standard conjunctivitis therapy (such as moxifloxacin three times daily) provides inadequate corneal penetration and dosing frequency for keratitis 1. This delay in appropriate treatment significantly worsens prognosis 1.

If Bacterial Conjunctivitis Were Confirmed (After Ruling Out Keratitis)

Only if ophthalmology examination excludes corneal involvement:

• Topical fluoroquinolones (moxifloxacin 0.5% three times daily) provide rapid symptom resolution within 48 hours 3, 4
• Follow-up in 3-4 days if no improvement to reassess diagnosis 3, 5
• However, given this presentation's severity, empiric conjunctivitis treatment without ophthalmology evaluation is inappropriate 1, 2