Treatment of Conjunctivitis with Eyelid Swelling in a 15-Year-Old Girl
For a 15-year-old girl with pink eye and swollen eyes, initiate a 5-7 day course of broad-spectrum topical fluoroquinolone antibiotic (such as moxifloxacin or levofloxacin) applied 4 times daily, while carefully assessing for features requiring immediate ophthalmology referral. 1, 2
Initial Assessment and Red Flags
Before starting treatment, evaluate for the following features that mandate immediate ophthalmology referral: 3, 1
- Visual loss
- Moderate or severe pain
- Severe, purulent discharge (suggests possible gonococcal infection)
- Corneal involvement
- Conjunctival scarring
- History of herpes simplex virus (HSV) eye disease
- Immunocompromise
If severe purulent discharge is present, obtain conjunctival cultures and Gram staining before initiating treatment, as gonococcal infection requires systemic antibiotics in addition to topical therapy. 1, 2
Determining the Etiology
The swelling and pink eye presentation requires differentiation between bacterial, viral, and allergic causes:
Bacterial Conjunctivitis Features: 4, 5
- Mattering and adherence of eyelids on waking
- Purulent discharge
- Lack of itching
- No history of recurrent conjunctivitis
Viral Conjunctivitis Features: 3, 4
- Watery discharge
- Burning, gritty sensation
- Often bilateral with swollen preauricular or submandibular lymph nodes
- Highly contagious (adenoviral)
Allergic Conjunctivitis Features: 4, 5
- Bilateral itching (most consistent sign)
- Watery discharge
- Seasonal pattern
Treatment Algorithm
For Presumed Bacterial Conjunctivitis:
Apply topical fluoroquinolone (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) 4 times daily for 5-7 days. 1, 2, 6 No specific topical antibiotic has demonstrated superiority over another, so choice can be based on cost and local resistance patterns. 2
Topical antibacterial therapy provides earlier clinical and microbiological remission, reduced transmissibility, and allows earlier return to school. 1, 7 While most bacterial conjunctivitis is self-limited and resolves in 1-2 weeks without treatment, antibiotics shorten the duration of clinical disease. 4, 7
For Severe Cases with Marked Eyelid Swelling:
If severe purulent discharge with marked swelling is present, consider gonococcal or chlamydial infection, particularly in sexually active adolescents. 3, 1
- Gonococcal conjunctivitis: Requires ceftriaxone 125 mg IM single dose (for patients ≥45 kg) PLUS topical antibiotics, with daily follow-up until resolution 1, 2
- Chlamydial conjunctivitis: Requires azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 1
- Sexual abuse must be considered and reported in adolescents with sexually transmitted conjunctivitis 3, 1
For Viral Conjunctivitis (if suspected):
There is no proven effective treatment for eradication of adenovirus infection. 3, 2 Management is supportive: 3, 2
- Artificial tears
- Topical antihistamines
- Cold compresses
- Oral analgesics
Topical corticosteroids may be helpful in severe cases with marked chemosis or eyelid swelling, epithelial sloughing, or membranous conjunctivitis, but require close ophthalmology follow-up. 3, 2 However, avoid antibiotics as they provide no benefit and risk adverse effects. 3, 2
If HSV conjunctivitis is suspected (vesicular lesions, dendritic pattern), treat with topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily, and NEVER use topical corticosteroids without antiviral coverage as they potentiate HSV infection. 3, 2
For Allergic Conjunctivitis (if suspected):
Use second-generation topical antihistamines with mast-cell stabilizing properties as first-line therapy. 2 Adjunctive measures include cold compresses, refrigerated preservative-free artificial tears, and sunglasses as an allergen barrier. 2
Follow-Up and Patient Education
Instruct the patient to return for evaluation in 3-4 days if no improvement is noted. 1, 6 If bacterial resistance is suspected (particularly methicillin-resistant S. aureus), consider culture and alternative antibiotics. 1, 6
Infection Control Measures: 3, 1
- Hand washing is crucial to reduce transmission
- Avoid sharing towels, pillows, and close contact with others
- For viral conjunctivitis, avoid contact with others for 10-14 days from symptom onset in the last eye affected
- Patient can return to school once treatment has been initiated for 24 hours and symptoms begin to improve
Common Pitfalls to Avoid
Do not use topical corticosteroids without ruling out infectious causes or without ophthalmology consultation, as they can worsen HSV infections and prolong adenoviral shedding. 3, 2
Do not miss gonococcal or chlamydial conjunctivitis in adolescents, as these require systemic therapy and consideration of sexual abuse. 3, 1, 6
Increasing bacterial resistance, particularly MRSA, is a concern—if no improvement after 3-4 days, consider resistant organisms and obtain cultures. 1, 6
If the patient wears contact lenses, refer to ophthalmology due to higher risk of corneal ulcers and complications. 1, 5