What is the management (mx) for a female patient with watery eye discharge and conjunctival injections, suspected to be an allergic reaction, with no systemic symptoms?

Management of Allergic Conjunctivitis

For a female patient presenting with watery eye discharge and conjunctival injection consistent with allergic conjunctivitis without systemic symptoms, artificial tears are the most appropriate initial management (Answer A). 1, 2

Rationale for Artificial Tears as First-Line Treatment

• The American Academy of Ophthalmology recommends artificial tears as part of initial management for mild allergic conjunctivitis because they provide symptomatic relief, dilute allergens and inflammatory mediators on the ocular surface, and address any coexisting tear deficiency that may worsen allergic symptoms. 1

• Artificial tears, combined with cold compresses and allergen avoidance measures, are the most appropriate initial management for this clinical presentation. 1

• Watery discharge strongly suggests viral or allergic etiology rather than bacterial conjunctivitis, which typically presents with purulent or mucopurulent discharge with matted eyelids. 2, 3

Why Other Options Are Incorrect

Antibacterial Eye Drops (Option B)

• Topical antibiotics have no role in allergic conjunctivitis management and should be avoided due to risk of inducing toxicity and promoting antimicrobial resistance. 1

• The American Academy of Ophthalmology advises against empirically prescribing antibiotics for watery discharge without evidence of bacterial infection, as this promotes resistance and provides no benefit. 2

• Most cases of conjunctivitis with watery discharge are viral or allergic and self-limited, and do not require antimicrobial therapy. 2

Antiviral Eye Drops (Option C)

• Antiviral therapy is not routinely indicated for viral conjunctivitis except in specific cases of herpes simplex virus with distinctive signs. 1

• Even in viral conjunctivitis (which presents similarly with watery discharge), treatment is supportive with artificial tears rather than antivirals in most cases. 2, 4

Ophthalmic Examination (Option D)

• Immediate ophthalmology referral is not required for straightforward allergic conjunctivitis without red flag features. 1

• Red flags requiring urgent ophthalmology referral include: decreased vision, severe pain, photophobia suggesting corneal involvement, recent ocular surgery, corneal opacity or infiltrate, and vesicular rash on eyelids or nose. 1, 2, 5

Complete Initial Management Algorithm

• Step 1: Immediate symptomatic measures including artificial tears (refrigerated for enhanced cooling effect), cold compresses, and sunglasses as a barrier to airborne allergens. 1

• Step 2: Allergen avoidance counseling, including avoiding eye rubbing, using hypoallergenic bedding and frequent clothes washing, and using eyelid cleansers to remove allergens. 1

• Step 3: If symptoms persist beyond simple measures, add over-the-counter topical antihistamine/vasoconstrictor or second-generation topical H1-receptor antagonist. 1

• Step 4: Reserve for inadequate response—a brief course of low side-effect profile topical corticosteroids, with caution for chronic corticosteroid use requiring monitoring for glaucoma and cataract. 1

Critical Pitfalls to Avoid

• Do not use punctal plugs in allergic conjunctivitis, as they prevent flushing of allergens and inflammatory mediators from the ocular surface. 1

• Avoid chronic vasoconstrictor use, as it can cause rebound vasodilation upon discontinuation. 1

• Oral antihistamines may worsen symptoms by inducing or exacerbating dry eye syndrome and impairing the tear film's protective barrier. 1

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided in undifferentiated conjunctivitis. 1