What medications can be used to treat redness around the eyes?

Treatment of Redness Around the Eyes

For redness around the eyes without red flag symptoms, start with preservative-free artificial tears 4 times daily and topical antihistamine/mast cell stabilizers (such as olopatadine twice daily) if itching is present, as this combination addresses the most common causes—allergic conjunctivitis, dry eye, and blepharitis. 1, 2

Immediate Assessment for Red Flags

Before initiating treatment, you must rule out conditions requiring urgent ophthalmology referral within 24 hours. Refer immediately if any of the following are present: 3, 4

• Visual loss or decreased visual acuity 1, 3
• Moderate to severe ocular pain (beyond mild irritation) 1, 3
• Photophobia (light sensitivity) 1, 3
• Corneal opacity or visible corneal damage 1, 3
• Severe purulent discharge 3, 4
• Unilateral presentation (suggests non-allergic causes like HSV, keratitis, or uveitis) 3, 4
• History of herpes simplex virus eye disease 1, 3
• Immunocompromised state 3, 4

Treatment Algorithm by Clinical Presentation

For Allergic Conjunctivitis (Itching Predominant, Bilateral)

First-line therapy: 1, 2

• Dual-action topical agents (antihistamine + mast cell stabilizer): olopatadine, ketotifen, epinastine, or azelastine—1 drop twice daily 1, 2
• Preservative-free artificial tears refrigerated, 4 times daily to dilute allergens 1, 2
• Cold compresses for symptomatic relief 1, 2
• Environmental modifications: sunglasses outdoors, hypoallergenic bedding, eyelid cleansers, showering before bed 1, 2
• Avoid eye rubbing (can lead to keratoconus in atopic patients) 1, 2

Second-line (if inadequate response after 48-72 hours): 2

• Add short course (1-2 weeks) of low-potency topical corticosteroid such as loteprednol etabonate 1, 2
• Monitor intraocular pressure at baseline and periodically if using corticosteroids 1, 2

Third-line (severe/refractory cases): 1, 2

• Topical cyclosporine 0.05% or tacrolimus for chronic cases 1, 2
• Consider ophthalmology referral for immunotherapy evaluation 2

For Blepharitis (Lid Margin Inflammation, Crusting)

Treatment approach: 1

• Warm compresses to eyelids 1
• Eyelid hygiene with lid scrubs 1
• Preservative-free artificial tears 4 times daily 1
• For moderate-to-severe cases: topical tacrolimus ointment to lid margins once daily 1
• For posterior blepharitis/meibomian gland dysfunction: consider oral doxycycline 50-100 mg daily (avoid in pregnancy, nursing, children <8 years) 1

For Viral Conjunctivitis (Watery Discharge, Follicular Reaction)

Management is supportive only—antibiotics provide no benefit: 1, 4

• Preservative-free artificial tears for symptomatic relief 1, 4
• Cold compresses 1
• Patient education: highly contagious for 10-14 days, avoid touching eyes, frequent handwashing, no sharing towels 4
• Do NOT use topical antibiotics (cause unnecessary toxicity) 1, 4
• Do NOT use topical corticosteroids unless under ophthalmology supervision (can prolong viral shedding and worsen HSV) 1, 4

For Bacterial Conjunctivitis (Purulent Discharge, Matted Lids)

For moderate-to-severe cases: 4

• Broad-spectrum topical antibiotic for 5-7 days (e.g., moxifloxacin 3 times daily) 4, 5
• No specific antibiotic has proven superiority—choose based on cost and convenience 4
• Mild cases often self-resolve without antibiotics 4

For Dupilumab-Related Ocular Surface Disorders (DROSD)

If patient is on dupilumab for atopic dermatitis: 1

Mild-to-moderate DROSD: 1

• Preservative-free lubricants 2-4 times daily 1
• Add olopatadine twice daily if inadequate response 1
• For severe cases: add tacrolimus ointment to lid margins once daily (seek ophthalmology advice for ages 7-17 years) 1

Refer to ophthalmology within 4 weeks if using tacrolimus or if classified as severe at onset 1

Critical Pitfalls to Avoid

• Never use topical corticosteroids without ophthalmology follow-up for IOP monitoring and cataract surveillance 1, 4, 2
• Avoid chronic vasoconstrictor use (>10 days) due to rebound hyperemia 2
• Do not prescribe oral antihistamines as primary therapy for allergic conjunctivitis—they worsen dry eye 1, 2
• Never use antibiotics for viral conjunctivitis—they provide no benefit and cause toxicity 1, 4
• Avoid topical corticosteroids in suspected viral or HSV conjunctivitis without ophthalmology consultation 1, 4

When to Refer to Ophthalmology

Non-urgent referral indicated for: 1, 4

• Lack of response to therapy after 3-4 days 1, 4
• Recurrent episodes 1, 4
• Conjunctival scarring 1, 4
• Need for prolonged corticosteroid therapy 1, 2
• Suspected vernal or atopic keratoconjunctivitis 2