What is the diagnosis and treatment for a 3-month-old female with right eye swelling, yellowish discharge, and no redness?

Diagnosis and Treatment of Right Eye Swelling with Yellowish Discharge in a 3-Month-Old

This 3-month-old infant most likely has bacterial conjunctivitis, and you should initiate topical erythromycin or polymyxin-bacitracin ointment applied 4 times daily for 5-7 days while carefully evaluating for red flags that require immediate ophthalmology referral. 1

Critical Initial Assessment

Before initiating treatment, you must immediately evaluate for conditions requiring urgent ophthalmology consultation:

• Check for severe, purulent discharge that rapidly reaccumulates after wiping—this suggests possible gonococcal conjunctivitis, which can cause corneal perforation within 24-48 hours and requires immediate referral 2, 1
• Perform fluorescein staining to assess for corneal involvement, as any corneal pathology mandates immediate ophthalmology consultation 2, 1
• Assess for moderate or severe pain—infants may demonstrate this through inconsolable crying or refusal to open the eye, which requires immediate referral 2
• Evaluate visual behavior—any concern for visual loss requires urgent referral 2

Primary Treatment Approach

For uncomplicated bacterial conjunctivitis without red flags, initiate topical antibiotic ointment:

• Erythromycin ophthalmic ointment approximately 1 cm applied directly to the infected eye 4 times daily for 5-7 days 1, 3
• Alternative: Polymyxin-bacitracin ointment applied 4 times daily for 5-7 days 1

Topical antibiotics shorten disease duration from 7 days to approximately 5 days, increase cure rates at 3-5 days, and enhance bacterial eradication 1, 4

Special Pathogen Considerations in Infants

Given the patient's age (3 months), you must consider specific pathogens:

• Chlamydial conjunctivitis: If you observe follicular conjunctivitis, systemic erythromycin is required—topical therapy alone is insufficient. You must also consider sexual abuse in this age group 1, 4
• Gonococcal conjunctivitis: Requires immediate systemic ceftriaxone plus daily follow-up. Again, consider sexual abuse 1, 4
• Late-onset ophthalmia neonatorum: Infants requiring systemic treatment should be managed in conjunction with a pediatrician, and hospitalization is mandatory for neonatal conjunctivitis 2, 4

Infection Control Measures

• Strict hand hygiene is essential—instruct caregivers to wash hands thoroughly after touching the infant's face or applying medication to prevent transmission to the unaffected eye or other household members 1, 4
• Keep the infant home from daycare until discharge resolves or after 24 hours of antibiotic treatment 1

Follow-Up and Escalation Criteria

Return for re-evaluation if no improvement after 3-4 days of treatment 1, 4

Refer immediately to pediatric ophthalmology if:

• Visual loss or abnormal visual behavior 2, 1
• Moderate-to-severe pain (inconsolable crying, eye rubbing) 2, 1
• Corneal involvement on fluorescein staining 2, 1
• Severe purulent discharge that rapidly reaccumulates 2, 1
• Lack of response to therapy after 3-4 days 2, 1

Common Pitfalls to Avoid

• Do not assume this is simple conjunctivitis without examining the cornea—fluorescein staining is essential in any infant with eye discharge 1
• Do not use topical corticosteroids without ophthalmology consultation, as they can worsen HSV infections and require monitoring for glaucoma and cataracts in children 4
• Do not miss concurrent otitis media—if present, prescribe amoxicillin-clavulanate rather than topical antibiotics alone, as these children require systemic antibiotics with enhanced coverage 1
• Do not delay referral if any red flags are present—infants and young children may require evaluations under anesthesia to obtain all necessary information 2