What is the best course of treatment for a patient with severe congestion and conjunctivitis in both eyes?

Treatment of Severe Congestion with Bilateral Conjunctivitis

The most critical first step is determining whether this patient requires immediate ophthalmology referral, as severe congestion with bilateral involvement may indicate serious underlying pathology requiring specialist management. 1

Immediate Assessment for Red Flags

Before initiating any treatment, evaluate for the following features that mandate same-day ophthalmology referral 1, 2:

• Visual acuity testing - any decrease in vision requires immediate referral 1, 2
• Pain severity - moderate to severe pain suggests keratitis, uveitis, or angle-closure glaucoma 1, 2
• Corneal involvement - perform fluorescein staining if available; any uptake requires specialist evaluation 1, 2
• Severe purulent discharge - particularly if rapidly reaccumulating, raises concern for gonococcal infection which can cause corneal perforation within 24-48 hours 1, 2
• History of HSV eye disease - increases risk of recurrence requiring specialist monitoring 1, 2
• Immunocompromised state - requires closer ophthalmology oversight 1, 2

If any red flag is present, refer immediately to ophthalmology same-day before initiating treatment. 2

Determining Etiology Based on Clinical Features

Viral Conjunctivitis (Most Common Overall)

Clinical presentation 3, 4:

• Watery discharge (not purulent or mucopurulent) 3, 4, 5
• Follicular reaction on inferior tarsal conjunctiva 3, 4
• Preauricular lymphadenopathy 3, 4
• Often starts unilateral but becomes sequentially bilateral 3, 4
• May have concurrent upper respiratory infection 4
• Subconjunctival hemorrhages, chemosis, and eyelid swelling are distinctive findings 4

Treatment approach 3:

• Supportive care only - avoid antibiotics entirely as they provide no benefit and may cause toxicity 3, 4
• Refrigerated preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 3
• Cold compresses for symptomatic relief 3, 5
• Topical antihistamines (second-generation) for itching and discomfort 3
• Strict hand hygiene with soap and water to prevent transmission 3
• Avoid close contact for 7-14 days from symptom onset 3

For severe cases with marked chemosis, lid swelling, or pseudomembranes 3, 4:

• Consider short course of topical corticosteroids only with close ophthalmology follow-up 3, 4
• Requires regular monitoring of intraocular pressure and periodic pupillary dilation 3, 4
• Warning: Corticosteroids prolong adenoviral shedding and can worsen HSV infections 3, 4

Bacterial Conjunctivitis (Second Most Common)

Clinical presentation 3, 4:

• Mucopurulent discharge with matted eyelids on waking 4, 6, 5
• Papillary (not follicular) reaction 4
• Lack of itching 6
• Preauricular lymphadenopathy less common unless hypervirulent organisms 4
• Can be unilateral or bilateral 4

Treatment approach 3:

• For mild to moderate cases: 5-7 day course of broad-spectrum topical fluoroquinolone 3
• Moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin are all effective 3, 7
• No evidence demonstrates superiority of any specific agent - choose based on cost and convenience 3
• Typical dosing: 3-4 times daily for 5-7 days 3, 7
• Note: Mild bacterial conjunctivitis is often self-limited and may resolve without treatment, but antibiotics decrease duration and allow earlier return to work/school 3, 6

For severe bacterial conjunctivitis with copious purulent discharge 3:

• Obtain conjunctival cultures and Gram staining before initiating treatment 3
• Consider MRSA in nursing home patients or community-acquired infections 3
• May require compounded topical vancomycin for resistant cases 3

Allergic Conjunctivitis

Clinical presentation 4:

• Itching is the most consistent and distinguishing feature 4, 6
• Bilateral presentation 4
• Watery discharge 4
• Absence of preauricular lymphadenopathy and matted eyelids 4
• May have concurrent allergic rhinitis or asthma 4
• Often seasonal or perennial depending on allergen exposure 4

Treatment approach 3, 4:

• First-line: Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 3, 4
• Environmental modifications: sunglasses as allergen barrier, cold compresses, refrigerated artificial tears 3, 4
• Avoid eye rubbing 4
• For refractory cases: brief 1-2 week course of low side-effect profile topical corticosteroids with IOP monitoring 3, 4

Special Considerations Requiring Systemic Treatment

Gonococcal Conjunctivitis

Presentation 4:

• Marked eyelid edema, severe purulent discharge, preauricular lymphadenopathy 4
• Can cause corneal perforation within 24-48 hours if untreated 4, 2

Treatment 3:

• Requires systemic antibiotics in addition to topical therapy 3
• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 3
• Hospitalization necessary for parenteral therapy 1
• Daily monitoring until resolution 1, 3
• Treat sexual partners concurrently 1, 3

Chlamydial Conjunctivitis

Treatment 3:

• Systemic therapy required - topical therapy alone is inadequate 3, 4
• Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 3
• Treat sexual partners and evaluate for concurrent genital infections 1, 3
• In children, consider sexual abuse and report to authorities 1, 2

Follow-Up Recommendations

Re-evaluate at 3-4 days if no improvement 2:

• If symptoms persist or worsen, refer to ophthalmology 2
• Lack of response to therapy after 3-4 days suggests resistant organisms, incorrect diagnosis, or more serious pathology 2

For severe viral conjunctivitis 4:

• Re-evaluate within 1 week 4
• Return if symptoms persist beyond 2-3 weeks 4

For patients on topical corticosteroids 3, 4:

• Regular monitoring of intraocular pressure required 3, 4
• Periodic pupillary dilation to monitor for cataract formation 3, 4

Critical Pitfalls to Avoid

• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage - they potentiate infection 3
• Do not use antibiotics indiscriminately for viral conjunctivitis - they cause unnecessary toxicity and contribute to resistance 3, 4
• Do not miss gonococcal conjunctivitis - delayed referral leads to corneal perforation and vision loss 4, 2
• Avoid contact lens wear during any form of infectious conjunctivitis 4, 7
• Do not use topical corticosteroids without close ophthalmology follow-up due to risk of elevated IOP, cataracts, and worsening infections 3, 4