What is the appropriate management for a patient with conjunctival chemosis in a homecare setting?

Management of Conjunctival Chemosis in Homecare Settings

Patients with conjunctival chemosis in homecare settings require ophthalmology referral when there is marked chemosis with lid swelling, persistent symptoms beyond 2-3 weeks, visual changes, moderate to severe pain, or corneal involvement. 1, 2

Initial Assessment and Triage

The homecare provider must first determine the underlying cause and severity of chemosis to guide appropriate referral timing:

• Immediate ophthalmology referral is warranted for marked chemosis with lid swelling, epithelial sloughing, membranous conjunctivitis, corneal epithelial defects, moderate to severe pain, or visual loss 1, 2
• Routine referral within 2-3 weeks is appropriate for mild chemosis with minimal symptoms that may be self-limited 1
• Look specifically for: bilateral vs unilateral presentation, presence of discharge (mucopurulent suggests bacterial, watery suggests viral/allergic), preauricular lymphadenopathy (suggests viral), and any history of recent eye surgery or trauma 1, 3

Symptomatic Management While Awaiting Ophthalmology Evaluation

For mild cases pending ophthalmology assessment, homecare providers can initiate conservative measures:

• Cold compresses and refrigerated artificial tears provide symptomatic relief and can be used liberally 1
• Apply artificial tears (preservative-free hyaluronate or carmellose) every 2 hours for lubrication 1
• Oral analgesics for discomfort as needed 1
• Avoid topical antibiotics or corticosteroids without ophthalmology guidance, as inappropriate use can worsen certain conditions (e.g., corticosteroids prolong adenoviral shedding and worsen HSV infections) 1

When Topical Corticosteroids May Be Indicated

Topical corticosteroids are specifically helpful for severe adenoviral keratoconjunctivitis with marked chemosis or lid swelling, but require close ophthalmology follow-up due to risks of prolonged viral shedding, elevated intraocular pressure, and cataract formation 1

• If prescribed by ophthalmology, use low-penetration steroids like loteprednol or fluorometholone to minimize IOP elevation risk 1, 4
• Patients on topical corticosteroids require monitoring of intraocular pressure and should not continue beyond 14 days without ophthalmology re-examination 4
• Never initiate corticosteroids in homecare without ophthalmology consultation, as they can mask corneal infection and worsen outcomes 1

Infection Control for Viral Causes

If adenoviral conjunctivitis is suspected (watery discharge, preauricular nodes, highly contagious nature):

• Educate patients that the virus survives weeks on surfaces and is highly contagious for 10-14 days from symptom onset in the last affected eye 1
• Strict hand hygiene, avoid sharing towels/pillows, and consider work-from-home arrangements for 10-14 days 1
• Disinfect surfaces with 1:10 dilution of household bleach 1

Red Flags Requiring Urgent Ophthalmology Referral

Immediately refer to ophthalmology or emergency department if any of the following develop:

• Corneal involvement (epithelial defects, ulceration, infiltrates) 2, 3
• Visual loss or significant visual changes 2
• Moderate to severe persistent pain 2
• Membranous or pseudomembranous conjunctivitis 1
• Symptoms persisting or worsening despite 2-3 days of appropriate treatment 1, 3
• Signs of systemic involvement (Stevens-Johnson syndrome, toxic epidermal necrolysis) 1

Special Populations

Elderly patients (>60 years) with chemosis warrant closer monitoring due to increased risk of giant fornix syndrome, nasolacrimal duct obstruction, and bacterial complications including MRSA 3

Immunocompromised patients require urgent ophthalmology evaluation due to risk of systemic spread and severe complications 3

Common Pitfalls to Avoid

• Do not prescribe topical antibiotics empirically for chemosis without clear bacterial signs (mucopurulent discharge, crusting), as this promotes resistance and toxicity 1
• Do not use topical vasoconstrictors chronically, as they cause rebound vasodilation 1
• Do not delay ophthalmology referral for severe chemosis hoping for spontaneous resolution, as conditions like Stevens-Johnson syndrome require early intervention to prevent permanent sequelae 1