What is the best treatment for a patient with eye soreness and redness?

Treatment of Eye Soreness and Redness

For acute eye soreness and redness, first determine if this is conjunctivitis (the most common cause), and if so, identify whether it is viral, bacterial, or allergic, as each requires distinctly different management—viral needs only supportive care, bacterial may benefit from topical antibiotics in moderate-to-severe cases, and allergic responds to topical antihistamines with mast cell stabilizers. 1

Initial Diagnostic Approach

Obtain specific history focusing on:

• Character of discharge: watery suggests viral, mucopurulent/purulent suggests bacterial, minimal with intense itching suggests allergic 1
• Unilateral vs bilateral onset: viral often starts unilateral then becomes bilateral, allergic is typically bilateral from onset 1
• Associated symptoms: upper respiratory infection and preauricular lymphadenopathy suggest viral, concurrent otitis media suggests bacterial, seasonal pattern with itching suggests allergic 1
• Contact lens wear: must be discontinued during any infectious conjunctivitis 1

Examine for:

• Type of conjunctival reaction: follicles on inferior tarsal conjunctiva indicate viral, papillae suggest bacterial or allergic 1
• Preauricular lymphadenopathy: present in viral, absent in bacterial and allergic 1
• Corneal involvement: requires urgent ophthalmology referral 1

Treatment Algorithm by Etiology

Viral Conjunctivitis (Most Common)

Do not prescribe antibiotics—they provide no benefit and cause unnecessary toxicity. 1, 2

Supportive care only:

• Artificial tears (preservative-free if used >4 times daily) for symptomatic relief 2
• Cold compresses to reduce inflammation 2
• Topical antihistamines for itching relief 2
• Oral analgesics for pain 2

Patient counseling is critical:

• Minimize contact with others for 10-14 days from symptom onset 2
• Strict hand hygiene with soap and water 1
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 2
• Avoid sharing towels, pillows, or personal items 1

For severe cases with marked chemosis, lid swelling, or subepithelial infiltrates causing vision changes:

• Consider topical corticosteroids (loteprednol 0.5% gel or suspension preferred due to lower intraocular pressure risk) 3, 2
• Mandatory close ophthalmology follow-up with regular intraocular pressure monitoring 2
• Taper slowly to minimum effective dose 2
• Never use corticosteroids if herpes simplex virus is suspected, as this can worsen infection and cause corneal scarring 2

Follow-up:

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

Bacterial Conjunctivitis

Mild cases are self-limited and may resolve without treatment, but topical antibiotics can shorten duration. 1

For moderate-to-severe cases:

• Prescribe 5-7 day course of broad-spectrum topical antibiotic 1
• No specific antibiotic is superior—choose most convenient or least expensive option 1:
  • Erythromycin ointment
  • Polymyxin B/trimethoprim drops
  • Fluoroquinolones (remain effective despite increasing MRSA prevalence) 1

Special considerations:

• Gonococcal conjunctivitis (marked lid edema, severe purulent discharge, preauricular lymphadenopathy): requires systemic antibiotics plus topical therapy, hospitalization for parenteral treatment, and daily follow-up until resolution 1
• Chlamydial conjunctivitis: requires systemic treatment and evaluation/treatment of sexual partners 1

Allergic Conjunctivitis

First-line treatment is topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen). 1

Additional measures:

• Environmental modifications: wear sunglasses as barrier to airborne allergens 1
• Cold compresses and refrigerated artificial tears 1
• Avoid eye rubbing 1
• Oral antihistamines as adjunct (less effective than topical for ocular symptoms) 3

For refractory cases:

• Short 1-2 week course of topical corticosteroids (loteprednol preferred) 1
• Consider allergen-specific immunotherapy for severe cases 1

Blepharitis-Related Redness and Soreness

If examination reveals eyelid margin inflammation, collarettes, or meibomian gland dysfunction:

Basic management:

• Daily eyelid hygiene with warm compresses and lid scrubs 3
• Artificial tears, especially oil-based or lipid-containing formulations 3
• If used >4 times daily, use preservative-free formulations to avoid toxicity 3

For moderate-to-severe cases:

• Topical azithromycin or oral doxycycline for anti-inflammatory effect 3
• Brief course of topical corticosteroids (loteprednol 0.5%) may help acute inflammation 3

For Demodex blepharitis (if not improving with above):

• Topical lotilaner 0.25% (FDA-approved) twice daily for 6 weeks significantly reduces collarettes and mites 3
• Alternative: tea tree oil preparations (use caution—can cause corneal epithelial defects at high concentrations) 3

Red Flags Requiring Urgent Ophthalmology Referral

Refer immediately if any of the following:

• Visual loss or decreased vision 1
• Moderate or severe pain 1
• Severe purulent discharge 1
• Corneal involvement (fluorescein staining positive) 1
• Conjunctival scarring 1
• History of herpes simplex virus eye disease 1
• Immunocompromised state 1
• Lack of response to therapy 1
• Recent ocular surgery 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics indiscriminately for red eye—most cases are viral and antibiotics cause unnecessary toxicity and contribute to resistance 1, 2
• Never use topical corticosteroids without confirming diagnosis is not HSV—can cause devastating corneal complications 2
• Never use topical vasoconstrictors (naphazoline) for >10 days—causes rebound hyperemia ("conjunctivitis medicamentosa") 3, 4
• Never allow contact lens wear during infectious conjunctivitis 1
• Avoid preserved artificial tears if using >4 times daily—benzalkonium chloride causes preservative toxicity 3