What is the appropriate management for a patient presenting with unilateral eye redness and discharge?

Management of Unilateral Eye Redness with Discharge

The appropriate management depends critically on the type of discharge and associated findings: purulent discharge requires immediate evaluation for gonococcal or bacterial infection with urgent corneal examination using fluorescein staining, while watery discharge with follicular conjunctivitis suggests viral etiology requiring supportive care and infection control measures. 1, 2

Immediate Assessment Priorities

Critical Red Flags Requiring Emergency Ophthalmology Referral

• Any purulent discharge must be evaluated immediately for gonococcal conjunctivitis, which can cause corneal perforation within 24-48 hours 2
• Perform fluorescein staining in all cases of purulent conjunctivitis to detect early corneal involvement, as corneal infiltrates or ulcers often begin superiorly and may rapidly progress to perforation 1, 2
• Severe ocular pain not relieved with topical anesthetics demands immediate ophthalmological consultation 3, 4
• Vision loss, corneal involvement, or distorted pupil require urgent referral 3

Discharge Characteristics Guide Initial Management

Purulent/mucopurulent discharge:

• Suspect bacterial conjunctivitis (nongonococcal or gonococcal) 1
• Gonococcal presents with marked eyelid edema, marked bulbar injection, and copious purulent discharge with preauricular lymphadenopathy 1
• Requires immediate systemic antibiotics in addition to topical therapy if gonococcal 2
• Broad-spectrum topical antibiotics for presumed bacterial conjunctivitis in mild cases 3

Watery to white discharge:

• Suggests viral etiology, most commonly adenovirus 2, 5
• Look for follicular reaction on inferior tarsal conjunctiva and preauricular lymphadenopathy to confirm viral cause 1, 2, 5
• Self-limited, resolving within 5-14 days 2

Algorithmic Approach by Clinical Presentation

Step 1: Assess Severity and Laterality

Unilateral with purulent discharge:

• Examine for corneal involvement with fluorescein immediately 2
• Check for preauricular lymphadenopathy 1
• If marked eyelid edema and copious purulent discharge: treat as gonococcal until proven otherwise with immediate systemic antibiotics 2
• If mild-moderate purulent discharge without corneal involvement: broad-spectrum topical antibiotics 3

Unilateral with watery discharge:

• Examine tarsal conjunctiva for follicles (viral) versus papillae (allergic) 5
• Check for vesicular lesions on eyelids suggesting HSV or VZV 1, 2
• Look for dome-shaped umbilicated lesions suggesting molluscum contagiosum 1

Step 2: Identify Vision-Threatening Conditions

Herpes simplex virus conjunctivitis:

• Usually unilateral with watery discharge and mild follicular reaction 1
• Can progress to keratitis, stromal keratitis, corneal scarring, perforation, uveitis, and retinitis 2
• Requires antiviral therapy and ophthalmology referral 1

Varicella zoster virus:

• Distinctive vesicular dermatomal rash or ulceration of eyelids with severe pain 1, 2
• Can cause corneal scarring, uveitis, retinitis, and late corneal anesthesia 2
• Requires systemic antivirals and ophthalmology consultation 1

Chlamydial conjunctivitis:

• Follicular conjunctivitis with distinctive follicles on bulbar conjunctiva and semilunar fold 2
• Requires systemic antibiotics (topical therapy alone is insufficient) 2

Step 3: Supportive Care for Viral Conjunctivitis

If adenoviral conjunctivitis confirmed (watery discharge, follicles, preauricular node):

• Warm soaks and artificial tear lubricants for symptom relief 6
• Strict infection control: avoid touching eyes, frequent handwashing, disposable towels, avoid group activities while discharge present 6
• Monitor for progression to epidemic keratoconjunctivitis with subepithelial infiltrates 2
• Do not prescribe topical corticosteroids or antibiotics in primary care, as this can mask serious conditions and lead to complications 6, 7

Critical Pitfalls to Avoid

• Never prescribe topical corticosteroids in primary care for red eye with discharge - they can worsen HSV keratitis, mask serious conditions, and cause complications 6, 7
• Always examine the cornea with fluorescein in purulent conjunctivitis before assuming simple bacterial infection 2
• Do not assume bilateral disease initially - adenoviral conjunctivitis often starts unilaterally before progressing to bilateral involvement within days 2
• If no improvement after 10 days of treatment, refer to ophthalmology 7
• Chronic or recurrent unilateral red eye requires ophthalmology evaluation 7

Special Population Considerations

Neonates:

• Any purulent conjunctivitis is an emergency until gonococcal and chlamydial causes are ruled out 2
• Gonococcal infection can lead to septicemia, meningitis, and death 2

Immunocompromised patients:

• Higher risk for severe complications and atypical presentations 2
• Molluscum contagiosum may present with multiple large periocular lesions 2