What is the appropriate management for a 17-year-old patient presenting with conjunctivitis (pink eye)?

Management of Pink Eye in a 17-Year-Old

For a 17-year-old with conjunctivitis, determine the etiology first through clinical features (discharge type, presence of itching, unilateral vs bilateral presentation), then treat viral cases with supportive care only, bacterial cases with topical antibiotics if moderate-to-severe, and allergic cases with topical antihistamine/mast cell stabilizers—but avoid antibiotics entirely for viral conjunctivitis as they provide no benefit and may cause harm. 1, 2

Initial Clinical Assessment

Focus your history and examination on these specific distinguishing features:

Discharge characteristics:

• Watery discharge with follicular reaction on inferior tarsal conjunctiva suggests viral etiology 2
• Mucopurulent discharge with matted eyelids and papillary (not follicular) reaction indicates bacterial conjunctivitis 2
• Minimal discharge with intense itching points to allergic conjunctivitis 2

Associated symptoms:

• Concurrent upper respiratory infection and preauricular lymphadenopathy strongly suggest adenoviral conjunctivitis 2
• Absence of itching, matted eyelids on waking, and no prior history of conjunctivitis favor bacterial etiology 3
• Itching as the predominant symptom with bilateral presentation indicates allergic conjunctivitis 2

Red flags requiring same-day ophthalmology referral:

• Visual loss or decreased vision 2, 4
• Moderate to severe pain 2, 4
• Corneal involvement or opacity 2, 4
• Severe purulent discharge 2, 4
• History of herpes simplex virus eye disease 2, 4

Treatment by Etiology

Viral Conjunctivitis (Most Common)

Do not prescribe antibiotics—they provide zero benefit and cause unnecessary toxicity. 1, 2, 4

Supportive care only:

• Preservative-free artificial tears 4 times daily 2, 4
• Cold compresses for symptomatic relief 1
• Topical antihistamines may provide additional symptomatic relief 2

Critical patient education:

• Highly contagious for 10-14 days from symptom onset 1, 2
• Wash hands frequently with soap and water 2
• Use separate towels and pillows 1
• Avoid close contact with others during contagious period 1, 2

Expected course: Self-limited, resolving within 5-14 days 2

When to consider corticosteroids: Only for severe cases with marked chemosis, lid swelling, or pseudomembranes—requires close ophthalmology follow-up for intraocular pressure monitoring, as steroids can prolong adenoviral infections and worsen HSV infections 1, 2

Bacterial Conjunctivitis

Mild cases are self-limited and may not require treatment. 1, 2

For moderate-to-severe cases:

• Prescribe 5-7 day course of broad-spectrum topical antibiotic 2
• No specific antibiotic is superior—choose the most convenient or least expensive option 2
• Options include: erythromycin ointment 5, polymyxin B/trimethoprim drops, or fluoroquinolones 2

Dosing for erythromycin ointment: Apply approximately 1 cm ribbon to affected eye(s) up to 6 times daily depending on severity 5

Special consideration: If concurrent otitis media is present (common in children), address both conditions 2

Allergic Conjunctivitis

First-line treatment:

• Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 2, 6
• Dosing: 1 drop in affected eye(s) twice daily 4

Environmental modifications:

• Wear sunglasses as barrier to airborne allergens 1
• Cold compresses and refrigerated artificial tears 1
• Avoid eye rubbing 1

For refractory cases:

• Brief 1-2 week course of low-potency topical corticosteroid (loteprednol etabonate) with baseline and periodic intraocular pressure monitoring 2, 6
• Avoid chronic use of vasoconstrictor agents due to rebound vasodilation 1

Critical Pitfalls to Avoid

Never use antibiotics indiscriminately for viral conjunctivitis—this contributes to resistance and causes unnecessary side effects without providing any benefit 1, 2

Never use topical corticosteroids without close ophthalmology follow-up—they can elevate intraocular pressure, cause cataracts, prolong adenoviral infections, and worsen HSV infections 1, 2

Do not miss gonococcal conjunctivitis—presents with marked lid edema, severe purulent discharge, and can cause corneal perforation; requires immediate systemic therapy plus topical treatment 2, 4

Do not miss chlamydial conjunctivitis—requires systemic treatment (azithromycin 1g orally single dose) and evaluation/treatment of sexual partners 2, 4

Follow-Up Recommendations

• Re-evaluate within 1 week if severe viral conjunctivitis with corneal involvement 2
• Return if symptoms persist beyond 2-3 weeks in viral cases not on corticosteroids 2
• Refer to ophthalmology for lack of response after 3-4 days of appropriate therapy, recurrent episodes, or conjunctival scarring 2, 4