What are the recommended treatment options for a patient with post-influenza (post-flu) eye irritation?

Post-Influenza Eye Irritation: Treatment Recommendations

For post-influenza eye irritation, start with preservative-free artificial tears (hyaluronate or carmellose) every 2 hours plus cold compresses for symptomatic relief, as this is most likely viral conjunctivitis requiring supportive care only. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, you must immediately rule out serious complications:

• Check visual acuity - any vision loss requires urgent ophthalmology referral, as influenza can rarely cause optic neuritis, papilledema, or retinopathy 3
• Assess pain severity - moderate to severe pain suggests corneal involvement or HSV and mandates ophthalmology consultation 1, 2
• Examine for purulent discharge - copious purulent discharge may indicate secondary bacterial infection or gonococcal conjunctivitis requiring systemic antibiotics 2
• Look for dendritic lesions or vesicular rash - HSV conjunctivitis is absolutely contraindicated for corticosteroids without antiviral coverage 1, 2

First-Line Treatment: Supportive Care

The cornerstone of post-viral eye irritation is symptomatic management without antibiotics or corticosteroids:

• Preservative-free artificial tears (hyaluronate 0.1% or carmellose 0.5%) every 2 hours while awake provide lubrication and dilute inflammatory mediators 1, 2
• Cold compresses applied for 10-15 minutes several times daily reduce inflammation and provide comfort 1
• Refrigerated artificial tears offer additional cooling sensation for symptomatic relief 1
• Topical antihistamines (second-generation like olopatadine or ketotifen) can be added if itching is prominent 1, 2

Avoid topical antibiotics entirely - they provide no benefit for viral conjunctivitis, cause unnecessary toxicity, and promote resistance 1, 2

When to Consider Topical Corticosteroids

Corticosteroids should be reserved for severe cases only and require close ophthalmology monitoring:

Consider a brief 1-2 week course of low side-effect profile topical corticosteroids (dexamethasone 0.1% twice daily, fluorometholone, or loteprednol) if the patient has: 1, 2

• Marked chemosis (severe conjunctival swelling)
• Severe eyelid swelling resembling orbital cellulitis
• Epithelial sloughing or membranous conjunctivitis
• Corneal subepithelial infiltrates causing photophobia and blurred vision (typically appearing 1+ weeks after initial infection)

Mandatory monitoring if corticosteroids are used: 1, 2

• Measure intraocular pressure at baseline and every 1-2 weeks
• Perform pupillary dilation to check for cataract formation
• Re-evaluate within 1 week for severe cases
• Taper slowly to minimum effective dose once inflammation controlled

Never use corticosteroids without first ruling out HSV - they potentiate viral replication and can cause corneal perforation 1, 2

Infection Control Counseling

Post-influenza viral conjunctivitis is highly contagious:

• Strict hand hygiene with soap and water after touching eyes 1, 2
• Avoid close contact for 10-14 days from symptom onset 2, 4
• Discard multiple-dose eyedrop containers if they contact the ocular surface 1
• Do not share towels, pillows, or personal items 4

When to Refer to Ophthalmology

Immediate ophthalmology referral is required for: 1, 2, 4

• Visual loss or decreased vision
• Moderate to severe pain
• Corneal involvement (infiltrate, ulcer, or opacity)
• Severe purulent discharge suggesting gonococcal infection
• History of HSV eye disease
• Immunocompromised state
• Lack of improvement after 2-3 weeks of supportive care
• Conjunctival scarring

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively - viral conjunctivitis will not respond and antibiotics cause toxicity 1, 2
• Do not use combination antibiotic-steroid drops (like Tobradex) empirically - corticosteroids prolong adenoviral infections and worsen HSV 2
• Do not use topical vasoconstrictors chronically - they cause rebound vasodilation 1
• Do not defer IOP measurement indefinitely if corticosteroids are used - steroid-induced glaucoma can develop rapidly 1, 2

Expected Clinical Course

Most post-influenza viral conjunctivitis is self-limited, resolving within 5-14 days with supportive care alone 4. Patients should return if symptoms persist beyond 2-3 weeks or if any red flag features develop 2, 4.