Initial Management: Ophthalmic Examination is Mandatory
The initial step is a comprehensive ophthalmic examination (Option D), as pain and photophobia are red flags indicating potential corneal involvement that requires immediate specialist assessment before any treatment is initiated. 1
Why Examination Must Come First
The combination of pain, photophobia, watery discharge, and conjunctival injection represents warning signs that demand urgent ophthalmologic evaluation before treatment. 1 These symptoms suggest possible:
- Viral keratoconjunctivitis with corneal epithelial defects or subepithelial infiltrates 1
- Herpes simplex keratitis which can cause devastating complications including corneal scarring and perforation 1
- Bacterial keratitis with suppurative stromal infiltrates requiring immediate intervention 1
The American Academy of Ophthalmology explicitly states that decreased vision, severe pain, and photophobia are warning signs demanding immediate ophthalmological consultation before treatment initiation. 1
Critical Diagnostic Sequence
The initial eye examination must include: 2
- Visual acuity measurement to detect any vision compromise
- External examination for regional lymphadenopathy (preauricular nodes suggest viral etiology), eyelid abnormalities, and skin lesions
- Slit-lamp biomicroscopy to identify corneal epithelial defects, infiltrates, anterior chamber reaction, or pseudomembranes
- Determination of need for cultures if severe purulent discharge or gonococcal infection suspected
Why Other Options Are Incorrect
Artificial tears (Option A) would be appropriate only after ruling out serious pathology, as they provide symptomatic relief for viral or allergic conjunctivitis but do nothing for sight-threatening conditions. 3
Antibacterial therapy (Option B) started before proper examination can worsen herpetic infections and mask accurate diagnosis. 1 Watery discharge strongly suggests viral or allergic etiology rather than bacterial (which presents with purulent/mucopurulent discharge). 2
Antiviral therapy (Option C) cannot be initiated without confirming HSV keratitis through slit-lamp examination, as empiric treatment risks missing other diagnoses and inappropriate steroid use can devastate HSV infections. 1
Common Pitfalls to Avoid
- Never assume "conjunctivitis" when pain and photophobia are prominent—these symptoms indicate deeper ocular structure involvement requiring specialist evaluation. 1
- Never start corticosteroids before proper examination, as they can worsen infectious keratitis from Acanthamoeba, Nocardia, fungus, or HSV. 1
- Avoid patching the eye in any patient with suspected infection, as it increases risk of bacterial keratitis progression. 1
When to Refer Urgently
Immediate ophthalmology referral is mandatory for: 2, 1
- Visual loss or blurred vision
- Moderate to severe pain
- Photophobia (as present in this case)
- Recent ocular surgery
- Corneal opacity or infiltrate
- Vesicular rash on eyelids or nose
- Immunocompromised state