How should I manage new eye swelling and redness with mild symptoms, no visual loss, no pain on eye movement, and no purulent discharge?

Management of Mild Eye Swelling and Redness Without Red Flags

For new eye swelling and redness with mild symptoms, no visual loss, no pain on eye movement, and no purulent discharge, initiate preservative-free ocular lubricants 2-4 times daily and observe for 1-2 weeks, as this presentation most likely represents viral or allergic conjunctivitis which are typically self-limited conditions. 1

Immediate Red Flag Assessment

Before initiating treatment, you must exclude vision-threatening conditions by checking for:

• Visual acuity - any decrease requires urgent ophthalmology referral 1, 2
• Moderate to severe pain (beyond mild irritation or foreign body sensation) - demands emergency evaluation within 24 hours 3, 1
• Photophobia - suggests corneal involvement or anterior uveitis requiring immediate ophthalmology consultation 3, 1, 4
• Purulent discharge - indicates bacterial infection potentially requiring antibiotics 1
• Unilateral presentation with redness - should prompt consideration of other causes beyond simple conjunctivitis 3, 1
• Pain with eye movement - suggests orbital involvement requiring urgent referral 3, 2

If any of these red flags are present, refer to ophthalmology within 24 hours before initiating any treatment. 1, 2

Determining the Most Likely Etiology

Viral Conjunctivitis (Most Common)

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 1
• Often starts unilateral but becomes sequentially bilateral within days 1
• May have concurrent upper respiratory infection 1
• Preauricular lymphadenopathy may be present 1
• Self-limited, typically resolving within 5-14 days 1

Allergic Conjunctivitis

• Itching is the most consistent and distinguishing feature 1
• Bilateral presentation 1
• Watery discharge with mild mucous component 1
• History of atopy, seasonal pattern, or known allergen exposure 1
• No preauricular lymphadenopathy 1

Bacterial Conjunctivitis (Less Likely Without Purulent Discharge)

• Mucopurulent discharge with matted eyelids 1
• Papillary rather than follicular reaction 1
• Can be unilateral or bilateral 1

Initial Treatment Algorithm

For Suspected Viral Conjunctivitis:

• Do NOT prescribe antibiotics - they provide no benefit and may cause unnecessary toxicity 1, 5
• Preservative-free artificial tears for symptomatic relief 2-4 times daily 1
• Topical antihistamines (olopatadine or ketotifen) may be used for symptomatic relief 1
• Cold compresses for comfort 1
• Patient education is critical: highly contagious for 10-14 days from symptom onset 1

For Suspected Allergic Conjunctivitis:

• First-line treatment: topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1, 6
• Preservative-free artificial tears 2-4 times daily 1
• Cold compresses and refrigerated artificial tears 1
• Environmental modifications: wear sunglasses as barrier to airborne allergens, avoid eye rubbing 1

If Mild Bacterial Conjunctivitis Cannot Be Excluded:

• Mild bacterial conjunctivitis is usually self-limited and may resolve without treatment 1
• If you choose to treat, use a 5-7 day course of broad-spectrum topical antibiotic (erythromycin ointment, polymyxin B/trimethoprim drops, or fluoroquinolones) 1
• No specific antibiotic is superior - choose the most convenient or least expensive option 1

Critical Pitfalls to Avoid

• Never use topical corticosteroids without ophthalmology consultation - they can prolong adenoviral infections, worsen herpes simplex virus infections, and cause increased intraocular pressure and cataracts 1
• Avoid indiscriminate antibiotic use for viral conjunctivitis - contributes to resistance and causes unnecessary side effects 1, 5
• Do not miss gonococcal conjunctivitis - marked eyelid edema with purulent discharge requires immediate systemic treatment to prevent corneal perforation 1
• Contact lens wear must be discontinued during any form of infectious conjunctivitis 1

Infection Control Measures

For suspected viral conjunctivitis (highly contagious):

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

Follow-Up Timing

• Re-evaluate within 1-2 weeks if symptoms persist or worsen 1, 7
• Immediate return if patient develops visual loss, severe pain, photophobia, or purulent discharge 1, 2
• If no improvement after 2-3 weeks, refer to ophthalmology for further evaluation 1
• Chronic or recalcitrant conjunctivitis may indicate underlying malignancy and requires ophthalmology referral 1