A patient has 2.5‑day‑old conjunctival redness with eyelid edema; what is the most likely diagnosis and initial management?

2.5-Day-Old Conjunctival Redness with Eyelid Edema

The most likely diagnosis is viral conjunctivitis (specifically adenoviral), and initial management should focus on ruling out bacterial causes (especially gonococcal in neonates), performing fluorescein staining to exclude corneal involvement, and providing supportive care while monitoring for complications. 1, 2

Immediate Assessment Required

Perform fluorescein staining immediately to detect corneal involvement, as this is mandatory in any case presenting with conjunctival injection and eyelid edema. 2, 3 Corneal involvement requires immediate ophthalmology referral. 2, 3

Critical Red Flags Requiring Emergency Evaluation

• Severe or rapidly reaccumulating purulent discharge – suggests gonococcal conjunctivitis, which can cause corneal perforation within 24-48 hours 2, 4
• Marked eyelid edema with copious purulent discharge – gonococcal infection until proven otherwise 1, 4
• Presence of eyelid vesicles – pathognomonic for herpes simplex virus, requires immediate ophthalmology referral 2, 4
• Proptosis or impaired extraocular muscle function – indicates orbital cellulitis requiring immediate CT imaging 2

Most Likely Diagnosis: Viral Conjunctivitis

Clinical Features Supporting Viral Etiology

• Abrupt onset with watery discharge and eyelid swelling/erythema are characteristic of adenoviral infection 1
• Follicular reaction of inferior tarsal conjunctiva with bulbar conjunctival injection is diagnostic 4
• May initially present unilaterally before progressing to sequential bilateral involvement 1, 4
• Preauricular lymphadenopathy is a distinctive sign when present 1
• Self-limited course with improvement within 5-14 days in most cases 1, 4

Management of Viral Conjunctivitis

Supportive care is the cornerstone, as viral conjunctivitis is self-limiting. 5, 6 Specific measures include:

• Warm compresses and artificial tears to relieve symptoms 6
• Strict hygiene measures: avoid touching eyes, frequent handwashing, disposable towels, avoid group activities while discharge present 6
• Monitor for progression to epidemic keratoconjunctivitis (EKC) with subepithelial infiltrates that can cause long-term visual sequelae 4
• Avoid topical corticosteroids before ruling out HSV keratitis, as this can mask serious conditions 3, 6

Differential Diagnoses to Exclude

Bacterial Conjunctivitis

Consider bacterial etiology if:

• Mattering and adherence of eyelids on waking with mucopurulent or purulent discharge 5
• Lack of itching and no history of previous conjunctivitis 5
• Unilateral or bilateral presentation with marked bulbar conjunctival injection 1

If bacterial conjunctivitis is suspected:

• Start broad-spectrum topical antibiotic (gatifloxacin, moxifloxacin, or azithromycin) empirically 3
• Topical antibiotics modestly improve clinical remission rates (RR 1.21) and microbiological cure (RR 1.37) by days 6-10 7
• Obtain cultures if: copious discharge, unresponsive to initial therapy, or suspected gonococcal/chlamydial infection 3

Age-Specific Considerations

In neonates (if applicable):

• Any purulent conjunctivitis is an emergency until gonococcal and chlamydial causes are ruled out 2, 4
• Gonococcal conjunctivitis manifests within 1-7 days after birth with marked eyelid edema, marked purulent discharge, and can cause septicemia, meningitis, and death 1, 4
• Chlamydial conjunctivitis presents 5-19 days after birth with eyelid edema and purulent/mucopurulent discharge (no follicles in neonates) 1
• Both require immediate systemic antibiotics, not just topical therapy 2, 4

Preseptal vs. Orbital Cellulitis

Preseptal cellulitis presents with:

• Eyelid swelling, erythema, and warmth without proptosis or impaired extraocular movements 2
• Can be managed with oral antibiotics if orbit and optic nerve not involved 8

If proptosis or impaired extraocular movements present:

• Obtain contrast-enhanced CT scan immediately to rule out orbital cellulitis, subperiosteal abscess, or orbital abscess 2
• Requires aggressive intervention with IV antibiotics and possible surgical drainage 8

Common Pitfalls to Avoid

• Never assume "just conjunctivitis" when eyelid edema is marked – always consider preseptal/orbital cellulitis 2, 8
• Never skip fluorescein examination – corneal involvement changes management completely 2, 3
• Never use topical corticosteroids empirically – can worsen HSV keratitis and mask serious conditions 3, 6
• Never treat neonatal purulent conjunctivitis with topical antibiotics alone – systemic treatment is mandatory for gonococcal and chlamydial infections 2, 4

Follow-Up

Re-evaluate in 48-72 hours if symptoms worsen or fail to improve. 5 Refer to ophthalmology if corneal involvement develops, vision decreases, or severe complications arise. 2, 3