What is the appropriate evaluation and management for a 54‑year‑old patient with left‑eye redness and swelling for four days?

Evaluation and Management of Left Eye Redness and Swelling for 4 Days

This 54-year-old patient requires immediate assessment for red-flag features that distinguish benign conjunctivitis from sight-threatening conditions, followed by targeted treatment based on the underlying etiology—most likely bacterial or viral conjunctivitis given the 4-day duration.

Immediate Red-Flag Assessment

Perform urgent evaluation for the following features that mandate same-day ophthalmology referral:

• Visual acuity testing – any vision loss or decreased vision below 20/40 requires urgent ophthalmology consultation 1
• Pain severity – moderate to severe pain unrelieved by over-the-counter analgesics suggests corneal involvement, iritis, or acute glaucoma 1, 2
• Corneal examination – use fluorescein staining to detect corneal ulceration, infiltrate, or opacity, which indicates keratitis rather than simple conjunctivitis 1
• Pupil assessment – distorted pupil shape suggests anterior uveitis or acute angle-closure glaucoma 2
• Severe purulent discharge – copious purulent discharge raises concern for gonococcal conjunctivitis, which can cause corneal perforation 1
• History of herpes simplex virus – recurrent HSV eye disease requires immediate specialist management 1
• Recent ocular surgery or trauma – these patients need urgent ophthalmology evaluation 3

Distinguish Bacterial vs. Viral vs. Allergic Conjunctivitis

Bacterial Conjunctivitis Features:

• Mucopurulent or purulent discharge with matted eyelids upon waking 1
• Papillary reaction on tarsal conjunctiva (not follicular) 1
• Unilateral or bilateral presentation 1
• May have concurrent otitis media, sinusitis, or pharyngitis 1
• Preauricular lymphadenopathy is uncommon unless caused by hypervirulent organisms 1

Viral Conjunctivitis Features:

• Watery discharge with minimal mucus 1
• Follicular reaction on inferior tarsal conjunctiva 1
• Preauricular lymphadenopathy is common, especially with adenovirus 1
• Often starts unilateral but becomes sequentially bilateral 1
• May have concurrent upper respiratory infection 1
• Subconjunctival hemorrhages and chemosis are distinctive findings 1

Allergic Conjunctivitis Features:

• Itching is the predominant and distinguishing symptom 1
• Bilateral presentation 1
• Watery discharge with mild mucous component 1
• History of atopy, asthma, or eczema 1
• No preauricular lymphadenopathy 1

Management Algorithm Based on Etiology

If Bacterial Conjunctivitis (Most Likely Given 4-Day Duration with Swelling):

For moderate to severe cases:

• Prescribe 5-7 day course of broad-spectrum topical antibiotic 1
• No specific antibiotic is superior—choose the most convenient or least expensive option such as erythromycin ointment, polymyxin B/trimethoprim drops, or fluoroquinolones 1, 4
• Moxifloxacin 0.5% ophthalmic solution dosed 3 times daily for 4 days achieves 66-69% clinical cure rates 4

Special considerations:

• If sexually active, perform aggressive workup including conjunctival Gram stain and culture due to risk of Neisseria gonorrhoeae, which requires systemic antibiotics and can cause corneal perforation 1
• If no improvement after 5-7 days, obtain cultures and susceptibility testing 1
• Advise patient to avoid contact lens wear during treatment 4

If Viral Conjunctivitis:

Do NOT prescribe antibiotics—they provide no benefit and cause unnecessary toxicity 1

Supportive care only:

• Preservative-free artificial tears for symptomatic relief 1
• Cold compresses to reduce swelling 1
• Topical antihistamines (e.g., olopatadine) for symptomatic relief 3

Patient education:

• Highly contagious for 10-14 days from symptom onset 1
• Wash hands frequently with soap and water 1
• Avoid sharing towels, pillows, or linens 1
• Virus remains infectious on dry surfaces for up to 28 days 1
• Do not rub eyes 1

When to consider topical corticosteroids:

• Only for severe cases with marked chemosis and lid swelling 1
• Requires close ophthalmology follow-up for monitoring intraocular pressure 1
• Never use corticosteroids without ophthalmology consultation—they prolong adenoviral infection and worsen HSV infections 1

If Allergic Conjunctivitis:

• First-line: topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1
• Environmental modifications: wear sunglasses as barrier to allergens, use cold compresses, avoid eye rubbing 1
• For refractory cases, consider brief 1-2 week course of topical corticosteroids with low side-effect profile 1

Follow-Up Recommendations

• Bacterial conjunctivitis: Re-evaluate if no improvement after 5-7 days of antibiotics 1
• Viral conjunctivitis: Return if symptoms persist beyond 2-3 weeks or worsen 1
• Severe cases with corneal involvement: Re-evaluate within 1 week with visual acuity measurement and slit-lamp examination 1
• Patients on topical corticosteroids: Regular monitoring of intraocular pressure and periodic pupillary dilation 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics indiscriminately for viral conjunctivitis—this contributes to resistance and causes toxicity 1
• Do not use topical corticosteroids without ophthalmology consultation—risk of elevated intraocular pressure, cataract formation, and worsening HSV infections 1
• Do not miss gonococcal conjunctivitis in sexually active patients—requires immediate systemic treatment to prevent corneal perforation 1
• Do not allow contact lens wear during any infectious conjunctivitis 4
• Do not ignore conjunctival scarring—this mandates immediate ophthalmology referral within 24 hours 1