A patient presents with a red, watery eye along with cough and sinus congestion; what is the most likely diagnosis and how should it be managed?

Viral Conjunctivitis Secondary to Upper Respiratory Infection

A patient presenting with red, watery eye accompanied by cough and sinus congestion most likely has viral conjunctivitis as part of a viral upper respiratory infection, and should receive supportive care only—no antibiotics are indicated. 1, 2

Diagnostic Reasoning

The constellation of conjunctivitis with concurrent respiratory symptoms strongly points to a viral etiology:

• Watery discharge (not purulent) combined with cough and sinus congestion is pathognomonic for viral conjunctivitis associated with upper respiratory infection 2, 3, 4
• Viral conjunctivitis frequently presents with concurrent upper respiratory tract symptoms including rhinorrhea, sore throat, and systemic symptoms 2
• The disease often begins unilaterally but becomes sequentially bilateral within days, with abrupt onset 2
• On examination, look for follicular reaction on the inferior tarsal conjunctiva (small dome-shaped elevations representing lymphoid hyperplasia) and preauricular lymphadenopathy—both highly specific for viral etiology 2

Key Differentiating Features from Bacterial Conjunctivitis

• Bacterial conjunctivitis presents with mucopurulent or purulent discharge with matted eyelids upon waking, and typically lacks concurrent respiratory symptoms 2, 3, 4
• The absence of purulent discharge and presence of respiratory symptoms effectively rule out bacterial infection in this scenario 2, 4

Evidence-Based Management

Primary Treatment: Supportive Care Only

Antibiotics must be avoided entirely because they provide no clinical benefit for viral conjunctivitis and cause unnecessary toxicity and antimicrobial resistance 1, 2, 3:

• Preservative-free artificial tears applied frequently for symptomatic relief 1, 2
• Cold compresses to reduce conjunctival swelling and improve comfort 1, 2, 3
• Topical antihistamines (e.g., olopatadine) may provide symptomatic relief of itching and redness without affecting viral course 2

Concurrent Upper Respiratory Symptoms Management

For the cough and sinus congestion component:

• Inhaled ipratropium bromide (2-3 puffs four times daily) has the strongest evidence for reducing mucus hypersecretion in post-viral cough 5
• First-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine) for nasal congestion—newer non-sedating antihistamines are ineffective 5, 6
• Saline nasal irrigation 2-3 times daily with no rebound effect 6
• Guaifenesin 200-400 mg every 4 hours (up to 6 times daily) to loosen phlegm 5

Critical caveat: If symptoms persist beyond 10 days without improvement AND the patient develops purulent nasal discharge with facial pain/pressure, this indicates bacterial superinfection requiring amoxicillin-clavulanate 1, 5, 6

Infection Control Education

The ophthalmologist plays a critical role in breaking the chain of transmission 1:

• Wash hands frequently with soap and water, especially after touching eyes or face 1, 2
• Use separate towels and avoid sharing pillows or linens 1, 2
• Avoid close contact with others for 10-14 days from symptom onset—the contagious period 1, 2
• Do not rub the eyes, as this exacerbates irritation and facilitates pathogen spread 2
• The causative virus may remain infectious on dry surfaces for up to 28 days, requiring environmental disinfection 2

Expected Clinical Course and Follow-Up

• Viral conjunctivitis is self-limited, typically resolving within 5-14 days 1, 2, 7
• Return immediately if symptoms persist beyond 2-3 weeks, vision decreases, moderate-to-severe pain develops, or purulent discharge appears 1, 2
• For the respiratory component, return if fever persists beyond 3-5 days, symptoms worsen after initial improvement, or purulent nasal discharge persists beyond 10 days without improvement 5, 6

Red Flags Requiring Urgent Ophthalmology Referral

Refer within 24 hours if any of the following develop 1, 2:

• Visual loss or decreased vision
• Moderate to severe ocular pain (beyond mild irritation)
• Corneal involvement (opacity, infiltrate, hazy appearance)
• Severe purulent discharge (suggests bacterial superinfection or gonococcal infection)
• Conjunctival scarring or pseudomembrane formation
• History of herpes simplex virus eye disease
• Recent ocular surgery or trauma
• Contact lens wear (risk of bacterial keratitis)
• Immunocompromised state

Common Pitfalls to Avoid

• Do not prescribe topical antibiotics—they contribute to resistance, cause toxicity, and provide zero benefit for viral conjunctivitis 1, 2, 3
• Do not use topical corticosteroids indiscriminately—they prolong adenoviral shedding, can worsen herpes simplex infections, and increase intraocular pressure 1, 2
• Do not obtain sinus imaging within the first week of viral URI symptoms—radiographic abnormalities are present in 87% of common colds and resolve spontaneously in 79% without antibiotics 5
• Do not assume colored (green/yellow) sputum indicates bacterial infection—it represents normal viral inflammatory response with white blood cells and desquamated epithelium 6
• Do not prescribe antibiotics for the respiratory symptoms unless all three bacterial sinusitis criteria are met: symptoms >10 days without improvement, purulent nasal discharge, AND facial pain/pressure 1, 5, 6