What is the most likely diagnosis and appropriate initial management for a 23‑year‑old woman presenting with ocular itching, burning, tearing, a cough‑like sensation, and fever?

Viral Conjunctivitis with Systemic Symptoms

This 23-year-old woman most likely has viral conjunctivitis with concurrent upper respiratory infection, and should receive supportive care only—no antibiotics—along with strict hygiene counseling to prevent transmission. 1

Most Likely Diagnosis

The combination of ocular itching, burning, tearing, cough, and fever strongly points to viral conjunctivitis with systemic involvement. 1 The presence of fever and respiratory symptoms (cough) alongside ocular complaints is characteristic of adenoviral conjunctivitis, which frequently presents with concurrent upper respiratory tract infection. 1, 2

Key Distinguishing Features Supporting Viral Etiology

• Watery discharge with tearing is the hallmark of viral conjunctivitis, as opposed to the mucopurulent discharge with matted eyelids seen in bacterial disease. 2, 3
• Systemic symptoms including fever, cough, and upper respiratory symptoms strongly favor viral conjunctivitis over bacterial or allergic causes. 1, 2
• The burning sensation combined with itching reflects the inflammatory response typical of viral infection. 1
• Viral conjunctivitis typically begins unilaterally but becomes sequentially bilateral within days, with abrupt onset. 1, 2

Critical Red Flags Requiring Urgent Ophthalmology Referral

Before initiating supportive care, you must rule out vision-threatening conditions:

• Visual loss or decreased visual acuity mandates same-day ophthalmology referral. 1, 4
• Moderate to severe ocular pain (beyond mild irritation) requires urgent evaluation within 24 hours. 1, 4
• Corneal involvement—any opacity, infiltrate, or loss of corneal transparency—necessitates immediate referral. 1, 2, 4
• Severe purulent discharge suggests possible gonococcal infection requiring emergency treatment. 1, 4
• History of herpes simplex virus eye disease is a red flag for potential HSV reactivation. 1, 4

Initial Management Algorithm

Step 1: Perform Focused Examination

• Check visual acuity in both eyes—any decrease requires urgent referral. 1, 4
• Examine the cornea with direct ophthalmoscope and fluorescein staining—any opacity or epithelial defect requires ophthalmology consultation. 1, 2
• Assess discharge character—watery favors viral; mucopurulent with matted lids favors bacterial. 2, 3
• Look for follicular reaction on inferior tarsal conjunctiva (small dome-shaped elevations)—this is characteristic of viral conjunctivitis. 1, 2
• Palpate preauricular lymph nodes—enlargement is common in adenoviral infection. 1, 2

Step 2: Supportive Care (No Antibiotics)

Topical antibiotics provide no benefit in viral conjunctivitis and should be avoided. 1, 2, 4 They contribute to antimicrobial resistance and cause unnecessary toxicity. 2

• Preservative-free artificial tears 4–6 times daily for symptomatic relief. 2, 4
• Cold compresses applied to closed eyelids to reduce swelling and discomfort. 2
• Topical antihistamines (e.g., olopatadine) may provide symptomatic relief of itching without affecting the viral course. 2

Step 3: Infection Control Counseling

• Strict hand hygiene with soap and water after touching eyes or face. 2
• Avoid sharing towels, pillows, or linens to prevent household transmission. 2
• Do not rub the eyes—this exacerbates irritation and facilitates spread. 2
• Highly contagious for 10–14 days from symptom onset—minimize close contact with others during this period. 2
• The virus can survive on dry surfaces for up to 28 days, requiring environmental cleaning. 2

Step 4: Follow-Up Instructions

• Return immediately if pain worsens, vision decreases, or heavy purulent discharge develops. 2
• Routine follow-up in 2–3 weeks if symptoms persist beyond the expected 5–14 day course. 1, 2
• Most cases are self-limited and resolve without sequelae. 1

Common Pitfalls to Avoid

• Do not prescribe topical corticosteroids without ophthalmology supervision—they can prolong adenoviral infection, worsen herpes simplex keratitis, and increase intraocular pressure. 1, 2
• Do not prescribe antibiotics empirically for presumed bacterial superinfection—this contributes to resistance and exposes the patient to unnecessary adverse effects. 2, 4
• Do not miss gonococcal conjunctivitis in sexually active patients—this requires systemic antibiotics and can cause corneal perforation. 1, 2
• Do not underestimate contagiousness—inadequate counseling facilitates community spread. 2

Alternative Diagnoses to Consider

If the clinical picture does not fit viral conjunctivitis:

• Allergic conjunctivitis would present with bilateral itching as the predominant symptom, watery discharge, and absence of fever or respiratory symptoms. 1, 2
• Bacterial conjunctivitis would show mucopurulent discharge with matted eyelids on waking, papillary (not follicular) reaction, and no systemic symptoms. 2, 3
• Measles (rubeola) can present with fever, cough, and conjunctivitis, but would include a characteristic maculopapular rash and is rare in vaccinated individuals. 1
• Zika or COVID-19 can cause conjunctivitis with fever, but would have additional distinguishing features (travel history, pandemic context). 1