Burning redness swelling of the eyes what will be the management

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Management of Burning, Redness, and Swelling of the Eyes (Conjunctivitis)

Burning, redness, and swelling of the eyes is the classic presentation of conjunctivitis - inflammation of the conjunctiva. The first step is identifying the cause, as management differs significantly between types.

Step 1 - Identify the Type

Before treating, classify the conjunctivitis based on history and signs:

Feature	Viral	Bacterial	Allergic
Discharge	Watery / serous	Mucopurulent (yellow/green)	Stringy / white
Itch	Mild-moderate	Mild	Prominent
Bilateral	Often starts unilateral	Usually bilateral	Bilateral
Lymph node	Palpable preauricular node	Absent (except gonorrhea)	Absent
History	Recent URI, contact with infected person	None specific	Allergy history, seasonal
Eyelids stuck shut	Morning crusting	More prominent	Less common

Purulent (thick yellow) discharge + no preauricular node = bacterial. Watery discharge + preauricular node + burning = viral. Itching + watery + allergy history = allergic. - Wills Eye Manual, §5.1; Textbook of Family Medicine 9e, p. 347

VIRAL CONJUNCTIVITIS

Viral conjunctivitis (Wills Eye Manual)

Most commonly adenovirus. Self-limited - usually resolves in 2-3 weeks. No antibiotic is indicated for uncomplicated viral conjunctivitis.

Treatment:

Artificial tears (preservative-free) 4-8 times/day for 1-3 weeks - use single-use vials to prevent spread
Cool compresses several times per day
Antihistamine drops (e.g., epinastine 0.05% b.i.d.) if itching is severe
Topical steroids only if:
- A membrane/pseudomembrane is present (peel gently with cotton-tip applicator first)
- Subepithelial infiltrates (SEIs) reduce vision or cause photophobia
- Use loteprednol 0.5% or prednisolone acetate 1% q.i.d., taper over weeks
Infection control - highly contagious for 10-12 days:
- Frequent hand washing
- Avoid touching eyes, sharing towels or pillows
- Restrict school/work while eyes are red and weeping

The Wills Eye Manual, §5.1

BACTERIAL CONJUNCTIVITIS

Most commonly caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. Usually self-limiting in 7-14 days but antibiotics shorten duration.

Treatment:

Topical broad-spectrum antibiotic drops for 5-7 days:
- Fluoroquinolones (first choice): Ciprofloxacin 0.3% or ofloxacin 0.3% - 4 times/day
- Tobramycin 0.3% or gentamicin 0.3% - q.i.d.
- Chloramphenicol 0.5% drops q.i.d. (widely used, effective)
- Azithromycin 1% b.i.d. × 3 days (convenient dosing)
Lid hygiene - clean crusting from lids with warm water and clean cloth
Irrigation to remove excessive discharge in hyperpurulent cases
Discontinue contact lenses until 48 hours after complete resolution

Special cases:

Gonococcal conjunctivitis (hyperacute, profuse purulent discharge, risk of corneal perforation): requires IV/IM ceftriaxone 1g single dose + topical fluoroquinolone + urgent referral
Neonatal conjunctivitis (ophthalmia neonatorum): requires urgent investigation (Gram stain, culture) and systemic treatment based on organism
Kanski's Clinical Ophthalmology 10th, p. 188-189; Bailey and Love's Surgery 28th, p. 754

ALLERGIC CONJUNCTIVITIS

Allergic conjunctivitis - chemosis and conjunctival swelling (Wills Eye Manual)

Treatment (stepwise):

Eliminate the inciting agent (dust, pollen, pet dander). Wash hair and clothes frequently
Cool compresses several times per day
Topical drops by severity:
- Mild: Artificial tears 4-8 times/day
- Moderate: Antihistamine/mast-cell stabilizer drops:
  - Olopatadine 0.2% once daily (OTC), or 0.7% once daily
  - Azelastine 0.05% b.i.d.
  - Ketotifen 0.025% b.i.d. (OTC)
  - Bepotastine 1.5% b.i.d.
  - Ketorolac 0.5% q.i.d. (NSAID - reduces inflammation but monitor for corneal toxicity with prolonged use)
- Severe: Add mild topical steroid for 1-2 weeks:
  - Loteprednol 0.2% q.i.d. or fluorometholone 0.1% q.i.d.
Oral antihistamine (e.g., cetirizine, loratadine, diphenhydramine 25 mg q6h) for systemic allergy symptoms

The Wills Eye Manual, §5.1; Textbook of Family Medicine 9e

General Supportive Measures (All Types)

Measure	Detail
Hand hygiene	Wash hands frequently; avoid rubbing eyes
Cold compresses	10-15 min, 3-4 times/day - reduces burning and swelling
Avoid contact lenses	Until fully resolved + 48h after last antibiotic dose
Avoid sharing	Towels, pillows, eye makeup
No eye patching	Patching worsens bacterial/viral conjunctivitis

Red Flags - Refer Urgently to Ophthalmology

These features suggest a more serious condition beyond simple conjunctivitis:

Photophobia + red ring around cornea (ciliary injection) - suggests iritis/uveitis
Visual loss at any point
Severe pain (not just irritation)
Corneal opacity or ulcer on fluorescein staining
Hyperacute profuse purulent discharge - gonococcal conjunctivitis
Neonatal conjunctivitis - always urgent
No improvement after 1 week of appropriate treatment

Textbook of Family Medicine 9e - "The triad of red eye, pain, and loss of vision should always alert the examiner to the possibility of a more serious ocular condition."

Quick Summary Table

Type	First-Line Treatment	Duration
Viral	Artificial tears + cool compresses	Self-limiting, 2-3 weeks
Bacterial (mild/moderate)	Topical ciprofloxacin or tobramycin	5-7 days
Bacterial (gonococcal)	IM/IV ceftriaxone + topical fluoroquinolone	Urgent/systemic
Allergic (mild)	Artificial tears, remove allergen	As needed
Allergic (moderate)	Olopatadine or ketotifen drops	Seasonal/as needed
Allergic (severe)	Above + loteprednol 0.2% q.i.d.	1-2 weeks
Chlamydial	Oral azithromycin 1g single dose OR doxycycline 100 mg b.i.d. × 7 days	Systemic treatment needed

Sources: The Wills Eye Manual (§5.1 Acute Conjunctivitis); Kanski's Clinical Ophthalmology 10th ed.; Bailey and Love's Short Practice of Surgery 28th ed.; Textbook of Family Medicine 9th ed.

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