What is the initial treatment for a patient presenting with conjunctivitis?

From the Guidelines

The initial treatment for conjunctivitis depends on its cause, and the most recent guidelines recommend a targeted approach to treatment, avoiding indiscriminate use of topical antibiotics or corticosteroids 1.

Causes of Conjunctivitis and Treatment Approaches

• Bacterial conjunctivitis: topical antibiotic eye drops or ointments such as erythromycin, polymyxin B-trimethoprim, or fluoroquinolones (like ciprofloxacin or moxifloxacin) are recommended, typically applied 4 times daily for 5-7 days.
• Viral conjunctivitis: supportive care with cold compresses and artificial tears for symptom relief is appropriate, as antibiotics are ineffective against viruses.
• Allergic conjunctivitis: antihistamine eye drops like ketotifen or olopatadine twice daily, or artificial tears to flush allergens are effective.

General Principles of Treatment

• Treatment aims to address the underlying cause - eliminating bacteria with antibiotics, providing symptomatic relief for viral cases until they resolve naturally, or reducing the allergic response in allergic conjunctivitis.
• Patients should practice good hygiene by avoiding touching their eyes, washing hands frequently, using separate towels, and discarding eye makeup.
• Cool compresses can reduce inflammation and discomfort for all types.
• If symptoms worsen or don't improve within 48-72 hours of treatment, patients should seek further medical evaluation 1.

Special Considerations

• Gonococcal conjunctivitis is a hyperacute, vision-threatening infectious condition that requires immediate systemic therapy.
• Herpes zoster can cause conjunctivitis, keratitis, and ocular inflammation in multiple tissues of the eye, and vaccination is strongly recommended in patients 50 years or older and patients 19 years or older who are immunocompromised 1.
• Chronic and/or recalcitrant conjunctivitis may be indicative of an underlying malignancy or inflammatory condition, and patients should be evaluated by an ophthalmologist if they experience visual loss, moderate or severe pain, or severe, purulent discharge 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: The ointment should be applied directly into the conjunctival sac 1 to 3 times daily. DOSAGE AND ADMINISTRATION In the treatment of superficial ocular infections, erythromycin ophthalmic ointment approximately 1 cm in length should be applied directly to the infected eye(s) up to six times daily, depending on the severity of the infection. The initial treatment for a patient presenting with conjunctivitis is applying an ointment, such as bacitracin or erythromycin, directly into the conjunctival sac.

• The frequency of application can range from 1 to 3 times daily for bacitracin 2
• Or up to six times daily for erythromycin, depending on the severity of the infection 3.

From the Research

Initial Treatment for Conjunctivitis

The initial treatment for a patient presenting with conjunctivitis depends on the cause of the condition.

• For viral conjunctivitis, treatment is supportive, including artificial tears, cold compresses, and antihistamine eye drops 4, 5.
• For bacterial conjunctivitis, topical antibiotics may be prescribed to decrease the duration of the infection and allow for an earlier return to school or work 4.
• For allergic conjunctivitis, treatment consists of topical antihistamines and mast cell stabilizers 4, 6.
• In cases of conjunctivitis caused by sexually transmitted diseases, such as chlamydia or gonorrhea, systemic treatment in addition to topical antibiotic therapy may be necessary 4.

Considerations for Treatment

When treating conjunctivitis, it is essential to consider the following:

• The presence of alarming signs, such as severe pain, decreased vision, or painful pupillary reaction, which may indicate a more serious condition 7.
• A thorough medical and ophthalmic history, as well as a physical examination, to determine the underlying cause of the conjunctivitis 7.
• The potential for long-term usage of eye drops with preservatives to cause toxic conjunctivitis 7.
• The need for ophthalmology referral in cases of conjunctivitis in neonates or patients with severe symptoms or underlying conditions 5.

Treatment Options

Various treatment options are available for conjunctivitis, including:

• Topical antihistamines and mast cell stabilizers for allergic conjunctivitis 6, 8.
• Topical antibiotics for bacterial conjunctivitis 4, 5.
• Supportive care, such as artificial tears and cold compresses, for viral conjunctivitis 4, 5.
• Corticosteroids, such as loteprednol etabonate, for severe or chronic cases of conjunctivitis 8.