Treatment for Conjunctivitis
The treatment for conjunctivitis depends on the specific type, with mild bacterial conjunctivitis typically managed with a 5-7 day course of broad-spectrum topical antibiotics, viral conjunctivitis managed supportively, and specific types requiring targeted therapy. 1
Bacterial Conjunctivitis
Mild Bacterial Conjunctivitis
- While often self-limiting in immunocompetent adults, topical antibiotics provide:
- Earlier clinical and microbiological remission
- Reduced transmissibility
- Earlier return to school/work 1
- Treatment approach:
- First-line: 5-7 day course of broad-spectrum topical antibiotic 1
- No clinical evidence suggests superiority of any particular antibiotic
- Choose the most convenient or least expensive option
- Common options include:
Moderate to Severe Bacterial Conjunctivitis
- Characterized by copious purulent discharge, pain, and marked inflammation
- Obtain conjunctival cultures and Gram stains if gonococcal infection is suspected
- Treatment guided by laboratory results
- Consider MRSA, which has been isolated with increasing frequency 1
- For suspected MRSA: Consider vancomycin (compounded) based on microbiology testing 1
Gonococcal Conjunctivitis
- Requires systemic antibiotic therapy
- Adults: Ceftriaxone 1 g IM single dose 1
- Children <45 kg: Ceftriaxone 25-50 mg/kg IV/IM (not exceeding 250 mg) 1
- Saline lavage for comfort and faster resolution
- Add topical treatment if corneal involvement present
- Daily follow-up until resolution
- Screen and treat sexual contacts
Chlamydial Conjunctivitis
- Requires systemic therapy (no topical therapy needed)
- Adults: Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally twice daily for 7 days 1
- Children <45 kg: Erythromycin 50 mg/kg/day divided into 4 doses for 14 days 1
- Children ≥8 years: Same as adults
- Re-evaluate after treatment due to 19% treatment failure rate 1
- Screen and treat sexual contacts
Viral Conjunctivitis
Adenoviral Conjunctivitis
- Primarily supportive care
- Cold compresses and artificial tears for symptom relief
- Topical antihistamines or vasoconstrictors may provide symptomatic relief
- Highly contagious - advise strict hand hygiene and no sharing of personal items
Herpes Simplex Virus Conjunctivitis
- Topical antiviral agents if corneal involvement
- Consider oral antivirals for severe cases
Varicella Zoster Virus Conjunctivitis
- For persistent/recalcitrant cases: Oral antivirals
- Acyclovir 800 mg five times daily for 7 days, OR
- Valacyclovir 1000 mg every 8 hours for 7 days, OR
- Famciclovir 500 mg three times daily for 7 days 1
Allergic Conjunctivitis
- Allergen avoidance
- Topical antihistamines/mast cell stabilizers
- Topical NSAIDs
- Topical steroids for severe cases (under ophthalmologist supervision)
Clinical Pearls and Pitfalls
Pearls:
- Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics when access to antibiotics is limited 1
- Moxifloxacin has shown faster clinical efficacy (81% resolution at 48 hours) compared to polymyxin B/trimethoprim (44% resolution) 4
- Azithromycin 1.5% for 3 days (6 drops total) has shown similar efficacy to tobramycin for 7 days (36 drops total) 5
Pitfalls:
- Avoid topical steroids in suspected viral or fungal conjunctivitis
- Don't use contact lenses during active infection 2, 3
- Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1
- Neisseria meningitidis should be ruled out before concluding N. gonorrhoeae is responsible 1
- Prolonged antibiotic use can lead to resistant organisms 2, 3
- Pregnant women should not receive doxycycline, quinolones, or tetracyclines 1
Follow-up Recommendations:
- Gonococcal conjunctivitis: Daily follow-up until resolution
- Other bacterial conjunctivitis: Return in 3-4 days if no improvement 1
- Chlamydial infection: Re-evaluate after treatment due to high failure rate