What is the treatment for conjunctivitis (pink eye)?

Treatment of Pink Eye (Conjunctivitis)

The treatment for conjunctivitis depends on the specific type (viral, bacterial, or allergic), with most cases being self-limited and requiring only supportive care rather than antibiotics. 1, 2

Diagnosis and Classification

First, determine the type of conjunctivitis based on clinical presentation:

Viral Conjunctivitis

• Presentation: Watery discharge, burning sensation, gritty feeling
• Common cause: Adenovirus (most common overall cause of infectious conjunctivitis)
• Signs: Often unilateral initially, may spread to both eyes, preauricular lymphadenopathy

Bacterial Conjunctivitis

• Presentation: Mucopurulent discharge, eyelids matted shut upon waking
• Signs: Lack of itching, mattering of eyelids
• More common in children than adults

Allergic Conjunctivitis

• Presentation: Bilateral itching (key symptom), watery discharge
• Signs: Eyelid edema, chemosis, papillary reaction

Treatment Approach

Viral Conjunctivitis

• Primary treatment: Supportive care 1, 2
  • Artificial tears
  • Cold compresses
  • Antihistamine eye drops for symptomatic relief
• Infection control: Strict hand hygiene, avoid sharing towels/pillows
• For severe cases with corneal subepithelial infiltrates:
  • Mild cases: Observation only
  • Symptomatic cases (blurring, photophobia): Topical corticosteroids at minimum effective dose 1
  • Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, loteprednol) to minimize IOP elevation risk 1

Bacterial Conjunctivitis

• Most uncomplicated cases resolve in 1-2 weeks without treatment 3
• Antibiotic options:
  • Broad-spectrum topical antibiotics (fluoroquinolones, erythromycin, bacitracin) 4
  • Delayed antibiotic prescribing has similar outcomes to immediate prescribing 2
• Special cases requiring aggressive treatment:
  • Contact lens wearers (higher risk of corneal ulcers) 5
  • Gonococcal conjunctivitis: Systemic ceftriaxone plus topical antibiotics 4
  • Chlamydial conjunctivitis: Systemic erythromycin plus topical antibiotics 4

Allergic Conjunctivitis

• First-line: Topical antihistamines with mast cell-stabilizing activity 2, 6
• Additional options:
  • Artificial tears for lubrication
  • Cold compresses
  • Systemic antihistamines for severe cases
• For severe acute exacerbations:
  • Short course of topical corticosteroids (preferably loteprednol etabonate for better safety profile) 6
  • Monitor IOP if corticosteroids are used for extended periods 1

Special Considerations

Neonatal Conjunctivitis

• Requires urgent evaluation and treatment
• Treatment based on onset timing:
  • 1-7 days: Suspect gonococcal (systemic ceftriaxone)
  • 5-19 days: Suspect chlamydial (systemic erythromycin)
  • First week: Common bacteria (appropriate antibiotics) 4

Membranous Conjunctivitis

• Consider membrane debridement to prevent corneal epithelial abrasions or permanent cicatricial changes 1
• Re-evaluate within 1 week

When to Refer to Ophthalmology

• Conjunctivitis in a neonate
• Severe pain or decreased vision
• Recent ocular surgery
• Vesicular rash on eyelids/nose (possible herpes)
• Immunocompromised patients
• No improvement after 1 week of treatment
• Suspected corneal involvement 2

Follow-up

• Uncomplicated cases: Return if symptoms persist beyond 2-3 weeks
• Cases treated with corticosteroids: Regular monitoring of IOP and pupillary dilation
• Severe cases: Re-evaluate within 1 week 1

Remember that most cases of conjunctivitis are self-limited, and antibiotics should be used judiciously to prevent antimicrobial resistance.