Treatment of Conjunctivitis (Pink Eye)
The treatment for conjunctivitis depends on the specific cause (viral, bacterial, or allergic), with most cases being self-limited and requiring only supportive care rather than antibiotics. 1
Diagnosis and Classification
Viral Conjunctivitis
- Presents with watery discharge, burning sensation, gritty feeling
- Often caused by adenovirus
- May spread to both eyes
- Preauricular lymphadenopathy may be present
Bacterial Conjunctivitis
- Presents with mucopurulent discharge
- Eyelids often matted shut upon waking
- Lacks itching
- More common in children than adults
Allergic Conjunctivitis
- Presents with bilateral itching
- Watery discharge
- Eyelid edema and chemosis
- Papillary reaction
Treatment Algorithm
1. Viral Conjunctivitis
- Primary treatment is supportive care 2:
- Cold compresses
- Artificial tears
- Topical antihistamines for symptomatic relief
- Infection control measures:
- Strict hand hygiene
- Avoid sharing towels and pillows
- Minimize contact with others for 10-14 days 2
- Avoid antibiotics as they are ineffective against viral infections
- For severe cases with subepithelial infiltrates:
- Consider topical corticosteroids at minimum effective dose
- Prefer corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize IOP elevation risk 2
2. Bacterial Conjunctivitis
- Mild cases often resolve spontaneously within 7-10 days 2
- Topical antibiotics hasten clinical and microbiological resolution 2:
- Broad-spectrum options include fluoroquinolones (e.g., moxifloxacin 0.5% one drop TID for 7 days) 3
- Erythromycin or bacitracin are alternatives
- Special cases requiring aggressive treatment:
- Gonococcal conjunctivitis: Systemic ceftriaxone plus topical antibiotics
- Chlamydial conjunctivitis: Systemic erythromycin plus topical antibiotics 2
3. Allergic Conjunctivitis
- Simple measures 2:
- Wearing sunglasses as barrier to allergens
- Cold compresses
- Refrigerated artificial tears
- Avoiding eye rubbing and allergen exposure
- Hypoallergenic bedding, eyelid cleansers
- Pharmacological treatment:
- Mild cases: OTC topical antihistamine/vasoconstrictor agents
- More effective: Second-generation topical histamine H1-receptor antagonists 2
- For persistent cases: Mast-cell stabilizers or combination antihistamine/mast-cell stabilizer medications
- For severe cases: Brief course (1-2 weeks) of topical corticosteroids with low side effect profile 2
Special Considerations
Neonatal Conjunctivitis
- Requires urgent evaluation and treatment
- Treatment based on onset timing and suspected pathogen
- May indicate systemic infection requiring systemic antibiotics 2
Membrane/Pseudomembrane Management
- Consider debridement to prevent corneal epithelial abrasions or permanent cicatricial changes 2
Referral to Ophthalmologist
Immediate referral for:
- Visual loss
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement
- Conjunctival scarring
- Lack of response to therapy
- Recurrent episodes
- History of HSV eye disease
- Immunocompromised patients 2
Follow-up and Monitoring
- 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 2
Pitfalls to Avoid
- Indiscriminate use of antibiotics for viral conjunctivitis
- Prolonged use of corticosteroids without monitoring IOP
- Delayed referral for severe or non-responsive cases
- Inadequate infection control leading to spread, especially in adenoviral conjunctivitis
- Continued contact lens wear during active infection 2, 1
Remember that most cases of conjunctivitis are self-limiting, and treatment should focus on symptom relief and preventing complications or spread of infection.