What is the best practice for treating conjunctivitis?

Best Practices for Conjunctivitis Management

The treatment of conjunctivitis must be tailored to the specific etiology, with viral conjunctivitis requiring primarily supportive care, bacterial conjunctivitis potentially benefiting from topical antibiotics, and allergic conjunctivitis responding to antihistamines and mast cell stabilizers. 1, 2

Diagnosis and Classification

Accurate diagnosis is essential for proper management:

Key Diagnostic Features

• Viral conjunctivitis: Watery discharge, follicular reaction, often bilateral, preauricular lymphadenopathy
• Bacterial conjunctivitis: Purulent/mucopurulent discharge, matted eyelids upon waking
• Allergic conjunctivitis: Intense itching, conjunctival edema, mucous discharge, often bilateral

Red Flags Requiring Ophthalmology Referral

• 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 1

Treatment Algorithm by Type

1. Viral Conjunctivitis (Most Common)

• Primary treatment: Supportive care
  • Artificial tears
  • Cold compresses
  • Antihistamine eye drops for symptomatic relief
• Avoid antibiotics: Will not respond to antibacterial agents 1
• Infection control: Critical to prevent transmission
  • Frequent handwashing
  • Use separate towels
  • Avoid close contact during contagious period
  • Proper disinfection of surfaces and equipment 1, 2

2. Bacterial Conjunctivitis

• Non-severe cases: Often self-limited within 1-2 weeks 3
• Antibiotic options:
  • Bacitracin ointment: Apply directly to conjunctival sac 1-3 times daily 4
  • Erythromycin ointment: Apply approximately 1cm length up to 6 times daily depending on severity 5
• Special cases:
  • Gonococcal conjunctivitis: Ceftriaxone 1g IM single dose plus ocular saline lavage 2
  • Chlamydial conjunctivitis: Azithromycin 1g orally single dose or doxycycline 100mg orally twice daily for 7 days 2

3. Allergic Conjunctivitis

• First-line: Topical antihistamines with mast cell-stabilizing activity 2, 6
• Additional measures:
  • Allergen avoidance
  • Cold compresses
  • Artificial tears
• Severe cases: Corticosteroids under ophthalmologic supervision only 2

Special Populations

Neonates

• Ophthalmia neonatorum:
  • Requires immediate referral to ophthalmologist
  • For prophylaxis: Erythromycin ointment (1cm ribbon) in each lower conjunctival sac 5
  • For confirmed gonococcal infection: Systemic treatment required (penicillin G) 5

Contact Lens Wearers

• Discontinue lens wear until resolution
• Consider antibiotic treatment even for mild cases 3
• Evaluate lens care regimen and replace lenses/case

Prevention Strategies

• Strict hand hygiene
• Avoid touching or rubbing eyes
• Proper cleaning and disinfection of contact lenses
• For tonometer disinfection: Use dilute bleach soak (1:10 concentration) 1
• Note: 70% isopropyl alcohol, 3% hydrogen peroxide, and ethyl alcohol are no longer recommended for tonometer disinfection 1

Common Pitfalls to Avoid

1. Indiscriminate antibiotic use: Avoid for viral conjunctivitis or mild bacterial cases 1
2. Corticosteroid misuse: Can worsen viral infections and mask serious conditions
3. Delayed referral: For severe cases or those with red flags
4. Inadequate infection control: Critical for preventing spread
5. Misdiagnosis: Clinical accuracy in diagnosing viral conjunctivitis is less than 50% without specific testing 2

Remember that most cases of conjunctivitis are self-limiting, but proper diagnosis and targeted treatment can reduce duration, complications, and transmission risk.