What are the treatment options for conjunctivitis?

Treatment Options for Conjunctivitis

The treatment of conjunctivitis should be directed at the underlying cause, with most cases requiring only supportive care rather than antibiotics. 1

Classification and Targeted Treatment

1. Viral Conjunctivitis (80% of all acute cases)

• Primary treatment (supportive care):
  • Cold compresses
  • Refrigerated artificial tears
  • Topical antihistamine eye drops for symptomatic relief
  • Strict hand hygiene to prevent spread
  • Avoid sharing towels and pillows
  • Minimize contact with others for 10-14 days

2. Bacterial Conjunctivitis

• Treatment options:
  • For mild to moderate cases: Delayed antibiotic prescribing may be appropriate as many cases are self-limited 2
  • For moderate to severe cases: Topical antibiotics (hasten clinical and microbiological resolution)
    • Fluoroquinolones (e.g., moxifloxacin 0.5% ophthalmic solution: one drop in affected eye 3 times daily for 7 days) 1, 3
    • Alternative options: erythromycin or bacitracin
  • For special cases:
    • Gonococcal conjunctivitis: systemic ceftriaxone plus topical antibiotics
    • Chlamydial conjunctivitis: systemic erythromycin plus topical antibiotics

3. Allergic Conjunctivitis

• Non-pharmacological measures:

  • Wearing sunglasses as allergen barrier
  • Cold compresses
  • Refrigerated artificial tears
  • Avoiding eye rubbing and allergen exposure
  • Using hypoallergenic bedding and eyelid cleansers

• Pharmacological treatment:

  • Mild cases: Over-the-counter topical antihistamine/vasoconstrictor agents
  • Moderate cases: Second-generation topical histamine H1-receptor antagonists
  • Persistent cases: Mast-cell stabilizers or combination antihistamine/mast-cell stabilizer medications

Special Considerations

Contact Lens Wearers

• Discontinue lens wear until conjunctivitis resolves (higher risk for Pseudomonas infection) 1
• Require antibiotic treatment even for mild cases 4

When to Refer to Ophthalmology

Immediate referral for cases involving:

• 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
• Neonates with conjunctivitis 2

Follow-up Recommendations

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

Common Pitfalls to Avoid

1. Indiscriminate use of antibiotics for viral conjunctivitis (80% of cases are viral) 5
2. Prolonged use of corticosteroids without monitoring intraocular pressure
3. Delayed referral for severe or non-responsive cases
4. Inadequate infection control leading to spread (especially for viral conjunctivitis)
5. Continued contact lens wear during active infection

Treatment Algorithm

1. Identify type of conjunctivitis based on presentation:

   • Viral: Watery discharge, burning sensation, gritty feeling, preauricular lymphadenopathy
   • Bacterial: Mucopurulent discharge, eyelids matted shut upon waking
   • Allergic: Bilateral itching, watery discharge, eyelid edema

2. For viral conjunctivitis: Supportive care only (cold compresses, artificial tears)

3. For bacterial conjunctivitis:

   • Mild: Consider delayed antibiotic approach
   • Moderate to severe: Topical antibiotics like moxifloxacin 0.5%
   • Special cases (gonococcal/chlamydial): Add systemic antibiotics

4. For allergic conjunctivitis: Antihistamines and mast cell stabilizers, allergen avoidance

5. Refer immediately if any warning signs are present