Initial Approach to Treating Conjunctivitis
The initial approach to treating conjunctivitis should be based on the suspected 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
Diagnosis and Classification
Before initiating treatment, it's essential to determine the type of conjunctivitis:
Viral Conjunctivitis
- Most common cause (80% of acute cases) 2
- Characterized by:
- Watery discharge
- Follicular reaction
- Possible preauricular lymphadenopathy
- Often bilateral, starting in one eye then spreading to the other
Bacterial Conjunctivitis
- Characterized by:
- Purulent or mucopurulent discharge
- Matutinal lid adhesion (eyelids "stuck" together upon waking)
- Often unilateral initially
- More common in children 3
Allergic Conjunctivitis
- Characterized by:
- Intense itching (most consistent sign)
- Conjunctival edema
- Mucous discharge
- Bilateral presentation
Treatment Algorithm
1. Viral Conjunctivitis
- Primary treatment: Supportive care only 1
- Artificial tears for comfort
- Cold compresses to reduce inflammation
- Antihistamine eye drops for symptomatic relief
- Avoid antibiotics as they are ineffective against viral pathogens
- Infection control measures:
- Frequent handwashing with soap and water
- Separate towels and pillows
- Avoid close contact during contagious period (7-14 days)
- Patient should be considered contagious for at least 10-14 days 4
2. Bacterial Conjunctivitis
Mild to moderate cases:
- Topical antibiotics (e.g., fluoroquinolones, aminoglycosides, macrolides)
- For azithromycin ophthalmic solution: Instill 1 drop in affected eye(s) twice daily, 8-12 hours apart for first two days, then once daily for five more days 5
- Delayed antibiotic prescribing may be considered as it has similar outcomes to immediate prescribing 3
Moderate to severe cases:
- Obtain conjunctival cultures and Gram stain if gonococcal infection is suspected 4
- Choice of antibiotic guided by laboratory results
Gonococcal conjunctivitis:
Chlamydial conjunctivitis:
3. Allergic Conjunctivitis
- Antihistamines and mast cell stabilizers as first-line treatment 1
- Vasoconstrictors for temporary relief
- Corticosteroids only for severe cases under ophthalmologic supervision
- Allergen-specific immunotherapy may be beneficial, especially in children 4
Special Considerations
When to Refer to Ophthalmology
Immediate referral is indicated 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 4
Contact Lens Wearers
- Should discontinue contact lens use during treatment
- Require antibiotic treatment even for mild bacterial conjunctivitis 6
- Need proper education on lens care and replacement to prevent recurrence 4
Neonatal Conjunctivitis
- Requires urgent evaluation and treatment
- May require hospitalization for parenteral therapy 4
- Prophylaxis with erythromycin 0.5% ophthalmic ointment is standard practice 4
Infection Control
- Strict hand hygiene with soap and water (not just sanitizer)
- Avoid touching or rubbing eyes
- Use separate towels and pillows
- Proper disinfection of surfaces and equipment
- Patients in high-transmission professions (healthcare, childcare) should avoid contact with others during the contagious period 4, 1
Remember that most bacterial conjunctivitis cases are self-limiting, but treatment with appropriate antibiotics can decrease duration and allow earlier return to work or school 6. For viral conjunctivitis, which is most common overall, treatment remains primarily supportive with a focus on preventing transmission.