What is the treatment approach for adult conjunctivitis?

Treatment Approach for Adult Conjunctivitis

The treatment of adult conjunctivitis should be tailored to the specific etiology, with viral conjunctivitis requiring primarily supportive care, bacterial conjunctivitis often benefiting from topical antibiotics, and allergic conjunctivitis responding to topical antihistamines with mast cell-stabilizing activity. 1

Diagnostic Approach

Determining the cause is essential for appropriate treatment:

• Viral conjunctivitis:

  • Most common cause in adults 2
  • Characterized by watery discharge, gritty sensation
  • Often preceded by respiratory infection
  • May present with preauricular lymphadenopathy

• Bacterial conjunctivitis:

  • Characterized by mucopurulent discharge and matted eyelids
  • Usually bilateral
  • Common pathogens: Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae 3

• Allergic conjunctivitis:

  • Characterized by severe itching (hallmark symptom)
  • Watery discharge
  • Bilateral presentation
  • History of allergies

Treatment Algorithm

1. Viral Conjunctivitis

• Primary treatment: Supportive care 2

  • Artificial tears for comfort
  • Cold compresses to reduce inflammation
  • Strict hygiene measures to prevent transmission

• For severe cases:

  • Topical corticosteroids at minimum effective dose may be considered for adenoviral cases with severe symptoms
  • Caution: Corticosteroids must be tapered and may prolong viral shedding 2
  • Warning: Avoid corticosteroids if HSV infection is suspected as they can potentiate the infection 1

• For herpes simplex virus conjunctivitis:

  • Topical antivirals (ganciclovir 0.15% gel)
  • Consider oral antivirals (acyclovir, valacyclovir) 1

2. Bacterial Conjunctivitis

• Mild cases: May resolve spontaneously within 7-10 days 1

• Moderate to severe cases:

  • Broad-spectrum topical antibiotics for 5-7 days 2, 1
  • Options include:
    • Fluoroquinolones (moxifloxacin 0.5%) 3
    • Azithromycin 1% ophthalmic solution 4

• Special cases:

  • Gonococcal conjunctivitis: Systemic antibiotics (ceftriaxone) plus topical antibiotics 2
  • Chlamydial conjunctivitis: Oral azithromycin or tetracycline plus topical antibiotics 2, 1
  • Contact lens wearers: Always treat with antibiotics and consider systemic treatment 1

3. Allergic Conjunctivitis

• First-line treatment: Topical antihistamines with mast cell-stabilizing activity 1
• For persistent cases: Consider allergen-specific immunotherapy 2
• For severe cases: Short course of topical corticosteroids may be considered 1

Prevention and Patient Education

1. Hygiene measures for infectious conjunctivitis:

   • Frequent handwashing
   • Avoid sharing towels, pillows, or washcloths
   • Avoid touching or rubbing eyes
   • Change pillowcases frequently during infection 1

2. Contact lens care:

   • Appropriate lens care and frequent replacement to reduce risk of giant papillary conjunctivitis 2
   • Avoid wearing contacts during active infection 3

3. Return to work/school:

   • For bacterial conjunctivitis, patients can typically return after 24 hours of antibiotic treatment 1
   • For viral conjunctivitis, patients should minimize contact with others for 10-14 days from onset of symptoms 2

When to Refer to Ophthalmology

Immediate referral is necessary for patients with:

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy within 3 weeks
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised status 2, 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral conjunctivitis, which is self-limiting 2
2. Prolonged use of corticosteroids without ophthalmology supervision, which can lead to glaucoma, cataracts, or potentiate HSV infection 2, 1
3. Failure to recognize potentially serious causes of conjunctivitis that may indicate systemic disease 2
4. Inadequate hygiene education, leading to spread of infectious conjunctivitis 2
5. Delayed referral for severe or non-responsive cases 1

By following this structured approach to diagnosis and treatment, most cases of adult conjunctivitis can be managed effectively with good outcomes for patient morbidity, mortality, and quality of life.