What is the treatment for conjunctivitis (pink eye)?

Treatment for Pink Eye (Conjunctivitis)

The treatment for conjunctivitis (pink eye) depends on its cause, with bacterial cases requiring topical antibiotics, viral cases needing supportive care, and allergic cases responding to antihistamines and mast cell stabilizers. 1, 2

Diagnosis and Classification

Before treatment, determine the type of conjunctivitis:

• Bacterial conjunctivitis:

  • Signs: Purulent discharge, mattering of eyelids (especially upon waking)
  • Common in children
  • Usually caused by Streptococcus pneumoniae or Haemophilus influenzae

• Viral conjunctivitis:

  • Signs: Watery discharge, burning/gritty sensation
  • Most common overall cause
  • Often adenoviral

• Allergic conjunctivitis:

  • Signs: Intense itching, bilateral involvement, watery discharge
  • Seasonal pattern common
  • Associated with allergen exposure

Treatment Algorithm

1. Bacterial Conjunctivitis

• Standard treatment: 5-7 day course of broad-spectrum topical antibiotics 2

  • Tobramycin 0.3%: 1-2 drops every 4 hours
  • Moxifloxacin 0.5%: 1 drop three times daily
  • Other options: Besifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, ofloxacin

• Special cases:

  • Gonococcal/chlamydial conjunctivitis: Requires systemic antibiotics (ceftriaxone + azithromycin) 2
  • Contact lens wearers: Always treat with antibiotics and evaluate for corneal ulcers 3
  • MRSA: Consider if standard therapy fails 2

• Evidence: Topical antibiotics speed clinical resolution (62% vs 28% cure rate at 3-5 days) and reduce transmission risk 4

2. Viral Conjunctivitis

• Primary treatment: Supportive care 2, 5

  • Cold compresses
  • Preservative-free artificial tears
  • Strict hand hygiene to prevent transmission

• For severe cases:

  • Ganciclovir 0.15% gel 3-5 times daily (if herpes suspected) 2
  • Avoid topical corticosteroids as they can potentiate HSV infection 2

3. Allergic Conjunctivitis

• First-line treatment: 1

  • Topical antihistamines with mast cell-stabilizing properties
    • OTC options: Ketotifen, olopatadine
    • Prescription options: Alcaftadine, bepotastine

• Environmental measures: 1

  • Avoid allergens and eye rubbing
  • Use hypoallergenic bedding and eyelid cleansers
  • Frequent clothes washing
  • Cool compresses

• For moderate-severe cases: 1

  • Brief course (1-2 weeks) of topical corticosteroids with low side effect profile (loteprednol, fluorometholone)
  • Monitor IOP and examine for cataract formation if using steroids
  • Consider topical cyclosporine 0.05% or tacrolimus for severe cases

• Avoid:

  • Punctal plugs (prevent flushing of allergens) 1
  • Prolonged corticosteroid use without monitoring 1

Follow-up Recommendations

• Routine bacterial conjunctivitis: Follow-up not usually necessary unless symptoms persist after 3-4 days 2
• Gonococcal conjunctivitis: Daily follow-up until resolution 2
• When using corticosteroids: Monitor IOP and examine for cataract formation 1

Common Pitfalls to Avoid

1. Inappropriate steroid use: Avoid in suspected viral conjunctivitis as it can worsen infection 2
2. Inadequate treatment duration: Complete full antibiotic course even if symptoms improve 2
3. Misdiagnosis: Obtain cultures for purulent discharge, suspected gonorrhea, or non-response to therapy 2
4. Overlooking special populations: Neonates with conjunctivitis require immediate referral 2
5. Ignoring underlying causes: Contact lens-related issues or systemic conditions may require specific management 1, 2

Special Considerations

• Neonatal conjunctivitis: Requires immediate referral to pediatrician 2
• Pregnancy: Use erythromycin or amoxicillin for chlamydial infections; avoid doxycycline, quinolones, or tetracyclines 2
• Keratoconus risk: Control allergic conjunctivitis and prevent eye rubbing to reduce risk of ectasia progression 1

By following this treatment algorithm and recognizing the specific type of conjunctivitis, most cases can be effectively managed with improved outcomes and reduced transmission risk.