What is the initial approach to treating conjunctivitis?

Initial Approach to Treating Conjunctivitis

The initial approach to treating conjunctivitis should be based on the suspected etiology, with implementation of infection control measures including frequent handwashing, separate towels and pillows, and avoiding close contact during the contagious period (7-14 days). 1

Diagnosis and Classification

Before initiating treatment, it's essential to determine the type of conjunctivitis:

• Viral Conjunctivitis

  • Most common overall cause
  • Typically presents with watery discharge
  • Follicular reaction on examination
  • Often associated with upper respiratory symptoms

• Bacterial Conjunctivitis

  • Second most common cause
  • Key indicators: mattering and adherence of eyelids on waking
  • Mucopurulent discharge
  • Lack of itching

• Allergic Conjunctivitis

  • Prominent itching is the most consistent sign
  • Watery discharge
  • Often bilateral and seasonal

Treatment Algorithm by Type

1. Viral Conjunctivitis

• Primary treatment: Supportive care only 1, 2
  • Artificial tears for comfort
  • Cold compresses
  • Antihistamine eye drops for symptomatic relief
• Avoid antibiotics as they are ineffective against viral causes
• Infection control: Critical to prevent spread
  • Strict hand hygiene
  • Separate towels and pillows
  • Avoid touching or rubbing eyes

2. Bacterial Conjunctivitis

• Mild to moderate cases:

  • Topical antibiotics (e.g., fluoroquinolones, aminoglycosides, macrolides) 1
  • For azithromycin ophthalmic solution: Instill 1 drop twice daily (8-12 hours apart) for first two days, then once daily for five more days 3

• Severe cases or specific pathogens:

  • Gonococcal conjunctivitis: Requires systemic therapy with ceftriaxone 1g IM as single dose plus saline lavage 1
  • Chlamydial conjunctivitis: Requires systemic therapy with azithromycin 1g orally as single dose or doxycycline 100mg orally twice daily for 7 days 1
  • Obtain conjunctival cultures and Gram stain if gonococcal infection is suspected

3. Allergic Conjunctivitis

• First-line treatment: Antihistamines and mast cell stabilizers 1, 4
• For temporary relief: Vasoconstrictors
• For severe cases: Corticosteroids only under ophthalmologic supervision
• Long-term management: Consider allergen-specific immunotherapy, especially beneficial in children

Special Considerations

Contact Lens Wearers

• Discontinue lens use during treatment
• Require antibiotic treatment even for mild bacterial conjunctivitis
• Need proper education on lens care and replacement 1

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
• Neonatal conjunctivitis 1, 5

Important Caveats

1. Diagnostic challenges: Clinical accuracy in diagnosing viral conjunctivitis is less than 50% without specific testing 1

2. Antibiotic resistance concerns: Unnecessary antibiotic use contributes to resistance. Consider delayed antibiotic prescribing for uncomplicated cases, which has shown similar symptom control as immediate prescribing 5

3. Medication administration: When using eye drops, proper technique is essential:

   • Wash hands before application
   • Avoid contaminating the applicator tip
   • For AzaSite: Invert and shake bottle once before each use 3

4. Contact lens precaution: Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 3

5. Comorbidities: Dry eye disease frequently coexists with allergic conjunctivitis and should be considered in management 4

By following this structured approach based on the suspected etiology, most cases of conjunctivitis can be effectively managed with appropriate treatment and infection control measures.