What is the best treatment for conjunctivitis?

Best Treatment for Conjunctivitis

The best treatment for conjunctivitis depends on its cause, with viral conjunctivitis requiring supportive care, bacterial conjunctivitis responding to topical antibiotics, and allergic conjunctivitis benefiting from antihistamines and mast cell stabilizers. 1

Diagnosis and Classification

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

• Bacterial conjunctivitis: Characterized by mucopurulent discharge and matted eyelids
• Viral conjunctivitis: Presents with watery discharge and often upper respiratory symptoms
• Allergic conjunctivitis: Distinguished by severe itching and history of allergies

Treatment Algorithm by Type

Viral Conjunctivitis (Most Common - 80% of cases)

1. First-line treatment:

   • Strict hygiene measures to prevent transmission
   • Cold compresses
   • Refrigerated artificial tears for symptomatic relief
   • Over-the-counter topical antihistamine/vasoconstrictor for severe symptoms 1

2. For severe cases:

   • Topical corticosteroids at minimum effective dose may be considered for adenoviral cases with severe symptoms
   • Must be tapered and monitored as they may prolong viral shedding 2, 1

3. For HSV conjunctivitis:

   • Topical antivirals: ganciclovir 0.15% gel (3-5 times daily) or trifluridine 1% solution (5-8 times daily)
   • Oral antivirals: acyclovir (200-400 mg five times daily), valacyclovir (500 mg 2-3 times daily), or famciclovir (250 mg twice daily)
   • Avoid topical corticosteroids as they potentiate HSV infection 2, 1

Bacterial Conjunctivitis

1. Standard cases:

   • Topical antibiotics such as gentamicin, tetracycline, or ofloxacin 1
   • Moxifloxacin 0.5% ophthalmic solution: one drop in affected eye 3 times daily for 7 days 3
   • Clinical cure rates with moxifloxacin range from 66-69% after 4 days of treatment, with microbiological success rates of 84-94% 3

2. For gonococcal conjunctivitis:

   • Systemic antibiotics (ceftriaxone) plus topical antibiotics 1

3. For chlamydial conjunctivitis:

   • Oral azithromycin or tetracycline plus topical antibiotics 1

Allergic Conjunctivitis

1. First-line treatment:

   • Cold compresses
   • Wearing sunglasses as barrier to allergens
   • Avoiding allergens and eye rubbing
   • Refrigerated artificial tears 1

2. Second-line treatment:

   • Second-generation topical histamine H1-receptor antagonists 1
   • For persistent cases, mast-cell stabilizers are more cost-effective for long-term use 1

Special Considerations

Corticosteroid Use

• Should be used at minimum effective dose when indicated
• Must be monitored by periodically measuring IOP and pupillary dilation
• Taper once inflammation is controlled
• Consider corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to reduce risk of elevated IOP or cataract formation 2

Return to Work/School

• Patients with bacterial conjunctivitis can typically return after 24 hours of antibiotic treatment
• Those with viral conjunctivitis should minimize contact with others for 10-14 days from onset 1

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
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised status 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral conjunctivitis, leading to unnecessary cost and antibiotic resistance
2. Prolonged use of corticosteroids without ophthalmology supervision
3. Failure to recognize potentially serious causes of conjunctivitis
4. Inadequate hygiene education to prevent spread
5. Delayed referral for severe or non-responsive cases 1

Most cases of bacterial conjunctivitis are self-limiting, but treatment with topical antibiotics can decrease duration and allow earlier return to normal activities 4. For viral conjunctivitis, which accounts for the majority of cases, supportive care and hygiene measures are the mainstay of treatment 5.