What is the initial treatment for a patient with conjunctivitis?

Initial Treatment for Conjunctivitis

The initial treatment for conjunctivitis should be based on the specific type identified through clinical assessment, with viral conjunctivitis typically requiring supportive care, bacterial conjunctivitis often benefiting from topical antibiotics, and allergic conjunctivitis responding to antihistamines and mast cell stabilizers. 1

Clinical Assessment and Diagnosis

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

Key Diagnostic Features

• Viral Conjunctivitis:

  • Watery discharge
  • Burning sensation or gritty feeling
  • Preauricular lymphadenopathy
  • Often bilateral (may start in one eye)

• Bacterial Conjunctivitis:

  • Mucopurulent discharge
  • Eyelids matted shut upon waking
  • Lack of itching
  • More common in children

• Allergic Conjunctivitis:

  • Bilateral itching (hallmark symptom)
  • Watery discharge
  • Eyelid edema
  • Chemosis (conjunctival swelling)

Treatment Algorithm

1. Viral Conjunctivitis (Most Common)

• Primary Treatment: Supportive care 1

  • Cold compresses
  • Refrigerated artificial tears
  • Topical antihistamine eye drops for symptomatic relief

• For Severe Cases:

  • Topical corticosteroids may be considered for severe cases with marked chemosis, lid swelling, or membranous conjunctivitis 2
  • Close follow-up required if using corticosteroids
  • Caution: Corticosteroids may prolong viral shedding 2

2. Bacterial Conjunctivitis

• Primary Treatment: Topical antibiotics 1, 3, 4

  • Bacitracin ointment applied directly to conjunctival sac 1-3 times daily 3
  • Erythromycin ointment applied up to 6 times daily depending on severity 4
  • Fluoroquinolones are also effective broad-spectrum options 1

• Special Cases:

  • Gonococcal conjunctivitis: Systemic ceftriaxone plus topical antibiotics 1
  • Chlamydial conjunctivitis: Systemic erythromycin plus topical antibiotics 1

3. Allergic Conjunctivitis

• Primary Treatment: 1

  • Topical antihistamines
  • Mast cell stabilizers
  • Combination antihistamine/mast cell stabilizer products

• For Moderate to Severe Cases:

  • Topical corticosteroids for acute exacerbations
  • Cyclosporine 0.05% for severe vernal/atopic conjunctivitis
  • Tacrolimus 0.1% for steroid non-responders

Important Considerations

Infection Control

• Strict hand hygiene
• Avoid sharing towels and pillows
• Minimize contact with others for 10-14 days for viral conjunctivitis 1

Contact Lens Wearers

• Suspend use of contact lenses until conjunctivitis resolves 1
• Higher risk for Pseudomonas infection

Corticosteroid Precautions

• Monitor intraocular pressure (IOP) when using corticosteroids 2, 1
• Use minimum effective dose
• Consider steroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) to reduce risk of IOP elevation 2

When to Refer to an Ophthalmologist

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Lack of response to therapy after 2-3 weeks
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised patients
• Neonatal conjunctivitis 1

Follow-up Recommendations

• Uncomplicated cases: Return if symptoms persist beyond 2-3 weeks
• Cases treated with corticosteroids: Regular monitoring of IOP and pupillary dilation 2, 1
• Severe cases with corneal involvement: Re-evaluate within 1 week 2

Remember that while many cases of bacterial conjunctivitis are self-limiting, proper treatment can decrease duration and allow earlier return to school or work 5. For viral conjunctivitis, which is the most common type, supportive care is typically sufficient as most cases resolve without specific antiviral treatment 6.