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 (viral, bacterial, or allergic), with topical antibiotics indicated for bacterial conjunctivitis, supportive care for viral conjunctivitis, and antihistamines/mast cell stabilizers for allergic conjunctivitis. 1

Diagnosis and Classification

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

Key Diagnostic Features

• Viral Conjunctivitis

  • Watery discharge
  • Burning sensation, gritty feeling
  • Preauricular lymphadenopathy
  • Often unilateral initially, may become bilateral

• Bacterial Conjunctivitis

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

• Allergic Conjunctivitis

  • Bilateral itching (key symptom)
  • Watery discharge
  • Eyelid edema and chemosis
  • Papillary reaction

Treatment Algorithm

1. Viral Conjunctivitis (most common overall)

• Primary Treatment: Supportive care 1, 2
  • Cold compresses
  • Refrigerated artificial tears
  • Topical antihistamine eye drops for symptomatic relief
• Avoid antibiotics as they provide no benefit 3
• Infection Control:
  • Strict hand hygiene
  • Avoid sharing towels/pillows
  • Minimize contact with others for 10-14 days 1
• For severe cases (marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis):
  • Topical corticosteroids may help reduce symptoms and scarring
  • Requires close follow-up and IOP monitoring 4

2. Bacterial Conjunctivitis

• Primary Treatment: Topical antibiotics 1, 3
  • Erythromycin ophthalmic ointment: Apply 1 cm directly to infected eye(s) up to six times daily 5
  • Bacitracin ophthalmic ointment: Apply directly into conjunctival sac 1-3 times daily 6
  • 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
  • Contact lens wearers: Suspend contact lens use until resolved 1

3. Allergic Conjunctivitis

• Primary Treatment: 1, 7, 8
  • Topical antihistamines with mast cell-stabilizing activity
  • Cold compresses
  • Lubricating eye drops
• For moderate to severe cases:
  • Topical corticosteroids for acute exacerbations
  • Consider loteprednol etabonate (safer corticosteroid with reduced risk of IOP elevation and cataract formation) 7
  • Cyclosporine 0.05% for severe vernal/atopic conjunctivitis
  • Tacrolimus 0.1% for steroid non-responders 1

Important Considerations and Pitfalls

1. Avoid unnecessary antibiotics for viral conjunctivitis, which represents 80% of all acute conjunctivitis cases 9

2. Monitor closely when using corticosteroids:

   • Measure baseline IOP
   • Perform periodic IOP measurements
   • Watch for cataract formation
   • Taper slowly to minimum effective dose 4, 1

3. Refer to ophthalmology for:

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

4. Follow-up:

   • Uncomplicated cases: Return if symptoms persist beyond 2-3 weeks
   • Cases treated with corticosteroids: Regular monitoring required 1

By following this algorithm and considering the specific type of conjunctivitis, you can provide effective initial treatment that addresses both symptoms and underlying causes while minimizing complications and unnecessary medication use.