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 (viral, bacterial, or allergic) determined through clinical presentation, with supportive care being appropriate for viral conjunctivitis, topical antibiotics for bacterial 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:

Viral Conjunctivitis (Most Common)

• Clinical Signs: Watery discharge, burning sensation, gritty feeling, preauricular lymphadenopathy
• Presentation: Often unilateral initially, may become bilateral
• Associated Factors: Recent upper respiratory infection, exposure to infected individuals

Bacterial Conjunctivitis

• Clinical Signs: Mucopurulent discharge, eyelids matted shut upon waking
• Presentation: More common in children than adults
• Key Indicators: Mattering and adherence of eyelids on waking, lack of itching

Allergic Conjunctivitis

• Clinical Signs: Bilateral itching, watery discharge, eyelid edema, chemosis
• Presentation: Typically bilateral and symmetric
• Key Indicator: Itching is the most consistent sign

Treatment Algorithm

1. Viral Conjunctivitis Treatment

• Primary Approach: Supportive care only (no antibiotics needed) 1, 2
  • Cold compresses to reduce inflammation
  • Refrigerated artificial tears for comfort
  • Topical antihistamine eye drops for symptomatic relief
• For Severe Cases (with marked chemosis, lid swelling, or membranous conjunctivitis):
  • Topical corticosteroids may be considered to reduce symptoms and scarring 3
  • Close follow-up required if using corticosteroids

2. Bacterial Conjunctivitis Treatment

• Primary Approach: Topical antibiotics 1, 4
  • 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
  • For blepharitis: Remove all scales and crusts before applying ointment uniformly over lid margins 6
• 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 Treatment

• Primary Approach: 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 (preferably loteprednol or other C-20 ester corticosteroids with better safety profile) 7
  • Cyclosporine 0.05% for severe vernal/atopic conjunctivitis 1
  • Tacrolimus 0.1% for patients who don't respond to topical corticosteroids 1

Important Precautions

Infection Control

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

Corticosteroid Monitoring

• Monitor intraocular pressure (IOP) when using corticosteroids
• Baseline and periodic measurements to evaluate for glaucoma and cataracts 1
• Use minimum effective dose and taper slowly 3

When to Refer to Specialist

Immediate referral for:

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Lack of response to therapy after 2-3 weeks
• History of HSV eye disease
• Immunocompromised patients
• Neonatal conjunctivitis 1, 9

Follow-up Recommendations

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

Remember that most viral and uncomplicated bacterial conjunctivitis cases are self-limiting, but proper identification and treatment can reduce duration of symptoms, prevent complications, and limit spread to others.