What is the appropriate management for a patient presenting with conjunctivitis?

Management of Conjunctivitis

The management of conjunctivitis should be tailored to the specific etiology, with most cases being self-limited and requiring only supportive care while avoiding indiscriminate use of antibiotics or corticosteroids. 1

Diagnosis and Classification

Conjunctivitis can be classified into three main categories:

1. Viral Conjunctivitis

   • Most common overall cause
   • Typically presents with watery discharge
   • Often associated with upper respiratory infection
   • Highly contagious

2. Bacterial Conjunctivitis

   • Second most common infectious cause
   • Presents with purulent or mucopurulent discharge
   • Matting of eyelids, especially upon waking
   • Absence of significant itching

3. Allergic Conjunctivitis

   • Characterized by intense itching
   • Watery discharge
   • Chemosis and eyelid edema
   • Often bilateral and seasonal

Management Algorithm

1. Viral Conjunctivitis

• Treatment:
  • Supportive care with artificial tears
  • Cold compresses for symptomatic relief
  • Antihistamine eye drops for itching
  • Avoid antibiotics as they are ineffective against viruses 1
• Prevention of Spread:
  • Frequent handwashing
  • Avoid sharing towels and pillowcases
  • Minimize contact with others for 10-14 days 2
  • Proper disinfection of surfaces with EPA-registered hospital disinfectant 1

2. Bacterial Conjunctivitis

• Treatment:
  • Most cases are self-limited and resolve within 1-2 weeks 3
  • For moderate to severe cases:
    • Broad-spectrum topical antibiotics (e.g., fluoroquinolones, polymyxin B-bacitracin, trimethoprim-polymyxin B) 2
    • Standard treatment course: 5-7 days 2
    • Continue until resolution of discharge and reduction in conjunctival injection
  • For mild cases:
    • Consider delayed antibiotic prescribing 2, 4
• Special Considerations:
  • Gonococcal conjunctivitis: Requires BOTH systemic (Ceftriaxone) and topical therapy 2
  • Chlamydial conjunctivitis: Requires systemic therapy (Azithromycin, Doxycycline, or Levofloxacin) 2

3. Allergic Conjunctivitis

• Treatment:
  • Topical antihistamines with mast cell-stabilizing activity 4
  • Avoidance of allergens
  • For severe vernal conjunctivitis, topical corticosteroids may be necessary 1

Red Flags Requiring Ophthalmology Referral

Refer to an ophthalmologist for any of the following:

• Lack of response to therapy after 3-4 days
• Moderate to severe pain
• Decreased vision
• Corneal involvement
• Conjunctival scarring
• Recurrent episodes
• History of herpes simplex virus eye disease
• Immunocompromised patients 2
• Neonatal conjunctivitis (especially if suspected gonococcal or chlamydial) 2

Special Populations

Neonates

• Conjunctivitis in neonates requires special attention:
  • 1-7 days after birth: Consider gonococcal infection
  • 5-19 days: Consider chlamydial infection
  • First week: Common bacterial infection (Staphylococcus aureus, Enterococcus, Klebsiella, E. coli) 2
• Evaluate and treat the mother and her sexual partner(s) for gonococcal and chlamydial infections 2

Prevention Measures

• Proper hand hygiene
• Avoid sharing personal items
• For epidemic adenoviral conjunctivitis:
  • Dilute bleach soak (sodium hypochlorite) at 1:10 concentration for disinfecting tonometers 1
  • Note: 70% isopropyl alcohol, 3% hydrogen peroxide, and ethyl alcohol are no longer recommended for tonometer disinfection 1
• Herpes zoster vaccination is strongly recommended in patients 50 years or older 1

Common Pitfalls to Avoid

1. Indiscriminate use of antibiotics: Viral conjunctivitis will not respond to antibacterial agents, and mild bacterial conjunctivitis is often self-limited 1

2. Inappropriate use of corticosteroids: Avoid topical corticosteroids without ophthalmology consultation, as they can potentiate viral infections 2

3. Failure to recognize serious underlying conditions: Early detection of conjunctivitis associated with systemic diseases (e.g., OMMP, GVHD, gonococcus, chlamydia) is important as treatment must address the underlying condition 1

4. Inadequate infection control: Proper disinfection protocols are essential to prevent spread, especially for highly contagious forms like adenoviral conjunctivitis 1

5. Delayed referral for concerning symptoms: Patients with severe pain, vision changes, or lack of improvement should be promptly referred to ophthalmology 4