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), with supportive care being the primary approach 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

• Characteristics: Watery discharge, burning sensation, gritty feeling, preauricular lymphadenopathy
• Most common overall cause (80% of acute conjunctivitis cases) 2
• Usually self-limiting without need for specific treatment

Bacterial Conjunctivitis

• Characteristics: Mucopurulent discharge, eyelids matted shut upon waking, lack of itching
• Second most common cause of infectious conjunctivitis
• Most uncomplicated cases resolve in 1-2 weeks

Allergic Conjunctivitis

• Characteristics: Bilateral itching, watery discharge, eyelid edema, chemosis, papillary reaction
• Affects up to 40% of the population, though many don't seek medical help 2

Treatment Algorithm

1. Viral Conjunctivitis

• Primary treatment: Supportive care only
  • Cold compresses
  • Refrigerated artificial tears
  • Topical antihistamine eye drops for symptomatic relief
• Avoid antibiotics as they provide no benefit and may cause adverse effects 1
• Infection control: Strict hand hygiene, avoid sharing towels/pillows, minimize contact with others for 10-14 days

2. Bacterial Conjunctivitis

• Treatment options:
  • Topical antibiotics: Apply directly to conjunctival sac
    • Bacitracin: 1-3 times daily 3
    • Erythromycin: Apply 1 cm length up to six times daily depending on severity 4
    • Fluoroquinolones are also effective broad-spectrum options 1
  • Special cases:
    • Gonococcal conjunctivitis: Systemic ceftriaxone plus topical antibiotics
    • Chlamydial conjunctivitis: Systemic erythromycin plus topical antibiotics

3. Allergic Conjunctivitis

• First-line treatment:
  • Topical antihistamines with mast cell-stabilizing activity 5
  • Cold compresses
  • Lubricating eye drops
• For severe cases:
  • Topical corticosteroids for acute exacerbations
  • Cyclosporine 0.05% for severe vernal/atopic conjunctivitis
  • Tacrolimus 0.1% for non-responders to corticosteroids 1

Important Considerations

When Using Corticosteroids

• Monitor intraocular pressure (IOP) with baseline and periodic measurements
• Watch for signs of glaucoma and cataract formation
• Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, loteprednol) to reduce risk of IOP elevation 6, 7
• Taper to minimum effective dose

For Contact Lens Wearers

• Suspend use of contact lenses until conjunctivitis resolves
• Higher risk for Pseudomonas infection requires antibiotic treatment 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
• Severe cases: Re-evaluation within 1 week 6

Indications for Specialist Referral

• 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, 5

Common Pitfalls to Avoid

1. Using antibiotics for viral conjunctivitis
2. Prolonged corticosteroid use without monitoring IOP
3. Failing to consider special cases like gonococcal or chlamydial conjunctivitis
4. Neglecting infection control measures for viral conjunctivitis
5. Using punctal plugs, which can prevent elimination of allergens and inflammatory mediators 1

By following this treatment algorithm based on the type of conjunctivitis, clinicians can provide effective care while minimizing unnecessary medication use and potential complications.