What is the appropriate treatment for conjunctivitis?

Treatment of Conjunctivitis

The appropriate treatment for conjunctivitis depends on the specific type (viral, bacterial, or allergic), with most viral cases requiring only supportive care, bacterial cases potentially benefiting from topical antibiotics, and allergic cases responding to antihistamines and mast cell stabilizers. 1, 2

Diagnosis and Classification

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

• Viral Conjunctivitis:

  • Watery discharge
  • Burning sensation or gritty feeling
  • Preauricular lymphadenopathy
  • Accounts for 80% of acute conjunctivitis cases 3

• Bacterial Conjunctivitis:

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

• Allergic Conjunctivitis:

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

Treatment Approach by Type

1. Viral Conjunctivitis (Most Common)

• Primary Management: Supportive care only, as no proven effective treatment exists for eradication 1

  • Artificial tears (refrigerated for added comfort)
  • Cold compresses
  • Topical antihistamines for symptomatic relief
  • Oral analgesics if needed

• Important: Avoid antibiotics as they provide no benefit and may cause adverse effects 1

• For Severe Cases:

  • Topical corticosteroids may be considered for severe adenoviral keratoconjunctivitis with marked chemosis, eyelid swelling, epithelial sloughing, or membranous conjunctivitis
  • Caution: Close follow-up is required as corticosteroids may prolong viral shedding 1

• Infection Control:

  • Highly contagious for 10-14 days
  • Strict hand hygiene
  • Avoid sharing towels and pillows
  • Consider abbreviated exam in dedicated room with limited physical interaction 1

2. Bacterial Conjunctivitis

• Treatment Options:

  • Topical antibiotics such as bacitracin or erythromycin ophthalmic ointment 4, 5
  • Apply directly to conjunctival sac 1-3 times daily (bacitracin) or up to six times daily (erythromycin) depending on severity 4, 5

• Special Cases:

  • Gonococcal conjunctivitis: Systemic ceftriaxone plus topical antibiotics 2
  • Chlamydial conjunctivitis: Systemic erythromycin plus topical antibiotics 2

3. Allergic Conjunctivitis

• First-Line Treatment:

  • Topical antihistamines with mast cell-stabilizing properties 2
  • Cold compresses
  • Refrigerated artificial tears
  • Environmental modifications to minimize allergen exposure

• For Moderate to Severe Cases:

  • Brief course (1-2 weeks) of topical corticosteroids with low side effect profile 1
  • Cyclosporine 0.05% for severe vernal/atopic conjunctivitis 2
  • Tacrolimus 0.1% for patients who don't respond to topical corticosteroids 2

Important Considerations and Precautions

• When Using Corticosteroids:

  • Monitor intraocular pressure (IOP) periodically
  • Evaluate for glaucoma and cataract development
  • Taper once inflammation is controlled 1

• Contact Lens Wearers:

  • Suspend contact lens use until conjunctivitis resolves
  • Higher risk for Pseudomonas infection 2

• Follow-up Recommendations:

  • Severe cases with corneal epithelial ulceration or membranous conjunctivitis: within 1 week
  • Patients on topical corticosteroids: regular monitoring
  • Uncomplicated cases: return if symptoms persist beyond 2-3 weeks 1, 2

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
• Recent ocular surgery 2

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral conjunctivitis (ineffective and may cause adverse effects)
2. Prolonged corticosteroid use without monitoring (can cause glaucoma and cataracts)
3. Inadequate infection control measures for viral conjunctivitis (highly contagious)
4. Failure to recognize special cases requiring systemic treatment (gonococcal, chlamydial)
5. Using alcohol wipes on tonometer tips (inadequate disinfection for adenoviral conjunctivitis) 1