What is the initial treatment for a patient with conjunctivitis?

Initial Treatment for Conjunctivitis

The initial treatment for conjunctivitis should be based on the clinical presentation, with topical broad-spectrum antibiotics for 5-7 days recommended as first-line treatment for bacterial conjunctivitis, supportive care for viral conjunctivitis, and topical antihistamines with mast cell stabilizers for allergic conjunctivitis. 1

Diagnosis and Classification

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

Key Diagnostic Features

• Viral conjunctivitis:

  • Watery discharge
  • Often associated with upper respiratory infection
  • Preauricular lymphadenopathy
  • Usually starts in one eye and spreads to the other

• Bacterial conjunctivitis:

  • Purulent or mucopurulent discharge
  • Matting of eyelids, especially upon waking
  • Conjunctival injection
  • Absence of significant pain or vision loss 1

• Allergic conjunctivitis:

  • Intense itching (most consistent sign)
  • Bilateral involvement
  • Seasonal pattern
  • History of atopy 2, 1

Treatment Algorithm

1. Bacterial Conjunctivitis

• First-line treatment: Topical broad-spectrum antibiotics for 5-7 days 1

  • Options include:
    • Polymyxin B-trimethoprim ophthalmic solution
    • Gentamicin ophthalmic solution
    • Moxifloxacin 0.5% ophthalmic solution
    • Bacitracin ophthalmic ointment 1-3 times daily 3
    • Erythromycin ophthalmic ointment up to 6 times daily 4

• Application: Apply approximately 1 cm of ointment directly into the conjunctival sac or instill drops as directed 3, 4

• Important note: Delayed antibiotic prescribing may be considered for mild cases, as it has similar symptom control as immediate prescribing 1, 5

2. Viral Conjunctivitis

• Treatment is supportive 2, 1, 6:

  • Artificial tears
  • Cold compresses
  • Topical antihistamines for symptomatic relief

• Avoid antibiotics as they are ineffective against viruses and their indiscriminate use should be avoided 1

• Special considerations:

  • For severe cases with marked chemosis, lid swelling, or membranous conjunctivitis, topical corticosteroids may be considered but require close follow-up 2
  • Povidone-iodine 0.4% with dexamethasone 0.1% may reduce the duration of viral conjunctivitis but can cause more stinging 7

3. Allergic Conjunctivitis

• First-line treatment: Topical antihistamines with mast cell-stabilizing activity 1, 5, 8

  • Second-generation topical histamine H1-receptor antagonists are more effective than over-the-counter options 2

• Additional measures:

  • Cold compresses
  • Refrigerated artificial tears
  • Avoiding allergen exposure
  • Wearing sunglasses as a barrier to airborne allergens 2

• For persistent or severe cases:

  • A brief course (1-2 weeks) of topical corticosteroids with a low side effect profile may be added 2
  • Loteprednol etabonate is preferred due to its improved safety profile 8

Special Considerations

Gonococcal and Chlamydial Conjunctivitis

• Require both systemic and topical therapy 1
• Gonococcal: Systemic ceftriaxone
• Chlamydial: Systemic azithromycin, doxycycline, or levofloxacin

Neonatal Conjunctivitis

• Requires immediate referral to ophthalmology 1, 5

Prevention and Hygiene

• Frequent handwashing
• Avoid sharing towels, washcloths, and pillowcases
• Proper disinfection of surfaces with dilute bleach solution (1:10) 1
• For contact lens wearers: discontinue lens wear until infection resolves 1

When to Refer to Ophthalmology

• No response to therapy after 3-4 days
• Moderate to severe pain
• Decreased vision
• Corneal involvement
• History of herpes simplex virus eye disease
• Immunocompromised patients 1, 5

Remember that while bacterial conjunctivitis is often self-limiting (41% resolve without antibiotics by days 6-10), treatment speeds resolution and reduces the risk of complications and spread 1, 6.