What is the treatment for bilateral conjunctivitis?

Treatment of Bilateral Conjunctivitis

The treatment of bilateral conjunctivitis should be based on the specific type (viral, bacterial, or allergic), with viral conjunctivitis primarily managed with supportive care, bacterial conjunctivitis treated with topical broad-spectrum antibiotics for 5-7 days, and allergic conjunctivitis managed with topical antihistamines and mast cell stabilizers. 1

Classification and Diagnosis

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

Viral Conjunctivitis

• Clinical signs: Abrupt onset, unilateral or bilateral (often sequentially bilateral), watery discharge, follicular reaction of inferior tarsal conjunctiva, chemosis, eyelid swelling 2
• Associated factors: Exposure to infected individuals, concurrent upper respiratory infection 2
• Natural history: Self-limited, with improvement within 5-14 days 2

Bacterial Conjunctivitis

• Clinical signs: Purulent or mucopurulent discharge, matting of eyelids, conjunctival injection, mild discomfort 1
• Common pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, Moraxella species 1
• Natural history: Often self-limiting, with 41% resolving without antibiotics by days 6-10 1

Allergic Conjunctivitis

• Clinical signs: Intense itching, watery discharge, bilateral involvement 1
• Associated factors: Seasonal allergies, exposure to allergens 1

Treatment Approach

1. Viral Conjunctivitis

• Primary treatment: Supportive care 1
  • Artificial tears for lubrication
  • Cold compresses to reduce inflammation and discomfort
  • Strict personal hygiene to prevent transmission
• Avoid antibiotics as they are ineffective against viruses 1
• Special considerations:
  • If herpes simplex virus is suspected (vesicular rash, dendritic lesions), refer to ophthalmologist 2, 3
  • For severe adenoviral conjunctivitis, ophthalmology referral may be needed 2

2. Bacterial Conjunctivitis

• Primary 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
    • Ofloxacin ophthalmic solution 4
• Application: 1-2 drops in affected eye(s) 4 times daily 4
• Warm compresses to soften discharge and loosen crusts 1
• Delayed antibiotic prescribing may be considered for mild cases 1, 5

3. Allergic Conjunctivitis

• Primary treatment: Topical antihistamines with mast cell-stabilizing activity 3, 5
• Additional measures:
  • Cold compresses
  • Artificial tears
  • Allergen avoidance

Special Considerations

Neonatal Conjunctivitis

• Immediate referral required as it may indicate serious infections 1
• Treatment based on onset:
  • 1-7 days after birth: Consider gonococcal infection
  • 5-19 days: Consider chlamydial infection
  • First week: Common bacterial infection 1

Sexually Transmitted Infections

• Gonococcal conjunctivitis: Requires both systemic (ceftriaxone) and topical therapy 1
• Chlamydial conjunctivitis: Requires systemic therapy (azithromycin, doxycycline, or levofloxacin) 1

Contact Lens Wearers

• Discontinue lens wear until infection resolves 1
• Consider switching to new lenses after resolution to prevent re-infection 1

Prevention and Hygiene

• Handwashing: Frequent handwashing by patients and caregivers 1
• Avoid sharing: Use separate towels, washcloths, and pillowcases 1
• Surface disinfection: Dilute bleach solution (1:10) for disinfecting surfaces 1

When to Refer to an Ophthalmologist

Refer patients with:

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• History of herpes simplex virus eye disease
• Immunocompromised status 1, 3

Treatment Efficacy

• Bacterial conjunctivitis: Topical antibiotics significantly improve clinical cure rates (62% vs 28% with placebo by days 3-5) and bacterial eradication rates (71% vs 19% by days 3-5) 6
• Viral conjunctivitis: Supportive care is the mainstay of treatment, as the condition is self-limiting 5
• Allergic conjunctivitis: Topical antihistamines and mast cell stabilizers effectively alleviate symptoms 5

Remember that most cases of viral and bacterial conjunctivitis are self-limiting, but appropriate treatment can reduce duration of symptoms, decrease risk of complications, and prevent transmission to others.