Initial Treatment for Conjunctivitis
The initial treatment for conjunctivitis should be supportive care, including artificial tears for comfort, cold compresses to reduce inflammation, and strict hygiene measures to prevent spread, as recommended by the American Academy of Ophthalmology. 1
Diagnosis and Classification
Before initiating treatment, it's crucial to identify the type of conjunctivitis:
Key Diagnostic Features
- Viral conjunctivitis: Watery discharge, follicular reaction of inferior tarsal conjunctiva, chemosis, eyelid swelling 1
- Bacterial conjunctivitis: Purulent or mucopurulent discharge, matting of eyelids on waking, conjunctival injection, mild discomfort 1
- Allergic conjunctivitis: Intense itching, watery discharge, bilateral presentation 1
Treatment Algorithm by Type
1. Viral Conjunctivitis (Most Common)
- Primary treatment: Supportive care only 2, 1
- Artificial tears (refrigerated for added comfort)
- Cold compresses
- Strict hygiene measures
- Duration: Self-limiting, typically resolves in 5-14 days 1, 3
- No antibiotics needed: Antibiotics are ineffective against viral infections and should be avoided 2, 3
2. Bacterial Conjunctivitis
- Mild cases: Consider delayed antibiotic prescribing, as many cases are self-limiting within 1-2 weeks 1, 3
- Moderate to severe cases: Topical broad-spectrum antibiotics for 5-7 days 1
- Warm compresses: Recommended over cold compresses to soften discharge and loosen crusts 1
3. Allergic Conjunctivitis
- First-line treatment: Topical antihistamines with mast cell-stabilizing activity 2, 1, 6
- Supportive measures:
- Cold compresses
- Refrigerated artificial tears
- Allergen avoidance
- For persistent cases: Consider brief course (1-2 weeks) of topical corticosteroids with low side effect profile 2
Special Considerations
Specific Bacterial Infections
- Gonococcal conjunctivitis: Requires both systemic (ceftriaxone) and topical therapy 1
- Chlamydial conjunctivitis: Requires systemic therapy (azithromycin, doxycycline, or levofloxacin) 1
Neonatal Conjunctivitis
- Requires immediate referral 1
- For prophylaxis of neonatal gonococcal or chlamydial ophthalmia: Erythromycin ointment (1 cm length) instilled into each lower conjunctival sac 4
Prevention and Hygiene Measures
- Frequent handwashing
- Avoid touching or rubbing eyes
- Use separate towels and washcloths
- Avoid sharing pillowcases
- Properly disinfect toys and surfaces with dilute bleach solution (1:10) 1
- For contact lens wearers: Discontinue lens wear until infection resolves 1
When to Refer to Ophthalmology
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
- Suspected herpes simplex virus (vesicular rash or dendritic lesions)
- History of rheumatologic disease
- Immunocompromised state 1, 7
Common Pitfalls to Avoid
- Indiscriminate use of antibiotics: Avoid prescribing antibiotics for viral conjunctivitis 2
- Inappropriate corticosteroid use: Corticosteroids can prolong adenoviral infections and worsen HSV infections 2
- Neglecting hygiene measures: Proper hygiene is essential to prevent spread 1
- Missing serious underlying causes: Be vigilant for signs requiring specialist referral 1, 7
- Overlooking comorbid dry eye: Tear film disruption can exacerbate symptoms 6
By following this treatment algorithm based on the type of conjunctivitis, most cases can be effectively managed with good outcomes for morbidity, mortality, and quality of life.