Treatment of Conjunctivitis (Pink Eye)
For conjunctivitis treatment, supportive care including artificial tears for comfort, cold compresses to reduce inflammation, and strict hygiene measures is the primary approach recommended by the American Academy of Ophthalmology, with specific antibiotic treatment reserved for confirmed bacterial cases. 1
Diagnosis and Classification
The first step is determining the type of conjunctivitis based on clinical presentation:
Viral conjunctivitis:
Bacterial conjunctivitis:
- Purulent or mucopurulent discharge
- Matting of eyelids (especially upon waking)
- Mild discomfort or foreign body sensation
- Common pathogens: H. influenzae, S. pneumoniae, S. aureus 1
Allergic conjunctivitis:
Treatment Algorithm
1. Viral Conjunctivitis
- Primary treatment: Supportive care only
- Artificial tears for comfort
- Cold compresses to reduce inflammation
- Strict hygiene measures to prevent spread 1
- Usually self-limiting within 5-14 days 1
- No antibiotic treatment needed 3, 2
2. Bacterial Conjunctivitis
- First-line treatment: Topical broad-spectrum antibiotics for 5-7 days
- Warm compresses (preferred over cold for bacterial cases) to soften discharge and loosen crusts 1
- Delayed antibiotic prescribing may be considered for mild cases 1, 2
- Evidence shows topical antibiotics decrease duration of bacterial conjunctivitis and allow earlier return to school/work 3
- Research demonstrates significantly better clinical cure rates with antibiotics (62%) vs. placebo (28%) by days 3-5 6
3. Allergic Conjunctivitis
- Primary treatment: Topical antihistamines with mast cell-stabilizing activity 2
- Supportive measures: Cold compresses, artificial tears 1
Special Considerations
Severe Cases Requiring Referral to Ophthalmologist
- 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)
- Severe adenoviral conjunctivitis
- Recent trauma or surgery
- Immunocompromised patients 1, 2
Sexually Transmitted Infections
- Gonococcal conjunctivitis: Requires both systemic (ceftriaxone) and topical therapy
- Chlamydial conjunctivitis: Requires systemic therapy (azithromycin, doxycycline, or levofloxacin) 1
Neonatal Conjunctivitis
- Requires immediate referral
- May indicate serious infections like gonococcal or chlamydial conjunctivitis 1
- Erythromycin ophthalmic ointment is indicated for prophylaxis of ophthalmia neonatorum 5
Prevention and Hygiene Measures
- Frequent handwashing
- Separate towels and washcloths
- Avoid sharing pillowcases
- Proper disinfection of toys and surfaces
- For contact lens wearers: Discontinue lens wear until infection resolves and consider switching to new lenses after resolution 1
- Dilute bleach solution (1:10) recommended for disinfecting surfaces 1
Clinical Pearls and Pitfalls
- Pitfall: Treating all red eyes with antibiotics. Most viral conjunctivitis cases are self-limiting and don't require antibiotics.
- Pitfall: Failing to recognize potentially serious causes of red eye that require urgent referral.
- Pearl: The presence of mucopurulent discharge strongly correlates with bacterial pathogens 7.
- Pearl: Compliance is significantly better with medications requiring fewer daily applications, such as fusidic acid twice daily versus tobramycin 4-6 times daily 7.
- Pearl: Bacterial conjunctivitis is self-limited but antibiotic treatment shortens duration and enhances pathogen eradication 6.