What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

The treatment of conjunctivitis must be tailored to the specific cause, with most viral cases being self-limited and requiring only supportive care, bacterial cases benefiting from topical antibiotics, and allergic conjunctivitis responding to antihistamines and mast cell stabilizers. 1

Diagnosis and Classification

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

• Conjunctivitis is an inflammation of the conjunctiva that can be classified as infectious (viral or bacterial) or non-infectious (allergic, mechanical/irritative/toxic) 1
• Viral conjunctivitis typically presents with watery discharge and is the most common cause of infectious conjunctivitis 2, 3
• Bacterial conjunctivitis often presents with mucopurulent discharge and eyelids matted shut, especially in children 3
• Allergic conjunctivitis is characterized by itching, which is the most consistent symptom 2

Treatment by Type

Viral Conjunctivitis

• Most cases are self-limited and do not require antimicrobial treatment 1
• Supportive care includes artificial tears, cold compresses, and antihistamine eye drops for symptomatic relief 3
• Strict personal hygiene with frequent handwashing is essential to prevent transmission 1, 3
• For adenoviral conjunctivitis (EKC), patients should minimize contact with others for 10-14 days from symptom onset 1
• Topical corticosteroids may be considered in severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, but require close follow-up 1

Herpes Simplex Virus Conjunctivitis

• Treatment options include topical ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily 1
• Oral antivirals may include acyclovir (200-400 mg five times daily), valacyclovir (500 mg two or three times daily), or famciclovir (250 mg twice daily) 1
• Avoid topical corticosteroids as they can potentiate HSV infection 1

Herpes Zoster Virus Conjunctivitis

• For persistent or recalcitrant disease, oral antivirals are recommended: acyclovir (800 mg five times daily for 7 days), valacyclovir (1000 mg every 8 hours for 7 days), or famciclovir (500 mg three times daily for 7 days) 1
• Herpes zoster vaccination is strongly recommended for patients 50 years or older and immunocompromised patients 19 years or older 1

Mild Bacterial Conjunctivitis

• Often self-limited in immunocompetent adults 1
• A 5-7 day course of broad-spectrum topical antibiotics can shorten the course of disease and allow earlier return to work or school 1, 2
• No particular antibiotic has been shown to be superior; choose the most convenient or least expensive option 1
• For example, moxifloxacin 0.5% ophthalmic solution can be instilled one drop in the affected eye 3 times a day for 7 days 4
• Alternatively, azithromycin ophthalmic solution can be used: 1 drop twice daily for the first two days, then once daily for five more days 5

Moderate to Severe Bacterial Conjunctivitis

• Characterized by copious purulent discharge, pain, and marked inflammation 1
• Obtain conjunctival cultures and Gram staining if gonococcal infection is suspected 1
• Consider methicillin-resistant S. aureus (MRSA) in patients with risk factors or treatment failure 1

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy (not just topical) 1
• Saline lavage may help with comfort and resolution of inflammation 1
• Daily follow-up until resolution is necessary 1
• Sexual contacts should be informed and treated 1

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, especially in infants who may have infection at other sites 1
• Sexual contacts should be treated simultaneously 1
• Follow-up evaluation is important due to potential treatment failure (up to 19%) 1

Allergic Conjunctivitis

• Topical antihistamines with mast cell-stabilizing activity are the treatment of choice 2, 3
• Symptoms include itching, mucoid discharge, chemosis, and eyelid edema 6

Special Considerations

• Patients with conjunctivitis should be referred to an ophthalmologist if they have: visual loss, moderate/severe pain, severe purulent discharge, corneal involvement, conjunctival scarring, lack of response to therapy, recurrent episodes, history of HSV eye disease, or immunocompromise 1
• Contact lens wearers should discontinue lens use during active infection 4, 5
• For neonates with conjunctivitis, prompt consultation with a pediatrician is necessary, especially for suspected HSV which can be life-threatening 1

Common Pitfalls to Avoid

• Using antibiotics for viral conjunctivitis, which is ineffective and may contribute to antibiotic resistance 2, 7
• Using topical corticosteroids without appropriate follow-up, which can lead to increased intraocular pressure and cataract formation 1
• Failing to recognize potentially serious causes of red eye that may mimic conjunctivitis but require different management 3
• Not addressing underlying conditions such as dry eye or blepharitis that may cause or exacerbate conjunctival inflammation 1