Treatment of Conjunctivitis
The treatment of conjunctivitis must be specifically tailored to the underlying cause, with antibiotics indicated for bacterial cases, antihistamines for allergic cases, and supportive care for viral cases. 1
Diagnosis and Classification
- Accurate identification of the type of conjunctivitis is crucial for appropriate treatment, as viral, bacterial, and allergic conjunctivitis require different management approaches 1
- Bacterial conjunctivitis typically presents with mucopurulent discharge and mattering of eyelids, especially upon waking 2
- Viral conjunctivitis (80% of infectious cases) usually presents with watery discharge and may be accompanied by preauricular lymphadenopathy 3
- Allergic conjunctivitis is characterized by itching as the most consistent symptom 2
Treatment by Type
Bacterial Conjunctivitis
- Mild bacterial conjunctivitis can resolve spontaneously without treatment, with most uncomplicated cases resolving in 1-2 weeks 2
- For moderate to severe bacterial conjunctivitis, topical antibiotics are indicated to decrease duration and allow earlier return to school or work 2
- Recommended antibiotics include fluoroquinolones such as moxifloxacin or gatifloxacin for broad coverage against common pathogens 4, 5
- Moxifloxacin ophthalmic solution 0.5% should be instilled as one drop in the affected eye 3 times a day for 7 days 4
- Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 6, 7
Special Cases of Bacterial Conjunctivitis
- Gonococcal conjunctivitis requires systemic antibiotics and daily follow-up until resolution 6, 7
- Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of infants with this condition may have infection at other sites 6
- Sexual contacts of patients with sexually transmitted conjunctivitis should be treated concurrently 6
- In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 6
Viral Conjunctivitis
- Most cases of viral conjunctivitis are self-limiting and require only supportive care 2
- Supportive measures include artificial tears, cold compresses, and avoiding eye rubbing 8
- Strict personal hygiene with frequent handwashing is essential to prevent transmission 8
- Corticosteroids should be avoided in suspected herpes simplex viral conjunctivitis 3
Allergic Conjunctivitis
- Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, refrigerated artificial tears, and avoiding allergen exposure 6
- Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 8
- For persistent or recurrent cases, mast cell stabilizers can be used 6
- In severe cases, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 6
Special Considerations
- Contact lens wearers should discontinue lens use until conjunctivitis resolves 4
- Patients should avoid sharing towels, pillows, or cosmetics to prevent transmission 1
- Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 6
Referral to Ophthalmologist
- Immediate referral is indicated for patients with any of the following 6:
- Visual loss
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement
- Conjunctival scarring
- Lack of response to therapy
- Recurrent episodes
- History of HSV eye disease
- History of immunocompromise
Common Pitfalls
- Indiscriminate use of topical antibiotics or corticosteroids should be avoided 6
- Antibiotics can induce toxicity and corticosteroids can potentially prolong adenoviral infections and worsen HSV infections 6
- Oral antihistamines may induce or worsen dry eye syndrome and impair the tear film's protective barrier 6
- Delayed diagnosis of herpes simplex viral conjunctivitis can lead to complications if corticosteroids are inappropriately used 3