What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

The treatment of conjunctivitis must be tailored specifically to its underlying cause, with topical antibiotics indicated for bacterial conjunctivitis, antihistamines for allergic conjunctivitis, and supportive care for viral conjunctivitis. 1

Classification and Diagnosis

Conjunctivitis is an inflammation affecting primarily the conjunctiva and can be classified as:

• Infectious (viral, bacterial) or non-infectious (allergic, mechanical/irritative/toxic, immune-mediated) 2
• Acute, chronic, or recurrent 2

Treatment by Type

Viral Conjunctivitis

• Adenoviral conjunctivitis (most common form in adults) is self-limited and does not require antimicrobial treatment 2
• Treatment is supportive and may include:
  • Artificial tears for symptomatic relief 2, 3
  • Topical antihistamines for symptomatic relief 2
  • Cold compresses 2, 3
  • Oral analgesics for pain relief 2
• Antibiotics should be avoided as they provide no benefit and may cause adverse effects 2
• Topical corticosteroids may be helpful in severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, but require close follow-up 2
• Patient education about high contagiousness is essential - advise minimizing contact with others for 10-14 days from symptom onset 2

Herpes Simplex Virus (HSV) Conjunctivitis

• Treatment options include:
  • Topical ganciclovir 0.15% gel three to five times daily 2
  • Topical trifluridine 1% solution five to eight times daily (not for >2 weeks due to epithelial toxicity) 2
  • Oral antivirals: acyclovir (200-400mg five times daily), valacyclovir (500mg two or three times daily), or famciclovir (250mg twice daily) 2
• Avoid topical corticosteroids as they potentiate HSV infection 2
• Follow-up within 1 week of treatment 2

Varicella Zoster Virus (VZV) Conjunctivitis

• Oral antivirals for persistent or recalcitrant disease:
  • Acyclovir 800mg five times daily for 7 days 2
  • Valacyclovir 1000mg every 8 hours for 7 days 2
  • Famciclovir 500mg three times daily for 7 days 2
• Topical antibiotics may be used to prevent secondary infection 2
• Immunocompromised patients may need more aggressive treatment 2

Bacterial Conjunctivitis

Mild Bacterial Conjunctivitis

• Often self-limited in immunocompetent adults and may resolve without specific treatment 2
• A 5-7 day course of broad-spectrum topical antibiotics can hasten clinical resolution 2
• Options include:
  • Azithromycin ophthalmic solution: 1 drop twice daily for first two days, then once daily for five days 4
  • Moxifloxacin ophthalmic solution: 1 drop three times daily for 7 days 5
• Povidone-iodine 1.25% ophthalmic solution may be an alternative when antibiotic access is limited 2
• Patients should return for evaluation if no improvement after 3-4 days 2

Moderate to Severe Bacterial Conjunctivitis

• Characterized by copious purulent discharge, pain, and marked inflammation 2
• Obtain conjunctival cultures and Gram stains if gonococcal infection is suspected 2
• Antibiotic choice should be guided by laboratory test results 2
• Consider methicillin-resistant S. aureus (MRSA) in resistant cases 2

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy 2
• Saline lavage may promote comfort and faster resolution 2
• Daily follow-up until resolution 2
• Treat sexual contacts concurrently 1
• Hospitalization may be necessary for severe cases 1

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy 2
• No data support additional topical therapy 2
• Treat sexual contacts concurrently 2, 1
• Re-evaluate following treatment due to potential treatment failure (up to 19%) 2

Allergic Conjunctivitis

• Simple measures include:
  • Wearing sunglasses as barriers to airborne allergens 1
  • Cold compresses 1
  • Refrigerated artificial tears 1
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1
• For persistent or recurrent cases, mast cell stabilizers can be used 1
• In severe cases, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 1

Special Considerations

Contact Lens Wearers

• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 4, 5
• Resume contact lens wear only after complete resolution 1

When to Refer to an Ophthalmologist

Immediate referral is recommended for patients with: 2, 1

• 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 to Avoid

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 1
• Antibiotics do not benefit viral conjunctivitis and may cause toxicity 2
• Topical corticosteroids can potentiate HSV infections and should be used with caution 2
• Prolonged use of antimicrobials may result in overgrowth of non-susceptible organisms 4, 5
• Failure to treat sexual contacts in cases of sexually transmitted conjunctivitis 2, 1