What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Diagnosis and Classification

• Accurate diagnosis is essential for proper treatment, with bacterial conjunctivitis typically presenting with yellow crusting and mucopurulent discharge, viral conjunctivitis with watery discharge, and allergic conjunctivitis with itching as the most consistent symptom 1, 2
• Clinical presentation with mattering and adherence of eyelids on waking, lack of itching, and absence of history of conjunctivitis are strongly associated with bacterial etiology 3
• Bilateral involvement with mucopurulent discharge is characteristic of moderate bacterial conjunctivitis, particularly in elderly patients 4

Treatment by Type

Bacterial Conjunctivitis

• For moderate to severe bacterial conjunctivitis, a 5-7 day course of broad-spectrum topical antibiotic such as moxifloxacin 0.5% ophthalmic solution three times daily is recommended as first-line treatment 4
• Alternatively, azithromycin ophthalmic solution can be used with a regimen of 1 drop twice daily for the first two days, then once daily for five more days 5
• Cleaning eyelids and lashes with warm water and gentle soap to remove crusts before applying medication is essential for effective treatment 4
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1
• Many uncomplicated cases of bacterial conjunctivitis are self-limiting and may resolve without treatment, though antibiotics can decrease duration and allow earlier return to work or school 1, 3

Gonococcal and Chlamydial Conjunctivitis

• Gonococcal conjunctivitis requires systemic antibiotics and daily follow-up until resolution 1
• Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of infants with this condition may have infection at other sites 1
• Sexual contacts of patients with sexually transmitted conjunctivitis should be treated concurrently 1
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 1

Viral Conjunctivitis

• Treatment for viral conjunctivitis is primarily supportive, including artificial tears, cold compresses, and antihistamine eye drops 2
• Strict personal hygiene with frequent handwashing is essential to decrease transmission risk 2
• Indiscriminate use of topical antibiotics or corticosteroids should be avoided as they can induce toxicity and potentially prolong adenoviral infections or worsen HSV infections 1

Allergic Conjunctivitis

• Simple measures such as wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears are recommended for initial management 1
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for allergic conjunctivitis 1, 2
• 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
• Identifying and avoiding triggering allergens is important for long-term management 1

Special Considerations

• Contact lens wearers with conjunctivitis should discontinue lens use until complete resolution 5, 6
• Patients with bacterial conjunctivitis should avoid sharing towels, pillows, or cosmetics to prevent transmission 1
• Elderly patients require close monitoring for potential complications due to age-related immune changes 4
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 1

Referral to Ophthalmologist

• Immediate referral is recommended for patients with 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, or history of immunocompromise 1
• Ophthalmology referral is also indicated for conjunctivitis in a neonate, patients with recent ocular surgery, vesicular rash on the eyelids or nose, history of rheumatologic disease, or immunocompromised state 2
• If symptoms persist despite appropriate therapy, conjunctival cultures should be considered, particularly to rule out methicillin-resistant S. aureus (MRSA) 4

Common Pitfalls

• Skipping doses or not completing the full course of antibiotic therapy may decrease effectiveness and increase the likelihood of bacterial resistance 5
• Indiscriminate use of antibiotics for viral conjunctivitis is ineffective and contributes to antibiotic resistance 1, 3
• Using corticosteroid-containing preparations without confirming the etiology can worsen herpetic infections 7
• Failing to recognize alarming signs of more serious intraocular conditions, such as severe pain, decreased vision, and painful pupillary reaction 8