What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Diagnosis and Classification

• Conjunctivitis can be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 1
• No single sign or symptom accurately differentiates viral from bacterial conjunctivitis, requiring comprehensive evaluation 2
• Bacterial conjunctivitis typically presents with mucopurulent discharge and matted eyelids, more common in children 2
• Viral and allergic conjunctivitis typically present with watery discharge, more common in adults 2
• Severe itching is the hallmark symptom of allergic conjunctivitis 3

Treatment by Type

Viral Conjunctivitis

• Most common cause of infectious conjunctivitis, usually self-limited and does not require specific treatment 3
• Supportive care options include artificial tears, cold compresses, and antihistamine eye drops 2
• Strict personal hygiene with frequent handwashing is essential to decrease transmission risk 2
• Patients should be instructed to return if symptoms persist beyond 2-3 weeks 4
• Topical corticosteroids should be avoided as they can potentially prolong adenoviral infections and worsen HSV infections 1

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 4
• For moderate to severe bacterial conjunctivitis, a 5-7 day course of broad-spectrum topical antibiotics is recommended 4
• Topical antibiotics decrease duration of bacterial conjunctivitis and allow earlier return to school or work 3
• Moxifloxacin 0.5% ophthalmic solution is indicated for bacterial conjunctivitis, dosed as one drop in the affected eye 3 times a day for 7 days 5
• Gatifloxacin ophthalmic solution is also indicated for bacterial conjunctivitis caused by susceptible strains 6
• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics when access to antibiotics is limited 4
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy, not just topical treatment 4
• Saline lavage may promote comfort and more rapid resolution of inflammation 4
• Patients should be seen daily until resolution of the conjunctivitis 4
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 1

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, as more than 50% of infants may have infection at other sites 1
• Sexual contacts should be treated concurrently 4
• Patients should be re-evaluated following treatment due to potential treatment failure (up to 19%) 4
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 4

Herpes Simplex Virus (HSV) Conjunctivitis

• Treatment options include ganciclovir 0.15% gel three to five times per day or trifluridine 1% solution five to eight times per day 4
• Oral treatments include acyclovir (200-400 mg five times per day), valacyclovir (500 mg two or three times per day), or famciclovir (250 mg twice a day) 4
• Topical corticosteroids should be avoided as they potentiate HSV infection 4
• Follow-up within 1 week of treatment is recommended 4

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 4
• Mild cases can be treated with over-the-counter topical antihistamine/vasoconstrictor agents 4
• Second-generation topical histamine H1-receptor antagonists are more effective for mild cases 4
• Topical medications with combined antihistamine activity and mast-cell stabilizing properties are preferred for both acute and chronic disease 1
• For persistent or recurrent cases, mast cell stabilizers are recommended 1
• For severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile can be added 4, 1
• Concomitant use of cooled preservative-free artificial tears may alleviate coexisting tear deficiency and dilute allergens 4

Special Considerations

Contact Lens Wearers

• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 5
• Contact lens wearers with conjunctivitis should be treated with antibiotics 3

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 4
• Topical corticosteroids should be tapered once inflammation is controlled 4
• Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) may be less likely to result in elevated IOP or cataract formation 4

Referral to Ophthalmologist

• Immediate referral is indicated for patients with 4, 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
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 4

Common Pitfalls

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 1
• Chronic use of vasoconstrictor agents can be associated with rebound vasodilation once the agent is stopped 4
• Oral antihistamines may induce or worsen dry eye syndrome and impair the tear film's protective barrier 4
• Topical trifluridine inevitably causes epithelial toxicity if used for more than 2 weeks; topical ganciclovir is less toxic to the ocular surface 4
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 1
• Not considering sexual abuse in children with gonococcal or chlamydial infections 4