What are the treatment options for conjunctivitis?

Treatment Options for Conjunctivitis

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

Classification and Diagnosis

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 2
• No single sign or symptom accurately differentiates viral from bacterial conjunctivitis, but a careful assessment of symptoms can guide diagnosis 3
• Yellow crusting around the eyes is highly indicative of bacterial infection rather than viral or allergic etiology 4

Treatment by Type

Viral Conjunctivitis

• Supportive care options include artificial tears, cold compresses, and antihistamine eye drops 3
• Patients should be instructed to return if symptoms persist beyond 2-3 weeks 2
• Avoid topical corticosteroids as they can potentially prolong adenoviral infections and worsen HSV infections 2
• Strict personal hygiene, including frequent handwashing, is essential to decrease the risk of transmission 3

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 2
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 2
• Moxifloxacin ophthalmic solution 0.5% is effective against many common bacterial pathogens, with clinical cure rates of 66-69% after 3 times daily dosing for 4 days 5
• Cleaning eyelids and lashes with warm water and gentle soap to remove crusts before applying medication is essential 4
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 2

Gonococcal Conjunctivitis

• Systemic antibiotic therapy is required, not just topical treatment 2
• Patients should be seen daily until resolution of the conjunctivitis 2
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 2

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, as more than 50% of infants may have infection at other sites 1, 2
• Sexual contacts should be treated concurrently 2
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1, 2

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 2
• Oral treatments include acyclovir, valacyclovir, or famciclovir 2
• Topical corticosteroids should be avoided as they potentiate HSV infection 2, 6

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 2
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1, 2
• For persistent or recurrent cases, mast cell stabilizers are recommended 1, 2
• In severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 1, 2
• Identifying and avoiding triggering allergens is important 1

Special Considerations

Contact Lens Wearers

• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 5
• In users of contact lenses with conjunctivitis, suspend use until complete resolution 1

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 2
• Topical corticosteroids should be tapered once inflammation is controlled 2
• Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) may be less likely to result in elevated IOP or cataract formation 2

When to Refer to an Ophthalmologist

• Immediate referral is indicated 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, 2
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 2

Common Pitfalls to Avoid

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