What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

The treatment of conjunctivitis must be specifically tailored to the underlying cause, with topical antibiotics for bacterial conjunctivitis, antihistamines for allergic conjunctivitis, and supportive care for viral conjunctivitis. 1, 2

Classification and Diagnosis

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 1
• Bacterial conjunctivitis typically presents with mucopurulent discharge and matted eyelids, especially in children 3
• Viral conjunctivitis often presents with watery discharge and is the most common form in adults 3
• Allergic conjunctivitis is distinguished by severe itching, which is the most consistent sign 4

Treatment by Type

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 1
• For moderate to severe bacterial conjunctivitis, a 5-7 day course of broad-spectrum topical antibiotics is recommended 1
• Moxifloxacin ophthalmic solution 0.5% is indicated for bacterial conjunctivitis and should be instilled one drop in the affected eye 3 times a day for 7 days 5
• Gatifloxacin ophthalmic solution is also effective against common bacterial pathogens causing conjunctivitis 6
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1, 2

Gonococcal and Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required for gonococcal conjunctivitis, not just topical treatment 1
• Chlamydial conjunctivitis also requires systemic antibiotics, as more than 50% of infants may have infection at other sites 1, 2
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 1
• Daily follow-up is necessary for gonococcal conjunctivitis until resolution 2

Viral Conjunctivitis

• Most cases are self-limiting and require only supportive care 4
• Supportive measures include artificial tears, cold compresses, and antihistamine eye drops 3
• Patients should be instructed to return if symptoms persist beyond 2-3 weeks 1
• Topical corticosteroids should be avoided as they can potentially prolong adenoviral infections and worsen HSV infections 1

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 1
• 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) 1
• Topical corticosteroids should be strictly avoided as they potentiate HSV infection 1, 7
• Follow-up within 1 week of treatment is recommended 1

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 2
• Mild cases can be treated with over-the-counter topical antihistamine/vasoconstrictor agents 1
• Topical medications with combined antihistamine activity and mast-cell stabilizing properties are preferred for both acute and chronic disease 1, 2
• For persistent or recurrent cases, mast cell stabilizers are recommended 1, 2
• For severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile can be added 1, 2

Special Considerations and Precautions

• Contact lens wearers should discontinue lens use until conjunctivitis resolves 5
• Patients using topical antibiotics should be warned about potential hypersensitivity reactions 5
• Strict personal hygiene, including frequent handwashing, is essential to decrease the risk of transmission 3
• Chronic use of vasoconstrictor agents can cause rebound vasodilation once discontinued 1
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 1

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 immunocompromised status 1, 2, 3
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 1, 2
• Conjunctivitis in neonates requires specialist evaluation due to risk of serious complications 3

Common Pitfalls

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 1, 2
• Topical corticosteroids should never be used unless the conjunctivitis is proven to be non-herpetic 7
• 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 1
• Topical trifluridine causes epithelial toxicity if used for more than 2 weeks; topical ganciclovir is less toxic to the ocular surface 1