What are the treatment options for conjunctivitis?

Treatment of Conjunctivitis

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

Diagnosis and Classification

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 2
• Yellow crusting around the eyes is highly indicative of bacterial infection rather than viral or allergic etiology 3
• Bilateral involvement with mucopurulent discharge is characteristic of moderate bacterial conjunctivitis 3
• Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are strongly associated with bacterial conjunctivitis 4

Treatment by Type

Viral Conjunctivitis

• Supportive care options include artificial tears, cold compresses, and antihistamine eye drops 5
• 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 5

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 2
• A 5-7 day course of broad-spectrum topical antibiotics (such as moxifloxacin 0.5% ophthalmic solution three times daily) is recommended for moderate to severe bacterial conjunctivitis 3, 2
• Bacitracin is indicated for superficial ocular infections involving the conjunctiva caused by susceptible organisms 6
• Cleaning eyelids and lashes with warm water and gentle soap to remove crusts before applying medication is essential 3
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1, 2

Gonococcal Conjunctivitis

• Systemic antibiotic therapy is required, not just topical treatment 1, 2
• Saline lavage may promote comfort and more rapid resolution of inflammation 2
• Patients should be seen daily until resolution of the conjunctivitis 2
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 1, 2

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, as more than 50% of patients may have infection at other sites 1, 2
• Erythromycin ophthalmic ointment is indicated for prophylaxis of ophthalmia neonatorum due to C. trachomatis 7
• Sexual contacts should be treated concurrently 2
• Patients should be re-evaluated following treatment due to potential treatment failure (up to 19%) 2

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 for both acute and chronic allergic conjunctivitis 1, 2, 5
• For persistent or recurrent cases, mast cell stabilizers like cromolyn sodium are recommended 1, 2, 8
• 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
• Cromolyn sodium ophthalmic solution 4% is specifically indicated for vernal keratoconjunctivitis, vernal conjunctivitis, and vernal keratitis 8

Special Considerations

Contact Lens-Related Conjunctivitis

• Contact lens wear should be discontinued until the cornea returns to normal 9
• A brief (1-2 weeks) course of topical corticosteroids may be prescribed, in addition to longer-term use of topical cyclosporine 0.05% 9
• Consider alternatives to contact lenses (e.g., eyeglasses or refractive surgery) once the keratoconjunctivitis has resolved 9
• For giant papillary conjunctivitis (GPC), consider replacing lenses more frequently, decreasing wearing time, using preservative-free lens care systems, or switching to daily disposable lenses 9

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 9, 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 2, 5
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 2

Common Pitfalls

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided as they can induce toxicity and potentially prolong adenoviral infections and worsen HSV infections 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 antibiotics containing corticosteroids should never be used unless the conjunctivitis is proven to be non-herpetic 10
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 2