What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Classification and Diagnosis

• Conjunctivitis is an inflammation affecting primarily the conjunctiva that can be classified as noninfectious (allergic, mechanical/irritative/toxic, immune-mediated) or infectious (viral, bacterial) 3
• Classification should be based on clinical presentation to determine appropriate treatment approach 2
• The patient population includes individuals of all ages who present with symptoms and signs suggestive of conjunctivitis, such as red eye or discharge 3

Treatment by Type

Viral Conjunctivitis

• Primarily self-limited and requires supportive care rather than antimicrobial treatment 4
• Supportive measures include artificial tears, cold compresses, and topical antihistamines for symptomatic relief 4
• 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, 4
• Strict personal hygiene with frequent handwashing is essential to decrease transmission risk 5

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
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1, 2
• Erythromycin ophthalmic ointment can be applied directly to the infected eye(s) up to six times daily, depending on the severity of the infection 6
• Bacitracin ophthalmic ointment is indicated for superficial ocular infections involving the conjunctiva caused by susceptible organisms 7

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy, not just topical treatment 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 3, 2

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, as more than 50% of patients may have infection at other sites 3, 1
• Sexual contacts should be treated concurrently 3, 2
• Patients should be re-evaluated following treatment due to potential treatment failure (up to 19%) 3
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 3, 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 2
• 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

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

Neonatal Conjunctivitis

• For prophylaxis of ophthalmia neonatorum, a ribbon of erythromycin ointment approximately 1 cm in length should be instilled into each lower conjunctival sac 6
• For infants born to mothers with clinically apparent gonorrhea, intravenous or intramuscular injections of aqueous crystalline penicillin G should be given (50,000 units for term infants or 20,000 units for infants of low birth weight) 6
• Topical prophylaxis alone is inadequate for these infants 6

When to Refer to an Ophthalmologist

• Immediate referral is indicated for patients with 3, 2, 5:

  • 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
  • Immunocompromised status

• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 3, 2

Common Pitfalls and Caveats

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided as they can induce toxicity and potentially prolong adenoviral infections and worsen HSV infections 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
• 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
• Delayed antibiotic prescribing has been found to have similar symptom control as immediate prescribing for bacterial conjunctivitis 5