What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

The treatment of conjunctivitis must be tailored specifically to its 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 and can be classified as infectious (viral, bacterial) or non-infectious (allergic, mechanical/irritative/toxic) 3
• Yellow crusting around the eyes strongly suggests bacterial infection rather than viral or allergic etiology 4
• Bilateral involvement with mucopurulent discharge is characteristic of moderate bacterial conjunctivitis 4

Treatment by Type

Viral Conjunctivitis

• Most cases of acute infectious conjunctivitis in adults are viral and self-limited, not requiring antimicrobial treatment 3
• Treatment options include artificial tears, topical antihistamines, cold compresses, and oral analgesics to mitigate symptoms 3
• Antibiotics should be avoided in viral conjunctivitis due to potential adverse effects 3
• Patients should be educated about the highly contagious nature of adenoviral conjunctivitis and advised to minimize contact with others for 10-14 days 3
• Topical corticosteroids may help reduce symptoms and scarring in severe cases but should be used cautiously as they can prolong viral shedding 3

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis often resolves spontaneously without specific treatment in immunocompetent adults 2, 4
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 4
• Patients should clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 4
• Return for evaluation is advised if no improvement is seen after 3-4 days of treatment 3, 4

Gonococcal Conjunctivitis

• Systemic antibiotic therapy is required, not just topical treatment 2, 4
• Daily follow-up until resolution is necessary 1
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 2, 4

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required as more than 50% of patients may have infection at other sites 1, 2
• Sexual contacts should be treated concurrently 3
• Re-evaluation following treatment is important due to potential treatment failure (up to 19%) 3

Herpes Simplex Virus (HSV) Conjunctivitis

• Treatment options include ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily 2
• Oral treatments include acyclovir (200-400 mg five times daily), valacyclovir (500 mg two or three times daily), or famciclovir (250 mg twice daily) 3
• Avoid topical corticosteroids as they potentiate HSV infection 3
• Follow-up within 1 week of treatment is recommended 3

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to 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 cases, mast cell stabilizers like cromolyn sodium are recommended 2, 4
• In severe cases, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 1, 2

Special Considerations

Corticosteroid Use

• Monitor patients treated with topical corticosteroids by periodically measuring IOP and pupillary dilation 2, 4
• Taper corticosteroids once inflammation is controlled 3
• Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) may reduce risk of elevated IOP or cataract formation 3

Contact Lens-Related Conjunctivitis

• Discontinue contact lens wear until the cornea returns to normal 4
• Consider replacing lenses more frequently, decreasing wearing time, using preservative-free lens care systems, or switching to daily disposable lenses for giant papillary conjunctivitis 4

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

Common Pitfalls

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 2, 4
• Chronic use of vasoconstrictor agents can cause rebound vasodilation once stopped 4
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 4
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 4
• Not considering sexual abuse in children with gonococcal or chlamydial infections 3

Medication-Specific Information

• For bacterial conjunctivitis, erythromycin ophthalmic ointment approximately 1 cm in length should be applied directly to the infected eye(s) up to six times daily, depending on severity 5
• For prophylaxis of neonatal gonococcal or chlamydial ophthalmia, a ribbon of erythromycin ointment approximately 1 cm in length should be instilled into each lower conjunctival sac 5
• Bacitracin ophthalmic ointment is indicated for treatment of superficial ocular infections involving the conjunctiva and/or cornea caused by susceptible organisms 6