What treatment should be ordered for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

For pink eye (conjunctivitis), treatment should be tailored to the specific cause - viral, bacterial, or allergic - with viral being most common in adults and bacterial most common in children. 1

Viral Conjunctivitis

• No proven effective treatment exists for eradication of adenovirus infection 2
• Treatment is symptomatic and includes:
  • Artificial tears 2, 3
  • Topical antihistamines 2, 3
  • Cold compresses 2, 3
  • Oral analgesics 2
• Antibiotics should be avoided as they provide no benefit and may cause adverse effects 2
• Topical corticosteroids may be helpful in severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close monitoring 2, 3
• For HSV conjunctivitis, use topical ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily 2, 3
• Oral antivirals (acyclovir, valacyclovir, famciclovir) may be used for HSV conjunctivitis 3

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is often self-limited and may resolve spontaneously 3, 4
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotic is recommended 3, 4
• Dosing frequency depends on the antibiotic:
  • Moxifloxacin 0.5%: Apply one drop to affected eye 3 times daily for 7 days 5
  • Other fluoroquinolones and antibiotics: Generally 4 times daily for 5-7 days 4
• Moxifloxacin has demonstrated faster clinical resolution (81% at 48 hours) compared to polymyxin B/trimethoprim (44% at 48 hours) 6
• For severe cases or suspected gonococcal infection, obtain cultures before initiating treatment 3, 4
• Gonococcal conjunctivitis requires systemic antibiotics in addition to topical therapy 3

Allergic Conjunctivitis

• Topical antihistamines with mast cell-stabilizing activity are the treatment of choice 1, 7
• Discontinue contact lens use during treatment 3

Patient Education and Prevention

• Educate patients about the contagious nature of viral and bacterial conjunctivitis 2, 3
• Advise frequent handwashing, use of separate towels and pillows, and avoiding close contact during the contagious period (10-14 days from onset) 2
• Patients should not wear contact lenses if they have signs or symptoms of conjunctivitis 5

When to Refer to an Ophthalmologist

• Visual loss 3
• Moderate or severe pain 3
• Severe purulent discharge 3
• Corneal involvement 3
• Conjunctival scarring 3
• Lack of response to therapy 3
• Recurrent episodes 3
• History of HSV eye disease 3
• Immunocompromised patients 3
• Neonates with conjunctivitis 1

Common Pitfalls

• Using antibiotics for viral conjunctivitis provides no benefit and may cause adverse effects 2
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage can worsen the infection 3
• Prolonged use of trifluridine (>2 weeks) can cause epithelial toxicity 3
• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 3
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 3, 4