What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Diagnosis and Classification

• Conjunctivitis is an inflammation of the conjunctiva that can be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 2
• Accurate diagnosis is essential for appropriate treatment, as different types require different management approaches 3

Treatment by Type

Viral Conjunctivitis

• Primarily self-limited requiring 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 including 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 such as erythromycin or bacitracin is recommended 2, 6, 7
• Erythromycin ophthalmic ointment should be applied directly to the infected eye(s) up to six times daily, depending on infection severity 6
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1, 2
• Delayed antibiotic prescribing has similar symptom control as immediate prescribing 5

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, 2
• 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
• In severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 1, 2

Special Considerations

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring intraocular pressure 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 intraocular pressure or cataract formation 2

When to Refer to an Ophthalmologist

• Immediate referral is indicated for patients with:
  • Visual loss 2
  • Moderate or severe pain 2
  • 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
  • History of immunocompromise 3
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 3, 2

Common Pitfalls to Avoid

• 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

Infection Control Measures

• Patient education about the contagious nature of infectious conjunctivitis is critical 4
• Patients should minimize contact with others, practice strict hand hygiene, and avoid sharing personal items 4
• Do not share towels, pillows, or cosmetics to prevent transmission 1
• Contact lens wearers with conjunctivitis should suspend use until complete resolution 1