What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Classification and Diagnosis

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 3
• Yellow crusting around the eyes strongly suggests bacterial infection rather than viral or allergic etiology 3
• Bilateral involvement with mucopurulent discharge is characteristic of moderate bacterial conjunctivitis 3

Treatment by Type

Viral Conjunctivitis (Most Common)

• No proven effective treatment for eradication of adenovirus infection; management focuses on symptom relief 4
• Supportive care includes artificial tears, topical antihistamines, oral analgesics, and cold compresses 4
• Avoid antibiotics as they provide no benefit and may cause adverse effects 4
• Topical corticosteroids may be helpful in severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, but require close follow-up 4
• Patients should be educated about high contagiousness and advised to minimize contact with others for 10-14 days 4

Bacterial Conjunctivitis

• Mild cases are usually self-limited and resolve spontaneously without specific treatment in immunocompetent adults 2, 3
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 3
• Bacitracin or erythromycin ophthalmic ointments are FDA-approved options for superficial ocular infections involving the conjunctiva 5, 6
• Clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 3
• Return for evaluation if no improvement after 3-4 days of treatment 2, 3

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy, not just topical treatment 2, 3
• Saline lavage may promote comfort and more rapid resolution of inflammation 2
• Daily follow-up until resolution is necessary 2
• Sexual contacts must be treated concurrently 2, 3

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, as more than 50% of patients may have infection at other sites 2, 3
• Sexual contacts should be treated concurrently 2
• Re-evaluation following treatment is important due to potential treatment failure (up to 19%) 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 4

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) 2
• Avoid topical corticosteroids as they potentiate HSV infection 2
• Follow-up within 1 week of treatment is essential 2

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to allergens, cold compresses, and refrigerated artificial tears 2, 3
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1, 2, 3
• For persistent or recurrent cases, mast cell stabilizers like cromolyn sodium are recommended 2, 3
• For severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile can be added 2, 3

Special Considerations

Corticosteroid Use

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

Contact Lens-Related Conjunctivitis

• Discontinue contact lens wear until the cornea returns to normal 3
• Consider replacing lenses more frequently, decreasing wearing time, using preservative-free lens care systems, or switching to daily disposable lenses for giant papillary conjunctivitis 3

When to Refer to an Ophthalmologist

• Immediate referral is indicated for patients with: 2

  • 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
  • History of immunocompromise

• 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 2, 3
• Chronic use of vasoconstrictor agents can lead to rebound vasodilation 2
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 2
• Topical trifluridine causes epithelial toxicity if used for more than 2 weeks 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