What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

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

Diagnosis and Classification

• Conjunctivitis is commonly classified as viral, bacterial, or allergic based on clinical presentation 2
• Yellow crusting around eyes suggests bacterial infection, while watery discharge is more common in viral and allergic conjunctivitis 3
• Itching is the most consistent symptom in allergic conjunctivitis 4
• Bilateral involvement with mucopurulent discharge is characteristic of moderate bacterial conjunctivitis 3

Treatment by Type

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is often self-limiting and typically resolves spontaneously without specific treatment in immune-competent adults 5, 1
• A 5-7 day course of broad-spectrum topical antibiotic is recommended for bacterial conjunctivitis to provide earlier clinical and microbiological remission 5, 1
• Moxifloxacin ophthalmic solution 0.5% three times daily for 7 days is an effective treatment option, with clinical cure rates of 66-69% by day 5-6 6
• Other fluoroquinolones (levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are also effective against common bacterial pathogens 1
• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics when access to antibiotics is limited 5
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 7
• Cleaning eyelids and lashes with warm water and gentle soap to remove crusts before applying medication is essential 3

Viral Conjunctivitis

• No proven effective treatment exists for eradication of adenovirus infection 1
• Symptomatic treatment includes artificial tears, topical antihistamines, and cold compresses 1, 8
• Avoid antibiotics due to potential adverse effects 1
• Topical corticosteroids may help in severe cases with marked chemosis, lid swelling, or membranous conjunctivitis, but require close monitoring 1
• For HSV conjunctivitis, topical ganciclovir 0.15% gel or topical trifluridine 1% solution is recommended 1
• Oral antivirals (acyclovir, valacyclovir, famciclovir) may be used for HSV conjunctivitis 1
• Avoid topical corticosteroids in HSV conjunctivitis as they potentiate infection 1

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 7
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 7
• For persistent or recurrent cases, mast cell stabilizers can be used 7
• In severe cases, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 7
• Concomitant use of cooled artificial tears may alleviate coexisting tear deficiency and dilute allergens 5

Special Considerations

Contact Lens Wearers

• Discontinue contact lens use in conjunction with topical anti-inflammatory agents for giant papillary conjunctivitis 1
• Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers 9

Pediatric Patients

• Bacterial conjunctivitis is more common in children than adults 2
• Fluoroquinolones are approved for conjunctivitis in children older than 12 months 1
• In infants with chlamydial conjunctivitis, systemic therapy is necessary as more than 50% may have infection at other sites 1

Severe Cases

• Moderate to severe bacterial conjunctivitis is characterized by copious purulent discharge, pain, and marked inflammation 5
• Conjunctival cultures and Gram staining should be obtained if gonococcal infection is suspected 5
• Gonococcal conjunctivitis requires systemic antibiotics and daily monitoring until resolution 1, 7
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 7

When to Refer to an Ophthalmologist

• Refer patients who experience 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 are immunocompromised 1, 7
• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 1

Common Pitfalls and Caveats

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided, as antibiotics can induce toxicity and corticosteroids can potentially prolong adenoviral infections and worsen HSV infections 7
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis can have serious consequences 1
• Prolonged use of topical trifluridine can cause epithelial toxicity if used for more than 2 weeks 1
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage can potentiate infection 1
• Methicillin-resistant S. aureus (MRSA) should be considered in patients from nursing homes or with community-acquired infections 1