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 for bacterial cases, antihistamines for allergic cases, and supportive care for viral cases, which is the most common form. 1, 2

Diagnosis and Classification

Before treatment, it's important to identify the type of conjunctivitis:

• Viral conjunctivitis (most common overall - 80% of acute cases):

  • Typically presents with watery discharge and burning sensation 3
  • Often accompanied by preauricular lymph node swelling 3

• Bacterial conjunctivitis:

  • Characterized by purulent discharge and matting of eyelids 4, 5
  • More common in children than adults 5, 6

• Allergic conjunctivitis:

  • Presents with itching (most consistent sign) and watery discharge 7
  • Often bilateral and seasonal 6

Treatment by Type

Viral Conjunctivitis

• No proven effective treatment for eradication of adenovirus infection 1
• Symptomatic treatment includes:
  • Artificial tears for lubrication 1, 5
  • Cold compresses to reduce inflammation 1, 2
  • Topical antihistamines for symptomatic relief 1
• Avoid antibiotics due to potential adverse effects 1
• For HSV conjunctivitis, treatment options include:
  • Topical ganciclovir 0.15% gel three to five times per day 4
  • Topical trifluridine 1% solution five to eight times per day 4
  • Oral antivirals such as acyclovir (200-400 mg five times daily), valacyclovir (500 mg two or three times daily), or famciclovir (250 mg twice daily) 4
• Avoid topical corticosteroids in HSV conjunctivitis as they potentiate infection 4, 1

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is often self-limited and may resolve spontaneously in immune-competent adults 4, 1
• However, topical antibiotics provide earlier clinical and microbiological remission compared to placebo 1, 8
• A 5-7 day course of a broad-spectrum topical antibiotic is recommended for bacterial conjunctivitis 4, 1
• Moxifloxacin ophthalmic solution 0.5% is indicated for bacterial conjunctivitis with dosing of one drop in the affected eye 3 times a day for 7 days 9
• Clinical trials showed moxifloxacin produced clinical cures in 66-69% of patients with bacterial conjunctivitis 9
• For moderate to severe bacterial conjunctivitis:
  • Obtain conjunctival cultures and Gram staining if gonococcal infection is suspected 4, 1
  • Treatment should be guided by laboratory results 4
  • Consider methicillin-resistant S. aureus (MRSA) in patients from nursing homes or with community-acquired infections 4, 1

Allergic Conjunctivitis

• Simple measures include:
  • Wearing sunglasses as barriers to airborne allergens 4, 2
  • Cold compresses 4, 2
  • Refrigerated artificial tears 4, 2
  • Avoiding eye rubbing 4
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1, 2, 5
• For persistent or recurrent cases, mast cell stabilizers can be used 4, 2
• In severe cases, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 4, 2

Special Considerations

Gonococcal and Chlamydial Conjunctivitis

• Require systemic antibiotics in addition to topical therapy 1, 2, 7
• Daily monitoring until resolution is recommended for gonococcal conjunctivitis 1, 2
• More than 50% of infants with chlamydial conjunctivitis may have infection at other sites, necessitating systemic treatment 1, 2
• Sexual contacts should be treated concurrently 2

Contact Lens Wearers

• Should discontinue lens use until resolution of conjunctivitis 2
• Should always be treated for bacterial conjunctivitis and evaluated for corneal ulcers 6

When to Refer to an Ophthalmologist

Immediate referral is recommended for patients with:

• Visual loss 1, 2
• Moderate or severe pain 1, 2
• Severe purulent discharge 1, 2
• Corneal involvement 1, 2
• Conjunctival scarring 1, 2
• Lack of response to therapy after 3-4 days 1, 2
• Recurrent episodes 1, 2
• History of HSV eye disease 1, 2
• Immunocompromised state 1, 2, 5
• Neonatal conjunctivitis 5

Common Pitfalls to Avoid

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 2
• Prolonged use of topical trifluridine can cause epithelial toxicity if used for more than 2 weeks 4, 1
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage can worsen infection 4, 1
• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 1
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1