How to manage conjunctivitis?

Management of Conjunctivitis

The management of conjunctivitis should be tailored to the specific etiology (viral, bacterial, or allergic), with most cases being self-limited and requiring only supportive care while avoiding indiscriminate use of antibiotics. 1, 2

Diagnosis and Classification

Clinical Features to Distinguish Types

• Viral conjunctivitis: Typically presents with abrupt onset, often unilateral initially but becomes sequentially bilateral, watery discharge, follicular reaction of the inferior tarsal conjunctiva, and possible preauricular lymphadenopathy 2
• Bacterial conjunctivitis: Characterized by purulent or mucopurulent discharge, papillary reaction, and mattering/adherence of eyelids on waking 2, 3
• Allergic conjunctivitis: Distinguished by severe itching, watery discharge, and history of allergen exposure 2, 3

Diagnostic Approach

• Comprehensive history should focus on duration of symptoms, character of discharge, unilateral vs bilateral presentation, and associated symptoms 1
• Physical examination should evaluate for conjunctival injection, type of discharge, presence of follicles or papillae, preauricular lymphadenopathy, and corneal involvement 1
• Laboratory testing is generally not required for uncomplicated cases but may include conjunctival swabs for culture in severe or recalcitrant cases 4

Treatment Algorithm

Viral Conjunctivitis (Most Common)

• Most cases are self-limited and do not require antimicrobial treatment 2
• Supportive care options include:
  • Artificial tears for symptomatic relief 2
  • Cold compresses to reduce inflammation 3
  • Topical antihistamines for symptomatic relief 2
• Patient education about contagiousness is essential:
  • Wash hands frequently with soap and water 1
  • Use separate towels and pillows 1
  • Avoid close contact with others for 10-14 days from symptom onset 2
  • Particularly important for healthcare workers and childcare providers 1

Bacterial Conjunctivitis

• Mild cases may resolve without specific treatment 2
• For moderate to severe bacterial conjunctivitis, a 5-7 day course of broad-spectrum topical antibiotic is recommended 2
• No evidence exists demonstrating the superiority of any particular topical antibiotic agent 1, 2
• For azithromycin ophthalmic solution (1%):
  • Instill 1 drop in affected eye(s) twice daily, 8-12 hours apart for first two days 5
  • Then instill 1 drop once daily for the next five days 5
  • Complete the full course to prevent bacterial resistance 5

Allergic Conjunctivitis

• Topical antihistamines with mast cell-stabilizing activity are the treatment of choice 3
• Allergen-specific immunotherapy is beneficial in reducing symptoms, more so in children than adults 1
• A multidisciplinary approach with pediatricians, internists, and allergists is recommended for management 1

Special Considerations

When to Refer to an Ophthalmologist

• Visual loss 1
• Moderate or severe pain 1
• Severe purulent discharge 1
• Corneal involvement 1, 6
• Conjunctival scarring 1
• Lack of response to therapy 1, 6
• Recurrent episodes 1
• History of HSV eye disease 1
• History of immunocompromise 1

Special Cases Requiring Urgent Care

• Gonococcal conjunctivitis: Requires systemic antibiotics in addition to topical therapy 2, 7
• Chlamydial conjunctivitis: Requires systemic treatment and evaluation of sexual partners 1, 7
• Neonatal conjunctivitis: Requires prompt evaluation and may need hospitalization for parenteral therapy 1
• Ligneous conjunctivitis: Rare form caused by plasminogen deficiency requiring specialized treatment 1

Prevention Strategies

• For infectious conjunctivitis:

  • Proper hand hygiene with soap and water 1
  • Avoid sharing personal items like towels and pillows 1
  • Disinfect surfaces with EPA-registered hospital disinfectant 1
  • For tonometer disinfection, use dilute bleach soak (sodium hypochlorite) at 1:10 concentration rather than alcohol wipes 1

• For allergic conjunctivitis:

  • Allergen avoidance 1
  • Consider immunotherapy for severe cases 1

• For contact lens wearers:

  • Appropriate lens care and frequent lens replacement to reduce risk of giant papillary conjunctivitis 1

Common Pitfalls to Avoid

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 1, 2
• Viral conjunctivitis will not respond to antibacterial agents 1
• Chronic and/or recalcitrant conjunctivitis may indicate underlying malignancy and requires further evaluation 2
• Failure to recognize potentially serious causes of conjunctivitis (e.g., gonococcal, herpes simplex) may lead to complications 2
• Inadequate patient education about contagiousness may lead to community spread 1