What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

The treatment for conjunctivitis should be tailored to the specific cause, with antibiotics indicated for bacterial conjunctivitis, antihistamines for allergic conjunctivitis, and supportive care for viral conjunctivitis. 1, 2

Diagnosis and Classification

• Conjunctivitis can be classified as viral, bacterial, or allergic based on clinical presentation 1, 3
• Bacterial conjunctivitis typically presents with mucopurulent discharge and matting of eyelids 4, 3
• Viral conjunctivitis usually presents with watery discharge and may be associated with preauricular lymphadenopathy 5
• Allergic conjunctivitis is characterized by itching, which is the most consistent symptom 4, 2

Treatment by Type

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is often self-limited and may resolve spontaneously without treatment in immune-competent adults 4, 1
• A 5-7 day course of broad-spectrum topical antibiotic is recommended for faster clinical and microbiological remission 4, 6
• Moxifloxacin 0.5% ophthalmic solution three times daily for 7 days is an effective first-line treatment 6
• Other fluoroquinolones or aminoglycosides may be used as alternatives 7, 6
• Povidone-iodine 1.25% ophthalmic solution can be considered when access to antibiotics is limited 4, 2
• Conjunctival cultures should be obtained if gonococcal infection is suspected 4, 1
• Moderate to severe bacterial conjunctivitis requires antibiotic treatment guided by laboratory results 4, 1
• Methicillin-resistant S. aureus should be considered in patients from nursing homes or with community-acquired infections 4, 1

Viral Conjunctivitis

• No proven effective treatment exists for eradication of adenovirus infection 1, 5
• Symptomatic treatment includes artificial tears, topical antihistamines, and cold compresses 1, 3
• Avoid antibiotics due to potential adverse effects 1, 5
• Topical corticosteroids may help in severe cases with marked chemosis, lid swelling, or membranous conjunctivitis, but require close monitoring 1, 2
• For HSV conjunctivitis, topical ganciclovir 0.15% gel or topical trifluridine 1% solution is recommended 1
• Oral antivirals may be used for HSV conjunctivitis 1
• Avoid topical corticosteroids in HSV conjunctivitis as they can potentiate infection 1, 2

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 4, 2
• Second-generation topical histamine H1-receptor antagonists are effective for mild allergic conjunctivitis 4, 1
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1, 2
• For persistent or recurrent cases, mast cell stabilizers are recommended 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

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 4, 2
• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 6, 8
• Sexual contacts of patients with sexually transmitted conjunctivitis should be treated concurrently 2
• Systemic antibiotics are necessary for chlamydial conjunctivitis in infants 1, 2
• Gonococcal conjunctivitis requires systemic antibiotics and daily monitoring until resolution 1, 2

Referral Guidelines

• Refer patients to an ophthalmologist if they experience:
  • Visual loss
  • Moderate or severe pain
  • Severe purulent discharge
  • Corneal involvement
  • Conjunctival scarring
  • Lack of response to therapy after 3-4 days
  • Recurrent episodes
  • History of HSV eye disease
  • Immunocompromised state 1, 2

Common Pitfalls

• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 1
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 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 1, 2
• Indiscriminate use of antibiotics for viral conjunctivitis 4, 9

Evidence on Antibiotic Efficacy

• Topical antibiotics decrease the duration of bacterial conjunctivitis and allow earlier return to school or work 9, 10
• By days 6-10,41% of bacterial conjunctivitis cases resolve spontaneously without antibiotics 10
• Moxifloxacin ophthalmic solution produced clinical cures in 66-69% of patients by day 5-6 6
• Microbiological success rates for moxifloxacin range from 84-94% 6