What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Classification and Diagnosis

• Conjunctivitis is inflammation of the conjunctiva that can be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 2
• Yellow crusting around the eyes strongly suggests bacterial rather than viral or allergic etiology 3
• Bilateral involvement with mucopurulent discharge typically indicates moderate bacterial conjunctivitis 3

Treatment by Type

Viral Conjunctivitis

• Most cases are self-limited and do not require antimicrobial treatment 4
• Management includes artificial tears, topical antihistamines, cold compresses, oral analgesics, or cold compresses to mitigate symptoms 4
• Avoid antibiotics as they provide no benefit and may cause adverse effects 4
• Topical corticosteroids should generally be avoided as they can prolong viral shedding and potentially worsen HSV infections 2
• Patient education about high contagiousness is essential; advise minimizing contact with others for 10-14 days from symptom onset 4

Bacterial Conjunctivitis

• Mild cases are often self-limited and resolve without specific treatment in immunocompetent adults 2
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 3
• FDA-approved options include bacitracin for Bacitracin-susceptible organisms 5 and erythromycin for susceptible organisms 6
• Apply erythromycin ophthalmic ointment (approximately 1 cm) directly to infected eye(s) up to six times daily, depending on infection severity 6
• Clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 3
• Patients should return for evaluation if no improvement occurs after 3-4 days of treatment 3

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy, not just topical treatment 2, 3
• Saline lavage may promote comfort and faster resolution of inflammation 2
• Daily follow-up until resolution is necessary 2
• Sexual contacts must be treated concurrently and informed about possible concomitant disease 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 recommended 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, 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

Contact Lens-Related Conjunctivitis

• Discontinue contact lens wear until the cornea returns to normal 3
• Consider a brief course of topical corticosteroids, with longer-term use of topical cyclosporine 0.05% 3
• For giant papillary conjunctivitis, consider replacing lenses more frequently, decreasing wearing time, using preservative-free lens care systems, or switching to daily disposable lenses 3

Corticosteroid Use

• Monitor patients treated with topical corticosteroids by measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 2, 3
• Taper corticosteroids once inflammation is controlled 2
• Consider corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) to reduce risk of elevated IOP or cataract formation 2

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 cause 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; topical ganciclovir is less toxic 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