Treatment for Pink Eye (Conjunctivitis)
The treatment for conjunctivitis should be directed at the root cause, with mild bacterial conjunctivitis often resolving spontaneously without specific treatment in immune-competent adults, while viral conjunctivitis requires supportive care and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing properties. 1, 2, 3
Treatment by Type of Conjunctivitis
Bacterial Conjunctivitis
- Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without treatment in immune-competent adults 1
- A 5-7 day course of broad-spectrum topical antibiotic provides earlier clinical and microbiological remission compared to placebo 2
- The choice of antibiotic is usually empiric as there is no clinical evidence suggesting superiority of any particular antibiotic 1
- Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics when access to antibiotics is limited 1
- Bacitracin ophthalmic ointment can be applied directly into the conjunctival sac 1-3 times daily for susceptible organisms 4
Moderate to Severe Bacterial Conjunctivitis
- Characterized by copious purulent discharge, pain, and marked inflammation 1
- Obtain conjunctival cultures and Gram staining if gonococcal infection is suspected 1
- Treatment should be guided by laboratory results, especially considering the increasing frequency of methicillin-resistant S. aureus (MRSA) 1, 2
- Systemic antibiotics are required in addition to topical therapy for gonococcal conjunctivitis 2
- Erythromycin ophthalmic ointment is indicated for superficial ocular infections involving the conjunctiva caused by susceptible organisms 5
Viral Conjunctivitis
- No proven effective treatment for eradication of adenovirus infection 2
- Symptomatic treatment includes artificial tears, topical antihistamines, and cold compresses 2, 6
- Avoid antibiotics due to potential adverse effects 2
- Topical corticosteroids may help in severe cases with marked chemosis, lid swelling, or membranous conjunctivitis, but require close monitoring 2
- For HSV conjunctivitis, topical ganciclovir 0.15% gel or topical trifluridine 1% solution is recommended 2
- Oral antivirals (acyclovir, valacyclovir, or famciclovir) may be used for HSV conjunctivitis 2
Allergic Conjunctivitis
- Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 3
- Mild allergic conjunctivitis can be treated with over-the-counter topical antihistamine/vasoconstrictor agents 1
- Second-generation topical histamine H1-receptor antagonists are more effective 1
- Many topical medications can be stored in the refrigerator for additional symptomatic relief 1
- For persistent or recurrent cases, mast cell stabilizers can be used 1, 3
- Medications combining antihistamine activity with mast cell stabilizing properties are effective for both acute and chronic disease 1
- In severe cases, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile can be added 1, 3
Special Considerations
When to Refer to an Ophthalmologist
- Visual loss 2, 3
- Moderate or severe pain 2, 3
- Severe purulent discharge 2, 3
- Corneal involvement 2, 3
- Conjunctival scarring 2, 3
- Lack of response to therapy after 3-4 days 2, 3
- Recurrent episodes 2, 3
- History of HSV eye disease 2, 3
- Immunocompromised patients 2, 3
Common Pitfalls to Avoid
- Indiscriminate use of topical antibiotics or corticosteroids should be avoided 3
- Antibiotics can induce toxicity 3
- Corticosteroids can potentially prolong adenoviral infections and worsen HSV infections 3
- Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 2
- Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 2
- Prolonged use of topical trifluridine can cause epithelial toxicity if used for more than 2 weeks 2
- Using topical corticosteroids in HSV conjunctivitis without antiviral coverage can potentiate infection 2