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

Classification and Diagnosis

• Conjunctivitis is an inflammation that affects the conjunctiva primarily and can be classified as noninfectious or infectious and as acute, chronic, or recurrent 2
• The most common types include viral, bacterial, and allergic conjunctivitis, each with distinct clinical presentations 3
• No single sign or symptom accurately differentiates viral from bacterial conjunctivitis, making careful assessment critical 4

Treatment by Type

Viral Conjunctivitis

• Supportive care is the mainstay of treatment, including artificial tears, cold compresses, and antihistamine eye drops 4
• Patients should be instructed to return if symptoms persist beyond 2-3 weeks 3
• Avoid topical corticosteroids as they can potentially prolong adenoviral infections and worsen HSV infections 3
• Strict personal hygiene, including frequent handwashing, is essential to decrease the risk of transmission 4

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is often self-limited and resolves spontaneously without specific treatment in immunocompetent adults 3
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 3
• Fluoroquinolones such as moxifloxacin are effective against common pathogens including Staphylococcus and Streptococcus species 5, 6
• Moxifloxacin dosing: Instill one drop in the affected eye 3 times a day for 7 days 5
• Azithromycin is also effective: Instill 1 drop in the affected eye(s) twice daily, eight to twelve hours apart for the first two days and then once daily for the next five days 7
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1

Gonococcal and Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required for gonococcal conjunctivitis, not just topical treatment 3
• Patients with gonococcal conjunctivitis should be seen daily until resolution 3
• Chlamydial conjunctivitis requires systemic antibiotic therapy as more than 50% of patients may have infection at other sites 2, 1
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 2, 1
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 2, 3

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 3
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1, 8
• For persistent or recurrent cases, mast cell stabilizers are recommended 1, 3
• In severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 1, 3
• Avoid chronic use of vasoconstrictor agents as they can cause rebound vasodilation 3

Special Considerations

Contact Lens Wearers

• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 5
• Contact lens wearers with conjunctivitis should suspend lens use until complete resolution 1

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 3
• Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) may be less likely to result in elevated IOP or cataract formation 3

When to Refer to an Ophthalmologist

• Immediate referral is indicated for patients with 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, or history of immunocompromise 2, 3
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 2, 3
• Ophthalmology referral is also indicated for conjunctivitis in a neonate or patients with vesicular rash on the eyelids or nose, history of rheumatologic disease, or immunocompromised state 4

Common Pitfalls to Avoid

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 3
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 3
• Not considering sexual abuse in children with gonococcal or chlamydial infections 3
• Skipping doses or not completing the full course of antibiotic therapy may decrease effectiveness and increase the likelihood of bacterial resistance 7
• Overlooking the possibility of a more serious intraocular condition when severe pain, decreased vision, or painful pupillary reaction is present 9