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

Viral Conjunctivitis

• Primarily supportive care with artificial tears, cold compresses, and antihistamine eye drops 1, 3
• Patients should return if symptoms persist beyond 2-3 weeks 1
• Avoid topical corticosteroids as they can prolong adenoviral infections and worsen HSV infections 1
• For HSV conjunctivitis, treatment options include ganciclovir 0.15% gel three to five times per day or trifluridine 1% solution five to eight times per day 1, 4
• Strict personal hygiene with frequent handwashing is essential to prevent transmission 3

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 1, 5
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 1
• FDA-approved topical fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective first-line treatments 6, 7, 8
• Moxifloxacin dosing: Instill one drop in the affected eye 3 times a day for 7 days 7
• Advise patients to return for evaluation if no improvement is seen after 3-4 days of treatment 1, 6
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics 1

Special Cases of Bacterial Conjunctivitis

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy, not just topical treatment 1, 2
• Saline lavage may promote comfort and more rapid resolution of inflammation 1
• Daily follow-up until resolution of the conjunctivitis 1, 2
• Sexual contacts should be treated concurrently 1, 2

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, as more than 50% of infants may have infection at other sites 1, 2
• Sexual contacts should be treated concurrently 1, 2
• Re-evaluation following treatment due to potential treatment failure (up to 19%) 1

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 2
• Mild cases can be treated with over-the-counter topical antihistamine/vasoconstrictor agents 1
• Second-generation topical histamine H1-receptor antagonists are more effective for mild cases 1
• Topical medications with combined antihistamine activity and mast-cell stabilizing properties are preferred for both acute and chronic disease 1, 2, 5
• For persistent or recurrent cases, mast cell stabilizers are recommended 1, 2
• For severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile can be added 1, 2

When to Refer to an Ophthalmologist

• Immediate referral is indicated for patients with:
  • Visual loss 1, 2
  • Moderate or severe pain 1, 2
  • Severe purulent discharge 1, 2
  • Corneal involvement 1, 2
  • Conjunctival scarring 1, 2
  • Lack of response to therapy 1, 2
  • Recurrent episodes 1, 2
  • History of HSV eye disease 1, 2
  • History of immunocompromise 1, 2
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 1, 2

Common Pitfalls to Avoid

• Indiscriminate use of topical antibiotics or corticosteroids 1, 2
• Chronic use of vasoconstrictor agents can cause rebound vasodilation 1
• Oral antihistamines may worsen dry eye syndrome 1
• Topical trifluridine causes epithelial toxicity if used for more than 2 weeks; topical ganciclovir is less toxic 1
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 1
• Not considering sexual abuse in children with gonococcal or chlamydial infections 1
• Using corticosteroid-containing antibiotics for unproven nonherpetic conjunctivitis 4