What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Classification and Diagnosis

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 2
• Yellow crusting around the eyes is highly indicative of bacterial infection rather than viral or allergic etiology 3
• Bilateral involvement with mucopurulent discharge is characteristic of moderate bacterial conjunctivitis 3

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 2
• Avoid topical corticosteroids as they can potentially prolong adenoviral infections and worsen HSV infections 2, 3

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 2, 5
• A 5-7 day course of broad-spectrum topical antibiotics is recommended for moderate to severe bacterial conjunctivitis 2, 3
• Moxifloxacin ophthalmic solution 0.5% is indicated for bacterial conjunctivitis, with dosing of one drop in the affected eye 3 times a day for 7 days 6
• Cleaning eyelids and lashes with warm water and gentle soap to remove crusts before applying medication is essential 3
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 1, 2

Gonococcal Conjunctivitis

• Systemic antibiotic therapy is required, not just topical treatment 2, 3
• Saline lavage may promote comfort and more rapid resolution of inflammation 2
• Patients should be seen daily until resolution of the conjunctivitis 2
• Sexual contacts should be treated concurrently and informed about possible concomitant disease 1, 2

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required, as more than 50% of patients may have infection at other sites 1, 3
• Sexual contacts should be treated concurrently 2
• Patients should be re-evaluated following treatment due to potential treatment failure (up to 19%) 2
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1

Herpes Simplex Virus (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 2
• Oral treatments include acyclovir (200-400 mg five times per day), valacyclovir (500 mg two or three times per day), or famciclovir (250 mg twice a day) 2
• Topical corticosteroids should be avoided as they potentiate HSV infection 2, 7
• Follow-up within 1 week of treatment is recommended 2

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 2, 3
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic allergic conjunctivitis 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 1, 2

Special Considerations

Contact Lens-Related Conjunctivitis

• Contact lens wear should be discontinued until the cornea returns to normal 3
• A brief (1-2 weeks) course of topical corticosteroids may be prescribed, in addition to longer-term use of topical cyclosporine 0.05% 3
• Consider alternatives to contact lenses (e.g., eyeglasses or refractive surgery) once the keratoconjunctivitis has resolved 3

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 2, 3
• Topical corticosteroids should be tapered once inflammation is controlled 2
• Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) may be less likely to result in elevated IOP or cataract formation 2

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 1, 2
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 2, 3

Common Pitfalls

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided as they can induce toxicity and potentially prolong adenoviral infections and worsen HSV infections 1, 3
• Chronic use of vasoconstrictor agents can be associated with rebound vasodilation once the agent is stopped 2
• Oral antihistamines may induce or worsen dry eye syndrome and impair the tear film's protective barrier 2
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 2, 3
• Not considering sexual abuse in children with gonococcal or chlamydial infections 2