What are the treatment options for conjunctivitis?

Treatment of Conjunctivitis

The treatment of conjunctivitis should be tailored to the specific type (viral, bacterial, allergic, or other causes) based on clinical presentation, with most cases being self-limited but requiring specific interventions for certain etiologies. 1, 2

Diagnosis and Classification

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 1
• Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are strongly associated with bacterial conjunctivitis 3
• Itching is the most consistent sign in allergic conjunctivitis 3

Treatment by Type

Viral Conjunctivitis

• Most cases are self-limited and require only supportive care including artificial tears, cold compresses, and antihistamine eye drops 1, 4
• Patients should be instructed to return if symptoms persist beyond 2-3 weeks 1
• Avoid topical corticosteroids as they can potentially prolong adenoviral infections and worsen HSV infections 1
• For HSV conjunctivitis, treatment options include:
  • Ganciclovir 0.15% gel three to five times per day (preferred due to less ocular surface toxicity) 5, 1
  • Trifluridine 1% solution five to eight times per day (limit to <2 weeks due to epithelial toxicity) 5, 1
  • Oral treatments: acyclovir (200-400 mg five times per day), valacyclovir (500 mg two or three times per day), or famciclovir (250 mg twice a day) 5, 1

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is often self-limited in immunocompetent adults 1, 2
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 1, 2
• Moxifloxacin ophthalmic solution 0.5% is FDA-approved for bacterial conjunctivitis with a dosing regimen of one drop in the affected eye 3 times a day for 7 days 6
• Obtain cultures before initiating treatment if gonococcal infection is suspected or in severe cases 2
• 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 both conditions, not just topical treatment 1, 2
• For gonococcal conjunctivitis:
  • Patients should be seen daily until resolution 1
  • Saline lavage may promote comfort and more rapid resolution of inflammation 1
• For chlamydial conjunctivitis:
  • Systemic therapy is necessary as more than 50% of infants may have infection at other sites 1, 2
  • Re-evaluation following treatment is important due to potential treatment failure (up to 19%) 1
• Sexual contacts should be treated concurrently for both conditions 1

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1
• Treatment options in order of escalation:
  1. Mild cases: Over-the-counter topical antihistamine/vasoconstrictor agents 1
  2. Second-generation topical histamine H1-receptor antagonists for mild cases 1
  3. Topical medications with combined antihistamine activity and mast-cell stabilizing properties for both acute and chronic disease 1, 3
  4. For persistent or recurrent cases: Mast cell stabilizers 1
  5. For severe cases not adequately controlled: Brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile 1

Special Considerations

Corticosteroid Use

• Patients treated with topical corticosteroids should be monitored by periodically measuring IOP and pupillary dilation to evaluate for glaucoma and cataract 5, 1
• Topical corticosteroids should be tapered once inflammation is controlled 5, 1
• Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) may reduce risk of elevated IOP or cataract formation 5, 1
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage as they potentiate infection 5, 1, 2

Pediatric Considerations

• Fluoroquinolones (besifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, moxifloxacin, and ofloxacin) are approved for conjunctivitis in children older than 12 months 2
• Neonatal conjunctivitis requires prompt consultation with pediatrician as systemic HSV infection is life-threatening 5

Referral Guidelines

• Immediate referral to an ophthalmologist 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
  • Immunocompromised state 1, 2
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 1

Common Pitfalls

• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 1
• Chronic use of vasoconstrictor agents can cause rebound vasodilation 1
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 1
• Topical trifluridine causes epithelial toxicity if used for more than 2 weeks 5, 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, 2
• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 2