What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

Treatment depends entirely on the underlying cause—viral conjunctivitis requires only supportive care, bacterial conjunctivitis may benefit from topical antibiotics (though most cases are self-limiting), and allergic conjunctivitis responds to topical antihistamines with mast cell stabilizers. 1, 2

Viral Conjunctivitis

Viral conjunctivitis is the most common cause overall and requires no specific treatment—only supportive measures. 2

Supportive Care

• Artificial tears (preferably cooled and preservative-free) 1
• Cold compresses for symptomatic relief 1
• Topical antihistamines to reduce discomfort 1
• Oral analgesics for pain management 1

When to Consider Corticosteroids

• Reserve topical corticosteroids for severe cases only: marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis 1
• Corticosteroids may prolong viral shedding in animal models, though human data is unclear 1
• If prescribed, use low-potency agents (fluorometholone, rimexolone, or loteprednol) and monitor IOP and for cataract development 1
• Taper slowly once inflammation is controlled 1

Critical Management Points

• Avoid antibiotics—they provide no benefit and risk toxicity 1
• Strict hygiene measures: frequent handwashing, avoid touching eyes, minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 3
• Povidone-iodine 0.4-0.6% with or without dexamethasone is under investigation but not yet standard of care 1

Bacterial Conjunctivitis

Most bacterial conjunctivitis is self-limiting, resolving in 1-2 weeks without treatment, but topical antibiotics can shorten duration and allow earlier return to work/school. 2

Clinical Features Suggesting Bacterial Etiology

• Mucopurulent discharge with eyelids matted shut on waking 3, 2
• Lack of itching 2
• No history of prior conjunctivitis 2

Antibiotic Approach

• Delayed prescribing strategy (wait-and-see approach) has similar outcomes to immediate treatment in uncomplicated cases 3
• Topical antibiotics indicated for:
  • Contact lens wearers (always treat and refer for corneal ulcer evaluation) 4
  • Gonococcal or chlamydial conjunctivitis (requires systemic antibiotics plus topical therapy) 2
  • Severe symptoms or high-risk patients 3

Antibiotic Options

• Bacitracin ophthalmic ointment for susceptible organisms 5
• Erythromycin ophthalmic ointment for superficial infections 6
• Broad-spectrum topical antibiotics are typically used since viral vs. bacterial differentiation is difficult 7

Special Considerations

• MRSA is increasingly common—consider conjunctival cultures before starting treatment in severe cases 1
• Giant fornix syndrome requires prolonged systemic anti-staphylococcal antibiotics plus intensive topical therapy 1

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity are first-line treatment for allergic conjunctivitis. 1, 2

Stepwise Treatment Algorithm

Mild Disease

• Environmental modifications: sunglasses as barrier, avoid allergens, hypoallergenic bedding, frequent clothes washing, shower before bed 1
• Cool compresses and refrigerated artificial tears (preservative-free preferred) 1
• Over-the-counter topical antihistamine/vasoconstrictor OR second-generation H1-receptor antagonists 1

Moderate Disease (Recurrent/Persistent)

• Topical mast cell stabilizers alone or combination antihistamine/mast cell stabilizers for acute or chronic disease 1
• Avoid chronic vasoconstrictor use—causes rebound vasodilation 1

Severe Disease (Inadequate Control)

• Brief course (1-2 weeks) of low-potency topical corticosteroids 1
• Topical cyclosporine 0.05% or tacrolimus for refractory cases 1
• Consultation with allergist/dermatologist for allergen-specific immunotherapy 1

Critical Pitfalls

• Avoid oral antihistamines as monotherapy—they worsen dry eye syndrome and impair the tear film's protective barrier 1
• Avoid punctal plugs—they prevent flushing of allergens and inflammatory mediators 1
• Control eye rubbing—associated with keratoconus progression in atopic patients 1

Vernal/Atopic Conjunctivitis (Severe Forms)

Topical corticosteroids are usually necessary for acute exacerbations of vernal conjunctivitis. 1

Treatment Escalation

• First-line: Environmental modification, cool compresses, ocular lubricants, topical/oral antihistamines, mast cell stabilizers 1
• Acute exacerbations: Topical corticosteroids required 1
• Steroid-sparing agents:
  • Cyclosporine 0.1% (FDA-approved for VKC in children and adults) 1
  • Cyclosporine 0.05% at least four times daily (off-label) 1
  • Tacrolimus 0.03% (ages 2-15) or 0.03-0.1% (age 16+) for eyelid involvement 1
• Refractory cases: Supratarsal corticosteroid injection 1

Monitoring Requirements

• If using corticosteroids: Baseline and periodic IOP measurement and dilated exam to evaluate for glaucoma and cataract 1
• Warn patients about potential corticosteroid complications and employ strategies to minimize use 1

When to Refer to Ophthalmology

Immediate referral indicated for: 3

• Neonatal conjunctivitis
• Severe pain not relieved by topical anesthetics
• Decreased vision
• Recent ocular surgery
• Vesicular rash on eyelids/nose (herpes)
• History of rheumatologic disease
• Immunocompromised state
• Contact lens wearers (evaluate for corneal ulcer)
• Copious purulent discharge
• Corneal involvement
• Traumatic eye injury