Treatment of Conjunctivitis
Classification and Initial Management
Treatment of conjunctivitis must be tailored to the specific etiology—viral, bacterial, allergic, or sexually transmitted—with bacterial cases requiring topical antibiotics only for moderate-to-severe disease, while viral cases need supportive care alone and allergic cases respond to topical antihistamines with mast cell-stabilizing properties. 1
The key to appropriate management is accurate classification based on clinical presentation:
- Yellow crusting around the eyes strongly indicates bacterial infection rather than viral or allergic causes 1
- Bilateral mucopurulent discharge characterizes moderate bacterial conjunctivitis 1
- Watery discharge with itching suggests allergic or viral etiology 2, 3
- Mattering and adherence of eyelids on waking, without itching, points to bacterial infection 2
Bacterial Conjunctivitis
Mild Cases
Mild bacterial conjunctivitis is self-limited and resolves spontaneously without antibiotics in immunocompetent adults 1
- Most uncomplicated cases resolve within 1-2 weeks without treatment 2
- Delayed antibiotic prescribing achieves similar symptom control as immediate prescribing 3
Moderate to Severe Cases
For moderate-to-severe bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotics 1, 4
- First-line: Moxifloxacin 0.5% ophthalmic solution, one drop three times daily for 7 days 4, 5
- Alternative options include other fluoroquinolones or aminoglycosides 4
- Essential step: Clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 1, 4
Follow-up Protocol
- Instruct patients to return if no improvement after 3-4 days of treatment 1, 6
- Complete resolution typically occurs within 7-10 days with appropriate treatment 4
- Consider conjunctival cultures if symptoms persist, particularly to rule out MRSA 4
Sexually Transmitted Conjunctivitis
Gonococcal Conjunctivitis
Gonococcal conjunctivitis requires systemic antibiotic therapy, not just topical treatment 1, 6
- Saline lavage promotes comfort and more rapid resolution 1
- Patients must be seen daily until complete resolution 1, 6
- Sexual contacts must be treated concurrently and informed about possible concomitant disease 1, 6
- Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 1, 6
Chlamydial Conjunctivitis
Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of patients have infection at other sites 1, 6
- Sexual contacts must be treated concurrently 1, 6
- Re-evaluate following treatment due to potential treatment failure (up to 19%) 1
- In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 6
Viral Conjunctivitis
Viral conjunctivitis requires supportive care only—no antibiotics or corticosteroids 1, 2
- Supportive measures include artificial tears, cold compresses, and antihistamine eye drops 3
- Instruct patients to return if symptoms persist beyond 2-3 weeks 1
- Critical pitfall: Avoid topical corticosteroids as they can prolong adenoviral infections and worsen HSV infections 1, 6
- Strict hand hygiene is essential to prevent transmission 3
Allergic Conjunctivitis
Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic allergic conjunctivitis 1, 6, 2
Stepwise Treatment Approach
Step 1: Simple measures
- Wear sunglasses as barriers to airborne allergens 1, 6
- Apply cold compresses 1, 6
- Use refrigerated artificial tears 1, 6
Step 2: Topical antihistamines with mast cell-stabilizing properties (first-line pharmacotherapy) 1, 6
Step 3: For persistent or recurrent cases
Step 4: For severe cases not adequately controlled
- Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile 1, 6
- Use corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) to minimize IOP elevation and cataract risk 1
Important Caveats
- Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 1
- Chronic use of vasoconstrictor agents causes rebound vasodilation once stopped 1
Contact Lens-Related Conjunctivitis
Discontinue contact lens wear immediately until the cornea returns to normal 1
- Brief (1-2 weeks) course of topical corticosteroids may be prescribed, plus longer-term topical cyclosporine 0.05% 1
- Consider alternatives to contact lenses (eyeglasses or refractive surgery) once resolved 1
- For giant papillary conjunctivitis: replace lenses more frequently, decrease wearing time, use preservative-free lens care systems, or switch to daily disposable lenses 1
Corticosteroid Monitoring
When prescribing topical corticosteroids, monitor IOP and perform pupillary dilation periodically to evaluate for glaucoma and cataract 1
- Taper corticosteroids once inflammation is controlled 1
- Prefer corticosteroids with poor ocular penetration or site-specific formulations to reduce complications 1
Immediate Ophthalmology Referral Criteria
Refer immediately for any of the following red flags 1, 6:
- 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
- History of immunocompromise
Critical Pitfalls to Avoid
- Never use topical antibiotics or corticosteroids indiscriminately—they induce toxicity and can prolong adenoviral infections and worsen HSV infections 1, 6
- Never prescribe combination antibiotic-corticosteroid preparations unless herpes is definitively ruled out 7
- Never allow contact lens wear during active conjunctivitis 1, 5
- Never fail to identify and treat sexual contacts in sexually transmitted conjunctivitis 1