What are the treatment options for conjunctivitis?

Treatment of Conjunctivitis

Classification and Initial Approach

Treatment of conjunctivitis depends entirely on identifying the underlying etiology—viral, bacterial, allergic, or other causes—with each requiring distinct management strategies. 1

The key clinical features that guide diagnosis include:

• Bacterial conjunctivitis: Mucopurulent discharge with eyelids matted shut, more common in children 2
• Viral conjunctivitis: Watery discharge, more common in adults, often self-limited 2, 3
• Allergic conjunctivitis: Severe itching is the hallmark symptom, allergen exposure history 1, 3

Bacterial Conjunctivitis

Mild Cases

For mild bacterial conjunctivitis in immunocompetent adults, observation without antibiotics is reasonable as most cases are self-limited and resolve spontaneously within 1-2 weeks. 1, 3

However, if treatment is desired:

• Prescribe a 5-7 day course of broad-spectrum topical antibiotics 1, 4
• Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective against common pathogens including S. aureus, S. pneumoniae, and H. influenzae 4, 5
• Instruct patients to return if no improvement after 3-4 days 1

Moderate to Severe Cases

Obtain conjunctival cultures and Gram staining before initiating treatment, especially if MRSA or gonococcal infection is suspected. 4

• Consider MRSA in nursing home patients or community-acquired infections 4
• Compounded topical vancomycin may be needed for resistant cases 4

Gonococcal Conjunctivitis

This requires systemic antibiotic therapy—topical treatment alone is inadequate. 1, 4

• Add saline lavage for comfort and faster resolution 1
• Monitor patients daily until complete resolution 1, 4
• Treat sexual contacts concurrently and evaluate for concomitant sexually transmitted diseases 1
• Consider sexual abuse in children presenting with gonococcal conjunctivitis 4

Chlamydial Conjunctivitis

Systemic antibiotic therapy is mandatory, as over 50% of infants have infection at other sites. 1, 4

• Treat sexual contacts concurrently 1
• Re-evaluate following treatment due to potential treatment failure rates up to 19% 1
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 1

Viral Conjunctivitis

Adenoviral Conjunctivitis

No proven effective treatment exists for eradicating adenovirus; management is purely supportive. 4

Symptomatic treatment includes:

• Artificial tears 4
• Cold compresses 4
• Topical antihistamines 4
• Avoid antibiotics due to potential adverse effects without benefit 4

Instruct patients to return only if symptoms persist beyond 2-3 weeks. 1

Severe Adenoviral Cases

For severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, topical corticosteroids may be considered but require close monitoring. 4

• Monitor intraocular pressure (IOP) and evaluate for glaucoma and cataract with periodic pupillary dilation 6, 1
• Taper corticosteroids once inflammation is controlled 6, 1
• Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, loteprednol) to minimize IOP elevation and cataract risk 6, 1

Herpes Simplex Virus (HSV) Conjunctivitis

Topical options include ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily. 6, 1, 4

Oral antiviral options:

• Acyclovir 200-400 mg five times daily 6, 1
• Valacyclovir 500 mg two to three times daily 6, 1
• Famciclovir 250 mg twice daily 6, 1

Critical: Topical corticosteroids are absolutely contraindicated as they potentiate HSV infection and should be avoided. 6, 1, 4

• Topical trifluridine causes inevitable epithelial toxicity if used beyond 2 weeks; topical ganciclovir is less toxic 6, 1
• Follow-up within 1 week of treatment initiation 6, 1
• Neonates require immediate pediatrician consultation due to life-threatening systemic HSV risk 6

Varicella Zoster Virus (VZV) Conjunctivitis

Topical antivirals alone are not helpful for VZV conjunctivitis. 6

• Many clinicians use topical antibiotics to prevent secondary bacterial infection of necrotic vesicles 6

Allergic Conjunctivitis

Mild Cases

Simple barrier measures and over-the-counter options are first-line. 1

• Wear sunglasses as barriers to airborne allergens 1
• Apply cold compresses 1
• Use refrigerated artificial tears 1
• Second-generation topical histamine H1-receptor antagonists are more effective than first-generation agents 1

Moderate Cases

Topical medications with combined antihistamine activity and mast-cell stabilizing properties are preferred for both acute and chronic disease. 1, 3

Persistent or Recurrent Cases

Mast cell stabilizers are recommended for ongoing prophylaxis. 1

Severe Cases

For inadequately controlled severe allergic conjunctivitis, add a brief 1-2 week course of topical corticosteroids with a low side-effect profile. 1

• Monitor IOP and evaluate for glaucoma/cataract if corticosteroids are used 1, 4

Giant Papillary Conjunctivitis

Discontinue contact lens use in conjunction with topical anti-inflammatory agents. 4

Critical Pitfalls to Avoid

• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage 4
• Avoid indiscriminate use of topical antibiotics or corticosteroids 1
• Chronic vasoconstrictor use causes rebound vasodilation upon discontinuation 1
• Oral antihistamines may worsen dry eye syndrome 1
• Always identify and treat sexual contacts in sexually transmitted conjunctivitis 1, 4
• Consider sexual abuse in children with gonococcal or chlamydial infections 1, 4

Mandatory Ophthalmology Referral

Immediate referral is indicated for: 1, 4

• 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
• Immunocompromised state
• Neonatal conjunctivitis (hospitalization mandatory) 1