What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment of conjunctivitis must be tailored to the specific etiology: viral conjunctivitis requires only supportive care, bacterial conjunctivitis benefits from topical antibiotics in moderate-to-severe cases, and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing properties. 1, 2

Initial Classification Algorithm

First, determine the type of conjunctivitis based on clinical presentation:

• Bacterial conjunctivitis: Look for yellow crusting around the eyes, mucopurulent discharge, matted eyelids upon waking, and absence of itching 3, 4
• Viral conjunctivitis: Typically presents with watery discharge, often bilateral involvement, and variable signs at presentation 2, 5
• Allergic conjunctivitis: Distinguished by severe itching (the most consistent sign), watery discharge, and history of allergen exposure 4, 6

Treatment by Type

Viral Conjunctivitis

• Supportive care only - no antibiotics needed as this is self-limited 2, 5
• Use artificial tears, cold compresses, and antihistamine eye drops for symptom relief 5
• Avoid topical corticosteroids - they prolong adenoviral infections and worsen HSV infections 1, 2
• Instruct patients to return only if symptoms persist beyond 2-3 weeks 2, 3
• Emphasize strict hand hygiene to prevent transmission 5

Special case - HSV conjunctivitis: If dendritic lesions are present, treat with ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily 2. Oral alternatives include acyclovir 200-400 mg five times daily, valacyclovir 500 mg two to three times daily, or famciclovir 250 mg twice daily 2. Follow up within 1 week 2.

Bacterial Conjunctivitis

Mild cases: Self-limited and resolve spontaneously in 1-2 weeks without treatment in immunocompetent adults 2, 3, 4

Moderate-to-severe cases:

• Prescribe a 5-7 day course of broad-spectrum topical antibiotics 2, 3
• Topical antibiotics decrease duration and allow earlier return to school/work 4
• Clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 3
• Patients must return if no improvement after 3-4 days 1, 2, 3

Alternative when antibiotics unavailable: Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics 2

Gonococcal Conjunctivitis

• Requires systemic antibiotics - topical treatment alone is insufficient 1, 2, 3
• Saline lavage promotes comfort and faster resolution 2, 3
• Daily follow-up is mandatory until complete resolution 1, 2, 3
• Treat sexual contacts concurrently and inform them about possible concomitant disease 1, 2, 3
• Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 1, 2, 3

Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required - more than 50% of infants have infection at other sites 1, 2, 3
• Treat sexual contacts concurrently 1, 2, 3
• Re-evaluate following treatment due to potential treatment failure (up to 19%) 2, 3
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 1, 2
• Consider sexual abuse in children with gonococcal or chlamydial infections 2

Allergic Conjunctivitis

First-line simple measures:

• Wear sunglasses as barriers to airborne allergens 1, 2, 3
• Apply cold compresses and refrigerated artificial tears 1, 2, 3

Pharmacologic treatment algorithm:

• Mild cases: Over-the-counter topical antihistamine/vasoconstrictor agents or second-generation topical H1-receptor antagonists 2
• Moderate cases (first-line): Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic disease 1, 2, 3
• Persistent/recurrent cases: Mast cell stabilizers like cromolyn sodium 2, 3
• Severe cases: Add a brief course (1-2 weeks) of topical corticosteroids with low side-effect profile 1, 2, 3

Contact Lens-Related Conjunctivitis

• Discontinue contact lens wear immediately until the cornea returns to normal 3
• Consider a brief (1-2 weeks) course of topical corticosteroids plus longer-term topical cyclosporine 0.05% 3
• For giant papillary conjunctivitis: replace lenses more frequently, decrease wearing time, use preservative-free lens care systems, or switch to daily disposable lenses 3

Corticosteroid Monitoring (When Used)

• Monitor intraocular pressure (IOP) periodically and perform pupillary dilation to evaluate for glaucoma and cataract 2, 3
• Taper corticosteroids once inflammation is controlled 2, 3
• Prefer corticosteroids with poor ocular penetration (fluorometholone) or site-specific agents (rimexolone, loteprednol) to reduce risk of elevated IOP or cataract formation 2, 3

Immediate Ophthalmology Referral Criteria

Refer immediately for any of the following 1, 2, 3:

• 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, prolong adenoviral infections, and worsen HSV infections 1, 2, 3
• Chronic vasoconstrictor use causes rebound vasodilation upon discontinuation 2, 3
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 2, 3
• Topical trifluridine causes inevitable epithelial toxicity if used beyond 2 weeks; topical ganciclovir is less toxic 2
• Always identify and treat sexual contacts in sexually transmitted conjunctivitis 1, 2, 3
• Never share towels, pillows, or cosmetics to prevent transmission 1