What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

For bacterial conjunctivitis, initiate a 5-7 day course of broad-spectrum topical antibiotics (fluoroquinolones or aminoglycosides) applied 3-4 times daily, though mild cases in immunocompetent adults often resolve spontaneously without treatment. 1, 2, 3

Initial Classification and Diagnosis

Determine the type of conjunctivitis based on clinical presentation:

• Bacterial: Mucopurulent discharge with eyelids matted shut on waking, lack of itching, marked inflammation 2, 4, 5
• Viral: Watery discharge, preauricular lymph node swelling, often bilateral presentation 3, 4, 5
• Allergic: Itching is the hallmark symptom, bilateral involvement, watery discharge, papillary reaction 1, 3, 5

Consider obtaining conjunctival cultures and Gram staining before treatment in moderate to severe cases, especially when purulent discharge is present. 2

Treatment by Etiology

Bacterial Conjunctivitis

First-line topical antibiotics (choose one):

• Fluoroquinolones: Moxifloxacin 0.5% or gatifloxacin - instill 1 drop 3 times daily for 7 days 2, 6
• Aminoglycosides: Tobramycin - effective against common pathogens including Streptococcus species 2
• Azithromycin 1%: Instill 1 drop twice daily (8-12 hours apart) for 2 days, then once daily for 5 days 7

Critical considerations:

• Mild bacterial conjunctivitis in immunocompetent adults is self-limited and may not require antibiotics 3, 5
• Advise patients to return if no improvement after 3-4 days of treatment 2, 3, 8
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution is as effective as topical antibiotics 3

Gonococcal Conjunctivitis

Requires systemic antibiotic therapy - topical treatment alone is insufficient. 1, 3, 8

• Add saline lavage for comfort and faster resolution 1, 3
• If corneal involvement is present, treat as bacterial keratitis with intensive topical antibiotics 1
• Daily follow-up is mandatory until complete resolution 1, 3, 8
• Treat all sexual contacts concurrently and screen for concomitant sexually transmitted infections 1, 3, 8
• Consider sexual abuse in children presenting with gonococcal conjunctivitis 1, 3
• Hospitalization is necessary for severe cases and mandatory for neonatal gonococcal conjunctivitis 3, 8

Chlamydial Conjunctivitis

Systemic antibiotic therapy is required because >50% of infected infants have concurrent nasopharyngeal, genital, or pulmonary infection. 1, 3, 8

• Topical therapy alone is inadequate - do not use topical antibiotics as monotherapy 1
• Re-evaluate after treatment completion due to treatment failure rates up to 19% 1, 3
• Treat sexual contacts simultaneously 1, 3, 8
• Screen for concomitant sexually transmitted infections 1, 3
• Consider sexual abuse in pediatric cases 1, 3
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1, 3, 8

Viral Conjunctivitis

Supportive care is the mainstay - most cases resolve spontaneously in 2-3 weeks. 3, 4, 5

Supportive measures:

• Cold compresses and refrigerated artificial tears 3, 8
• Topical antihistamines for symptomatic relief 3
• Strict hand hygiene to prevent transmission 4, 9

Avoid topical corticosteroids - they prolong adenoviral infections and worsen HSV infections. 3, 8

For HSV conjunctivitis specifically:

• Topical: Ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 3
• Oral: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 3
• Never use topical corticosteroids - they potentiate HSV infection 3
• Follow-up within 1 week of initiating treatment 3
• Important: Trifluridine causes epithelial toxicity if used >2 weeks; ganciclovir is less toxic 3

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are first-line for both acute and chronic disease. 3, 8

Treatment algorithm:

1. Mild cases:

   • Simple measures: Sunglasses as allergen barriers, cold compresses, refrigerated artificial tears 3, 8
   • Over-the-counter topical antihistamine/vasoconstrictor agents 3
   • Second-generation topical H1-receptor antagonists 3

2. Moderate to severe or persistent cases:

   • Topical medications with combined antihistamine and mast cell-stabilizing properties (preferred) 3, 8
   • Mast cell stabilizers for persistent or recurrent disease 3, 8

3. Severe refractory cases:

   • Add brief course (1-2 weeks) of topical corticosteroids with low side-effect profile (fluorometholone, rimexolone, or loteprednol) 3, 8
   • Monitor intraocular pressure and perform pupillary dilation periodically to screen for glaucoma and cataracts 3
   • Taper corticosteroids once inflammation is controlled 3

Avoid chronic vasoconstrictor use - causes rebound vasodilation upon discontinuation. 3

Avoid oral antihistamines - they worsen dry eye syndrome and impair the tear film's protective barrier. 3

Immediate Ophthalmology Referral Required

Refer immediately for any of the following: 1, 3, 8

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised state
• Neonatal conjunctivitis

Critical Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately - they prolong adenoviral shedding, worsen HSV infections, and can cause glaucoma and cataracts 3, 8
• Do not use topical antibiotics alone for gonococcal or chlamydial conjunctivitis - systemic therapy is mandatory 1, 3
• Do not overlook sexual contacts - concurrent treatment is essential for sexually transmitted conjunctivitis 1, 3, 8
• Screen for sexual abuse in children with gonococcal or chlamydial infections 1, 3
• Avoid contaminating the applicator tip - do not allow it to touch the eye, fingers, or other surfaces 7, 6

Patient Education and Infection Control

Bacterial and viral conjunctivitis are highly contagious: 2, 3

• Wash hands frequently and avoid touching eyes 2
• Do not share towels, pillowcases, or makeup 2, 3
• Avoid wearing contact lenses until complete resolution 3, 7, 6
• Complete the full antibiotic course even if symptoms improve to prevent resistance 7