What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

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

Algorithmic Approach to Treatment

Step 1: Identify the Type Based on Clinical Presentation

Bacterial Conjunctivitis:

• Yellow crusting around eyes, mattering and adherence of eyelids on waking 3
• Mucopurulent discharge with eyelids matted shut 4
• Lack of itching and no history of prior conjunctivitis 5
• More common in children 4

Viral Conjunctivitis:

• Watery discharge, more common in adults 4
• Variable presentation at onset 5
• Most common overall cause of infectious conjunctivitis 5

Allergic Conjunctivitis:

• Itching is the most consistent and distinguishing sign 1, 5
• Watery discharge, bilateral involvement 4
• History of allergen exposure 6

Step 2: Treatment by Etiology

Bacterial Conjunctivitis

Mild Cases:

• Usually self-limited and resolve spontaneously in 1-2 weeks without treatment in immunocompetent adults 2, 5
• No antibiotics required for uncomplicated mild cases 1, 5

Moderate-to-Severe Cases:

• Prescribe a 5-7 day course of broad-spectrum topical antibiotics 2, 3
• Options include azithromycin ophthalmic solution (1 drop twice daily for 2 days, then once daily for 5 days) 7 or moxifloxacin 0.5% (1 drop three times daily for 7 days) 8
• Clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 3
• Advise patients to return if no improvement after 3-4 days of treatment 1, 2, 3

Special Bacterial Cases Requiring Systemic Antibiotics:

Gonococcal Conjunctivitis:

• Requires systemic antibiotic therapy, not just topical treatment 1, 2, 3
• Saline lavage promotes comfort and faster resolution 2, 3
• Daily follow-up until complete resolution 1, 2
• Treat sexual contacts concurrently 1, 2, 3
• Hospitalization may be necessary for severe cases and is mandatory for neonatal cases 1, 2, 3

Chlamydial Conjunctivitis:

• Requires systemic antibiotic therapy because >50% of patients have infection at other sites 1, 2, 3
• Treat sexual contacts concurrently 2, 3
• Re-evaluate after 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

Viral Conjunctivitis

Supportive Care Only:

• Artificial tears, cold compresses, and topical antihistamine eye drops for symptom relief 4
• Avoid topical corticosteroids—they prolong adenoviral infections and worsen HSV infections 1, 2, 3
• Instruct patients to return if symptoms persist beyond 2-3 weeks 2, 3
• Emphasize strict hand hygiene to prevent transmission 4

HSV Conjunctivitis (Special Case):

• Topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 2
• Oral options: acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 2
• Avoid topical corticosteroids as they potentiate HSV infection 2
• Follow-up within 1 week 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:

• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic disease 1, 2, 3
• For persistent or recurrent cases, use mast cell stabilizers like cromolyn sodium 1, 2, 3
• For severe cases not adequately controlled, add a brief 1-2 week course of topical corticosteroids with low side-effect profile (fluorometholone, rimexolone, or loteprednol) 1, 2, 3

Corticosteroid Monitoring:

• Periodically measure intraocular pressure (IOP) and perform pupillary dilation to evaluate for glaucoma and cataract 2, 3
• Taper corticosteroids once inflammation is controlled 2, 3

Contact Lens-Related Considerations

• Discontinue contact lens wear until complete resolution 1, 8
• For giant papillary conjunctivitis, consider replacing lenses more frequently, decreasing wearing time, or switching to daily disposable lenses 3

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately for: 1, 2, 3

• 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

Common Pitfalls to Avoid

• Never use topical antibiotics or corticosteroids indiscriminately—they cause toxicity, prolong adenoviral infections, and worsen HSV infections 1, 2, 3
• Chronic vasoconstrictor use causes rebound vasodilation 2, 3
• Oral antihistamines may worsen dry eye syndrome 2, 3
• Topical trifluridine causes epithelial toxicity if used >2 weeks; ganciclovir is less toxic 2
• Always identify and treat sexual contacts in sexually transmitted conjunctivitis cases 1, 2, 3
• Consider sexual abuse in children with gonococcal or chlamydial infections 2