What are the guidelines for treating conjunctivitis (pink eye)?

Guidelines for Treating Conjunctivitis (Pink Eye)

Primary Treatment Goals

The primary objectives are to eliminate signs and symptoms, restore normal visual function, prevent ocular surface damage, and stop infectious spread when applicable. 1

Diagnostic Approach

Essential History Elements

• Character and timing of discharge (purulent vs watery), duration, unilateral vs bilateral presentation 1
• Specific symptoms: mattering/adherence of eyelids upon waking (suggests bacterial), itching (suggests allergic), pain and photophobia (red flags) 1, 2
• Exposure history: recent contact with infected individuals, contact lens use, recent surgery, trauma 1
• Systemic symptoms: genitourinary discharge, dysuria, upper respiratory infection, fever 1
• Medical history: immunocompromised status, atopy, previous HSV eye disease 1

Physical Examination Requirements

• Visual acuity measurement, external examination, and slit-lamp biomicroscopy 1
• Evaluate for: preauricular lymphadenopathy, skin findings (rosacea, eczema), conjunctival injection pattern 1

Treatment by Etiology

Mild Bacterial Conjunctivitis

Apply broad-spectrum topical antibiotic (bacitracin ophthalmic ointment) 1-3 times daily for 5-7 days directly into the conjunctival sac. 3, 4

• Mild bacterial conjunctivitis is often self-limited in immunocompetent adults, but topical antibiotics provide earlier clinical remission at days 2-5 4
• Fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective against common pathogens including S. aureus, S. pneumoniae, and H. influenzae 4
• Delayed antibiotic prescribing has similar symptom control as immediate prescribing 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics 1

Moderate to Severe Bacterial Conjunctivitis

Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection or MRSA is suspected. 1, 4

• Characterized by copious purulent discharge, pain, and marked inflammation 1, 4
• MRSA is increasingly common, particularly in nursing home residents and community-acquired infections 1
• Compounded topical vancomycin may be needed for resistant cases 1
• Gram-negative organisms in neonates may be gentamicin-resistant 1

Gonococcal Conjunctivitis

Systemic antibiotic therapy is mandatory; topical treatment alone is insufficient. 1, 4

• Add saline lavage for comfort and more rapid resolution 1
• If corneal involvement present, add topical treatment as for bacterial keratitis 1
• Daily follow-up visits required until resolution, including visual acuity and slit-lamp examination 1
• Rule out N. meningitidis before concluding N. gonorrhoeae is causative 1
• Inform patients and sexual contacts about concomitant disease risk; consider sexual abuse in children 1

Chlamydial Conjunctivitis

Systemic therapy is indicated because >50% of infants have infection at other sites (nasopharynx, genital tract, lungs). 1, 4

• No data support adding topical therapy to systemic treatment 1
• Treatment failure rate can reach 19%; re-evaluation following treatment is essential 1
• Treat sexual contacts simultaneously; consider sexual abuse in children 1
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 1

Viral Conjunctivitis (Adenoviral)

No proven effective treatment for adenovirus eradication; provide symptomatic care with artificial tears, topical antihistamines, and cold compresses. 4, 2

• Avoid antibiotics due to potential adverse effects without benefit 4
• Topical corticosteroids may help in severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close monitoring for complications 4
• Strict hand hygiene is essential to prevent transmission 5, 2

HSV Conjunctivitis

Apply topical ganciclovir 0.15% gel or topical trifluridine 1% solution; oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used. 4

• Never use topical corticosteroids without antiviral coverage, as they potentiate HSV infection 4
• Prolonged trifluridine use (>2 weeks) causes epithelial toxicity 4

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity are first-line treatment. 4, 6

• Itching is the most consistent sign of allergic conjunctivitis 6
• Brief course of topical corticosteroids may be considered for severe inflammation, but requires intraocular pressure monitoring 3, 4
• For giant papillary conjunctivitis, discontinue contact lens use in conjunction with topical anti-inflammatory agents 4

Critical Red Flags Requiring Ophthalmology Referral

Refer immediately for any of the following: 3, 4

• 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 status
• Neonatal conjunctivitis

Follow-Up Protocol

• For bacterial conjunctivitis: advise return in 3-4 days if no improvement 1
• For gonococcal conjunctivitis: daily visits until resolution 1
• All follow-up visits should include: interval history, visual acuity measurement, and slit-lamp biomicroscopy 3
• Complete resolution typically occurs within 7-10 days with appropriate treatment 3
• If symptoms persist despite appropriate therapy, obtain conjunctival cultures to rule out MRSA 4

Common Pitfalls to Avoid

• Delayed referral for gonococcal conjunctivitis leads to poor outcomes; systemic antibiotics and daily monitoring are mandatory 4
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 4
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage potentiates infection 4
• Prescribing antibiotics for viral conjunctivitis causes unnecessary adverse effects 4
• Failing to treat sexual contacts in chlamydial or gonococcal cases 1