What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Initial Classification and Approach

Treatment of conjunctivitis depends entirely on identifying the underlying etiology—viral, bacterial, allergic, or other causes—with each requiring distinctly different management strategies. 1, 2

The key clinical differentiators include:

• Bacterial conjunctivitis: Mucopurulent discharge with eyelids matted shut, more common in children 3
• Viral conjunctivitis: Watery discharge, preauricular lymphadenopathy, highly contagious, accounts for 80% of acute infectious conjunctivitis 3, 4
• Allergic conjunctivitis: Itching as the hallmark symptom, bilateral presentation, watery/mucoid discharge 1, 2

Treatment by Etiology

Bacterial Conjunctivitis

For mild bacterial conjunctivitis in immunocompetent adults, no treatment is necessary as it is self-limited and resolves spontaneously within 1-2 weeks. 2, 5

For moderate to severe cases:

• Prescribe broad-spectrum topical antibiotics for 5-7 days, applied 4 times daily 6, 2
• Fluoroquinolones (moxifloxacin 0.5% or gatifloxacin) are first-line agents, effective against Streptococcus species and other common pathogens 6, 7
• Aminoglycosides like tobramycin are alternative effective options 6
• Patients should return if no improvement after 3-4 days 6, 2, 8

Critical warning: Avoid topical corticosteroids unless under close supervision, as they prolong bacterial shedding and worsen infection 6, 2

Gonococcal Conjunctivitis (Medical Emergency)

Systemic antibiotic therapy is mandatory—topical treatment alone is insufficient. 1, 2

Management protocol:

• Administer systemic antibiotics immediately (see specific regimens in guidelines) 1
• Add saline lavage for comfort and faster resolution 1, 2
• Daily follow-up visits are required until complete resolution 1, 2, 8
• If corneal involvement exists, add topical treatment as for bacterial keratitis 1
• Treat all sexual contacts concurrently and screen for concomitant STDs 1, 2, 8
• Consider sexual abuse in children presenting with gonococcal conjunctivitis 1, 2
• Hospitalization may be necessary for severe cases and is mandatory for neonatal cases 2, 8

Chlamydial Conjunctivitis

Systemic antibiotic therapy is required because more than 50% of infants have concurrent infection at other sites (nasopharynx, genital tract, lungs). 1, 2, 8

Key management points:

• Topical therapy adds no benefit to systemic treatment 1
• Re-evaluate after treatment completion due to treatment failure rates up to 19% 1, 2
• Treat sexual contacts simultaneously 1, 2, 8
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can substitute when antibiotics are unavailable 1, 2, 8
• Consider sexual abuse in pediatric cases 1, 2

Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—no specific treatment is needed for most cases. 2, 3

Supportive measures include:

• Artificial tears for comfort 2
• Cold compresses 2, 8
• Topical antihistamines for symptomatic relief 3
• Strict hand hygiene and surface disinfection to prevent spread 3, 4
• Patients should return if symptoms persist beyond 2-3 weeks 2, 8

Critical warning: Avoid topical corticosteroids as they prolong adenoviral infections and worsen HSV infections 2, 8

For HSV conjunctivitis specifically:

• Topical options: Ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 2
• Oral options: Acyclovir 200-400mg five times daily, valacyclovir 500mg 2-3 times daily, or famciclovir 250mg twice daily 2
• Trifluridine causes epithelial toxicity if used beyond 2 weeks; ganciclovir is less toxic 2
• Follow-up within 1 week of treatment initiation 2

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic allergic conjunctivitis. 2, 8

Treatment algorithm:

1. Simple measures first: Sunglasses as allergen barriers, cold compresses, refrigerated artificial tears 2, 8
2. Mild cases: Over-the-counter topical antihistamine/vasoconstrictor agents OR second-generation H1-receptor antagonists 2
3. Persistent/recurrent cases: Mast cell stabilizers 2, 8
4. Severe refractory cases: Add brief course (1-2 weeks) of low side-effect profile topical corticosteroids (fluorometholone, rimexolone, or loteprednol) 2, 8

Important caveats:

• Chronic vasoconstrictor use causes rebound vasodilation upon discontinuation 2
• Oral antihistamines may worsen dry eye syndrome 2
• Patients on topical corticosteroids require periodic IOP monitoring and pupillary dilation to screen for glaucoma and cataracts 2
• Taper corticosteroids once inflammation is controlled 2

Mandatory Ophthalmology Referral

Immediate referral is required for: 2, 8

• 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

Patient Education and Prevention

For all infectious conjunctivitis:

• Avoid sharing towels, pillowcases, and makeup 6, 2
• Frequent handwashing and avoid touching eyes 6, 3
• Contact lens wearers must discontinue use until complete resolution 2, 8
• Do not touch dropper tip to any surface to prevent contamination 7