What is the treatment for conjunctivitis (pink eye)?

Treatment for Pink Eye (Conjunctivitis)

Treatment depends on the underlying cause: bacterial conjunctivitis benefits from topical antibiotics (though mild cases are self-limited), viral conjunctivitis requires only supportive care, and allergic conjunctivitis responds to topical antihistamines with mast cell-stabilizing properties. 1

Bacterial Conjunctivitis

Mild Cases

• Mild bacterial conjunctivitis is self-limited and resolves spontaneously in immune-competent adults without treatment 1
• However, topical antibacterial therapy provides earlier clinical and microbiological remission during days 2-5 of treatment 1
• The American Academy of Ophthalmology recommends a 5-7 day course of broad-spectrum topical antibiotics for mild bacterial conjunctivitis 1
• Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 1
• Alternative options include bacitracin ointment applied 1-3 times daily 2 or erythromycin ointment 3
• Return for evaluation if no improvement after 3-4 days of treatment 4

Moderate to Severe Cases

• Characterized by copious purulent discharge, pain, and marked inflammation 1
• Obtain conjunctival cultures and Gram staining before initiating treatment 1
• Treatment should be guided by laboratory results 1
• Consider MRSA in patients from nursing homes or with community-acquired infections; compounded topical vancomycin may be needed for resistant cases 1

Special Bacterial Pathogens

• Gonococcal conjunctivitis requires systemic antibiotics plus topical therapy with daily monitoring until resolution 1, 4
• Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 4
• Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of infants have infection at other sites 1, 4
• Sexual contacts of patients with sexually transmitted conjunctivitis should be treated concurrently 4
• In low-resource settings with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 4

Viral Conjunctivitis

General Management

• No proven effective treatment exists for eradication of adenovirus infection 1
• Avoid antibiotics as they provide no benefit and may cause adverse effects 1, 5
• Patients should minimize contact with others for 10-14 days from symptom onset in the last affected eye 5

Symptomatic Treatment

• Artificial tears provide comfort and help dilute viral particles 1, 5
• Cold compresses reduce inflammation and provide relief 1, 5
• Topical antihistamines alleviate itching and discomfort 1, 5
• Oral analgesics for pain management 5

Severe Adenoviral Cases

• Topical corticosteroids may help in severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis 1
• Close monitoring is mandatory when using corticosteroids: measure intraocular pressure periodically and evaluate for glaucoma and cataract 6, 5
• Prefer corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize side effects 6, 5
• Taper slowly to minimum effective dose once inflammation is controlled 6, 5
• Re-evaluate patients with severe disease within 1 week 6, 5

Herpes Simplex Virus (HSV) Conjunctivitis

• Topical ganciclovir 0.15% gel three to five times daily OR trifluridine 1% solution five to eight times daily 6, 1
• Oral antivirals: acyclovir 200-400 mg five times daily, valacyclovir 500 mg two or three times daily, or famciclovir 250 mg twice daily 6, 1
• Topical corticosteroids potentiate HSV infection and must be avoided 6, 1
• Topical trifluridine causes epithelial toxicity if used for more than 2 weeks 6, 1
• Follow-up within 1 week with visual acuity measurement and slit-lamp biomicroscopy 6

Varicella Zoster Virus (VZV) Conjunctivitis

• Topical antibiotics to prevent secondary bacterial infection as vesicles undergo necrosis 6, 5
• Oral antivirals for persistent cases: acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg every 8 hours for 7 days, or famciclovir 500 mg three times daily for 7 days 5
• Use caution in patients with impaired renal clearance 5

Allergic Conjunctivitis

First-Line Treatment

• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 4
• Simple measures: wear sunglasses as barriers to airborne allergens, apply cold compresses, use refrigerated artificial tears 4
• Identify and avoid triggering allergens 4

Persistent or Recurrent Cases

• Mast cell stabilizers can be used for persistent or recurrent cases 4
• For severe cases, a brief course (1-2 weeks) of topical corticosteroids with low side-effect profile may be added 4
• Baseline and periodic intraocular pressure measurement if corticosteroids are used 1

Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately for: 1, 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 state
• Contact lens wearers (evaluate for corneal ulcers)
• Neonatal conjunctivitis

Critical Pitfalls to Avoid

• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage, as they potentiate infection 1, 4
• Avoid indiscriminate use of topical antibiotics or corticosteroids, which can induce toxicity and potentially prolong adenoviral infections 4
• Do not use topical trifluridine for more than 2 weeks due to epithelial toxicity 6, 1
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1
• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 1

Infection Control Measures

• Strict handwashing is essential to prevent transmission 5, 7
• Do not share towels, pillows, or cosmetics 4
• Contact lens wearers must discontinue use until complete resolution 4
• Adenovirus can survive for weeks on surfaces; disinfect with sodium hypochlorite 5