What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

Treatment depends on the underlying cause: bacterial conjunctivitis receives 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 often resolves spontaneously without treatment in immunocompetent adults 1
• A 5-7 day course of broad-spectrum topical antibiotics is recommended by the American Academy of Ophthalmology, as it provides earlier clinical and microbiological remission (days 2-5) compared to placebo 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 ophthalmic ointment 3
• Patients should return for evaluation if no improvement occurs 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 Requiring Systemic Treatment

• 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 gonococcal 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 resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 4

Viral Conjunctivitis

Adenoviral Conjunctivitis (Most Common)

• No proven effective treatment exists for eradication of adenovirus infection 1
• Symptomatic treatment includes artificial tears, cold compresses, and topical antihistamines 1, 5
• 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
• Strict handwashing and disinfection of surfaces with sodium hypochlorite is essential, as adenovirus survives for weeks on surfaces 5

Severe Adenoviral Keratoconjunctivitis

• Topical corticosteroids may be considered for severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close monitoring 1, 5
• Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize risk of elevated intraocular pressure and cataract formation 6
• Monitor intraocular pressure and pupils periodically during corticosteroid use 6
• Taper slowly to the minimum effective dose 6, 5
• For membranous conjunctivitis, debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 5

Subepithelial Infiltrates (Late Complication)

• Typically occur 1 or more weeks after onset of adenoviral conjunctivitis 6
• Mild cases require only observation 6, 5
• Cases with blurring, photophobia, and decreased vision may require topical corticosteroids at minimum effective dose 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 are recommended 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) are also effective 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; topical ganciclovir is less toxic 6
• Neonates require prompt consultation with pediatrician, as systemic HSV infection is life-threatening 6

Varicella Zoster Virus (VZV) Conjunctivitis

• Topical antibiotics are recommended to prevent secondary bacterial infection, as vesicles undergo necrosis before healing 6, 5
• Topical antivirals alone have not been shown to be helpful 6, 5
• Oral antivirals (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) are beneficial for persistent or recalcitrant disease 5
• Use caution with oral antivirals in patients with impaired renal clearance 5

Molluscum Contagiosum-Related Conjunctivitis

• Treatment requires removal of causative eyelid lesions through incision and curettage, simple excision, excision and cautery, or cryotherapy 5
• Conjunctivitis may require weeks to resolve after lesion elimination 5

Allergic Conjunctivitis

First-Line Treatment

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

Persistent or Recurrent Cases

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

Giant Papillary Conjunctivitis

• Discontinue contact lens use in conjunction with topical anti-inflammatory agents 1
• Baseline and periodic measurement of intraocular pressure if corticosteroids are used 1

Follow-Up Guidelines

• Patients with severe disease (corneal epithelial ulceration or membranous conjunctivitis) should be re-evaluated within 1 week 6, 5
• Patients not treated with corticosteroids should return if symptoms persist beyond 2-3 weeks 6, 5
• Follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 6, 5

Immediate Ophthalmology Referral Indications

Refer immediately for: 1, 4

• 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
• Immunocompromised state
• Contact lens wearers with suspected bacterial conjunctivitis (to evaluate for corneal ulcers) 7

Critical Pitfalls to Avoid

• Indiscriminate use of topical antibiotics or corticosteroids can induce toxicity and potentially prolong adenoviral infections and worsen HSV infections 4
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage potentiates infection 1
• Prolonged use of topical trifluridine (>2 weeks) causes epithelial toxicity 6, 1
• Delayed referral for gonococcal conjunctivitis can lead to poor outcomes 1
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1

Infection Control Measures

• Do not share towels, pillows, or cosmetics 4
• Contact lens wearers should suspend use until complete resolution 4
• Frequent handwashing is essential 1
• In clinical settings, consider abbreviated exams in dedicated rooms and disinfect exposed surfaces 5