What is the treatment for conjunctivitis (pink eye)?

Treatment for Pink Eye (Conjunctivitis)

Treatment depends on the underlying cause—viral conjunctivitis requires only supportive care, bacterial conjunctivitis may benefit from topical antibiotics (though often self-limited), and allergic conjunctivitis responds to topical antihistamines with mast cell stabilizers. 1, 2

Initial Diagnostic Approach

The key to appropriate treatment is distinguishing between viral, bacterial, and allergic etiologies based on specific clinical features:

Viral Conjunctivitis:

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 3
• Often starts unilateral but becomes sequentially bilateral 1, 3
• Preauricular lymphadenopathy present 1, 3
• May have concurrent upper respiratory infection 1
• Subconjunctival hemorrhages and chemosis are distinctive findings 3

Bacterial Conjunctivitis:

• Mucopurulent discharge with matted eyelids upon waking 4, 5
• Papillary (not follicular) reaction 3
• Lack of itching and no history of prior conjunctivitis 4
• Preauricular lymphadenopathy less common unless hypervirulent organisms 3

Allergic Conjunctivitis:

• Itching is the most consistent and distinguishing feature 3, 4
• Bilateral presentation with watery discharge 3
• Seasonal or perennial pattern depending on allergen exposure 3
• May have concurrent allergic rhinitis or asthma 3

Treatment by Etiology

Viral Conjunctivitis

Avoid antibiotics entirely—they provide no benefit and may cause toxicity. 3

Supportive care includes:

• Artificial tears to dilute viral particles and provide comfort 2, 6
• Cold compresses to reduce inflammation 2, 6
• Topical antihistamines for itching relief 2, 6
• Oral analgesics for pain management 6

Patient education is critical:

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 2, 6
• Frequent handwashing and avoid touching eyes 6
• Use disposable towels and disinfect surfaces 3
• Avoid sharing personal items like towels and pillows 3

For severe adenoviral keratoconjunctivitis with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis:

• Consider topical corticosteroids (fluorometholone, rimexolone, or loteprednol preferred) 1, 2
• Requires close ophthalmology follow-up for monitoring intraocular pressure and cataract formation 2, 6
• Taper slowly to minimum effective dose 1, 6
• Be aware corticosteroids may prolong viral shedding 3, 6

Special viral subtypes:

• HSV conjunctivitis: Topical ganciclovir 0.15% gel three to five times daily OR trifluridine 1% solution five to eight times daily 1, 2

  • Oral antivirals: acyclovir 200-400 mg five times daily, valacyclovir 500 mg two to three times daily, or famciclovir 250 mg twice daily 1, 2
  • Avoid topical corticosteroids as they potentiate HSV infection 1, 2
  • Topical trifluridine causes epithelial toxicity if used beyond 2 weeks 1, 2

• VZV conjunctivitis: Topical antibiotics to prevent secondary bacterial infection 6, 7

  • 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 6

Bacterial Conjunctivitis

Mild bacterial conjunctivitis is often self-limited and resolves spontaneously in 1-2 weeks without treatment. 2, 4

For moderate to severe bacterial conjunctivitis:

• 5-7 day course of broad-spectrum topical antibiotic 2, 3
• No evidence demonstrates superiority of any particular agent—choose the most convenient or least expensive option 3
• Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 2
• Alternative options include bacitracin ointment 1-3 times daily 7 or erythromycin ointment 8

Special considerations:

• Gonococcal conjunctivitis: Requires systemic antibiotics in addition to topical therapy with daily monitoring until resolution 2, 3

  • Obtain conjunctival cultures and Gram staining before treatment 2
  • Can lead to corneal perforation if untreated 3

• Chlamydial conjunctivitis: Requires systemic treatment and evaluation of sexual partners 3, 4

  • Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 2

• MRSA suspected: Consider in patients from nursing homes or with community-acquired infections 2

  • Obtain cultures before initiating treatment 2
  • Compounded topical vancomycin may be needed for resistant cases 2

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity are first-line treatment. 2, 3

Environmental modifications:

• Wear sunglasses as barrier to airborne allergens 3
• Use cold compresses and refrigerated artificial tears 3
• Avoid eye rubbing 3
• Allergen avoidance strategies 3

For refractory cases:

• Short-term topical corticosteroids (1-2 week course with low side-effect profile) 3
• Baseline and periodic measurement of intraocular pressure if corticosteroids used 2
• Consider allergen-specific immunotherapy, particularly beneficial in children 3

For giant papillary conjunctivitis:

• Discontinue contact lens use in conjunction with topical anti-inflammatory agents 2

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present: 2, 3

• Visual loss or decreased vision
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy after 2-3 weeks
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised state
• Neonatal conjunctivitis
• Contact lens wearers (evaluate for corneal ulcers)
• Recent ocular surgery
• Vesicular rash on eyelids or nose

Follow-Up Recommendations

For severe viral conjunctivitis:

• Re-evaluate within 1 week 3, 6
• Patients not on corticosteroids should return if symptoms persist beyond 2-3 weeks 3, 6

For patients on topical corticosteroids:

• Regular monitoring of intraocular pressure and pupillary dilation 2, 3
• Taper once inflammation is controlled 1

Common Pitfalls to Avoid

• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage—this potentiates infection 2, 3
• Avoid indiscriminate antibiotic use in viral conjunctivitis—provides no benefit and causes unnecessary toxicity 2, 3
• Do not use topical trifluridine for more than 2 weeks—causes epithelial toxicity 2
• Avoid contact lens wear during any form of infectious conjunctivitis 3
• Chronic vasoconstrictor use causes rebound conjunctival injection 3
• Delayed referral for gonococcal conjunctivitis can lead to corneal perforation 2
• Chronic/recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma)—requires further evaluation 3