Treatment of Conjunctivitis
Immediate Classification and Treatment Algorithm
Treatment must be tailored to the specific type of conjunctivitis—bacterial, viral, allergic, or sexually transmitted—with bacterial cases requiring antibiotics only for moderate-to-severe disease, viral cases needing supportive care alone, and allergic cases responding to topical antihistamines with mast cell stabilization. 1, 2
Step 1: Identify the Type Based on Clinical Presentation
Bacterial Conjunctivitis:
- Yellow crusting around the eyes strongly indicates bacterial infection 1, 3
- Bilateral mucopurulent discharge with eyelids matted shut on waking 1, 4
- Lack of itching and no history of prior conjunctivitis 5
Viral Conjunctivitis:
- Watery discharge without significant crusting 4
- Often unilateral initially, may become bilateral 1
- Variable presentation at onset 5
Allergic Conjunctivitis:
- Severe itching is the hallmark symptom 1, 6
- Watery discharge with bilateral involvement 4
- History of allergen exposure 6
Sexually Transmitted (Gonococcal/Chlamydial):
- Severe, bilateral purulent discharge in sexually active adults 6
- Requires immediate systemic treatment 1, 2
Treatment by Type
Bacterial Conjunctivitis
Mild Cases:
- No antibiotics needed—mild bacterial conjunctivitis is self-limited and resolves spontaneously in immunocompetent adults within 1-2 weeks 1, 5
Moderate-to-Severe Cases:
- Prescribe moxifloxacin 0.5% ophthalmic solution three times daily for 5-7 days 1, 3
- Alternative fluoroquinolones or aminoglycosides if moxifloxacin unavailable 3
- Moxifloxacin achieves clinical cure rates of 66-69% by day 5-6 and microbiological eradication rates of 84-94% 7
- Before applying medication, clean eyelids and lashes with warm water and gentle soap to remove crusts 1, 3
- Instruct patients to return if no improvement after 3-4 days 1, 2
- Complete resolution typically occurs within 7-10 days 3
Common Pitfall: Avoid indiscriminate antibiotic use in mild cases, as most resolve without treatment and unnecessary antibiotics increase resistance risk 1, 2
Viral Conjunctivitis
Supportive Care Only:
- Cold compresses and refrigerated artificial tears for symptom relief 1, 4
- Topical antihistamines may provide additional comfort 4
- Instruct patients to return only if symptoms persist beyond 2-3 weeks 1
Critical Warning: Never use topical corticosteroids—they prolong adenoviral infections and worsen HSV infections 1, 2
Infection Control:
- Strict hand hygiene is essential to prevent transmission 3, 4
- Avoid sharing towels, pillows, or cosmetics 2
Gonococcal Conjunctivitis
Requires Aggressive Systemic Treatment:
- Systemic antibiotics are mandatory—topical treatment alone is insufficient 1, 2
- Saline lavage promotes comfort and faster resolution 1
- Daily follow-up until complete resolution 1, 2
- Treat sexual contacts concurrently and screen for other sexually transmitted infections 1, 2
- Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 1, 2
Chlamydial Conjunctivitis
Systemic Antibiotics Required:
- Systemic therapy is essential because >50% of patients have infection at other sites 1, 2
- Treat sexual contacts concurrently 1, 2
- Re-evaluate after treatment due to potential treatment failure rates up to 19% 1
- In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be considered 2
Allergic Conjunctivitis
First-Line Treatment:
- Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic cases 1, 2, 4
- Simple measures: sunglasses as barriers to airborne allergens, cold compresses, refrigerated artificial tears 1, 2
Persistent or Recurrent Cases:
Severe Cases:
- Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile (fluorometholone, loteprednol, or rimexolone) 1, 2
- Monitor intraocular pressure and check for cataracts periodically during corticosteroid use 1
- Taper corticosteroids once inflammation is controlled 1
Common Pitfall: Avoid oral antihistamines—they may worsen dry eye syndrome and impair the tear film's protective barrier 1
Special Populations and Situations
Contact Lens Wearers
- Discontinue contact lens wear immediately until the cornea returns to normal 1, 2
- Consider topical corticosteroids (1-2 weeks) plus longer-term cyclosporine 0.05% 1
- For giant papillary conjunctivitis: replace lenses more frequently, decrease wearing time, use preservative-free solutions, or switch to daily disposables 1
Elderly Patients
- Higher risk for complications due to age-related immune changes 3
- Monitor for giant fornix syndrome and nasolacrimal duct obstruction 3
- Consider MRSA if symptoms persist despite appropriate therapy 3
When to Refer to Ophthalmology Immediately
Immediate referral is mandatory for: 1, 2
- 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 patients
Critical Warnings
Avoid these common errors:
- Never use topical corticosteroids for viral conjunctivitis—they prolong adenoviral infections and worsen HSV 1, 2
- Chronic vasoconstrictor use causes rebound vasodilation 1
- Always identify and treat sexual contacts in gonococcal/chlamydial cases 1, 2
- Do not prescribe antibiotics for mild bacterial conjunctivitis—most cases are self-limited 1, 5