Treatment of Conjunctivitis
Initial Classification and Approach
Treatment of conjunctivitis depends critically on identifying the underlying etiology—viral, bacterial, allergic, or other causes—with each requiring distinct management strategies. 1, 2
The key distinguishing features include:
- Bacterial conjunctivitis: Mucopurulent discharge with matted eyelids, more common in children 3, 4
- Viral conjunctivitis: Watery discharge, highly contagious, more common in adults 3, 4
- Allergic conjunctivitis: Itching is the hallmark symptom, bilateral presentation with watery/mucoid discharge 2, 4
Treatment by Etiology
Bacterial Conjunctivitis
For mild bacterial conjunctivitis in immunocompetent adults, treatment is optional as the condition is self-limited and resolves spontaneously in 1-2 weeks without antibiotics. 2, 4
For moderate to severe bacterial conjunctivitis, prescribe broad-spectrum topical antibiotics for 5-7 days applied 4 times daily. 5, 2
Preferred antibiotic options:
- Fluoroquinolones (moxifloxacin 0.5% or gatifloxacin): Effective against common pathogens including Streptococcus and Staphylococcus species 5, 6
- Aminoglycosides (tobramycin): Alternative effective option 5
Instruct patients to return if no improvement occurs after 3-4 days of antibiotic therapy. 5, 2, 7
In resource-limited settings, povidone-iodine 1.25% ophthalmic solution may be used as an alternative when antibiotics are unavailable 2, 7
Special Bacterial Cases Requiring Systemic Treatment
Gonococcal conjunctivitis requires immediate systemic antibiotic therapy—topical treatment alone is insufficient. 1, 2, 7
Management protocol:
- Systemic antibiotics (see specific protocols for dosing) 1, 2
- Saline lavage for comfort and faster resolution 1, 2
- Daily follow-up visits until complete resolution 1, 2, 7
- Treat all sexual contacts concurrently 2, 7
- Consider sexual abuse in pediatric cases 1
- Rule out Neisseria meningitidis before confirming N. gonorrhoeae 1
Chlamydial conjunctivitis requires systemic antibiotic therapy because >50% of infected infants have concurrent infection at other sites (nasopharynx, genital tract, lungs). 1, 2, 7
Management protocol:
- Systemic antibiotics only—no proven benefit from adding topical therapy 1
- Re-evaluate after treatment due to failure rates up to 19% 1, 2
- Treat sexual contacts concurrently 1, 2, 7
- Consider sexual abuse in pediatric cases 1
- In resource-limited settings, povidone-iodine 1.25% can be used 1, 2, 7
Viral Conjunctivitis
Viral conjunctivitis requires only supportive care in most cases, as it is self-limited. 2, 3
Supportive measures include:
Instruct patients to return only if symptoms persist beyond 2-3 weeks. 2
Critical: Avoid topical corticosteroids as they can prolong adenoviral infections and worsen HSV infections. 2
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
- Never use topical corticosteroids—they potentiate HSV infection 2
- Follow-up within 1 week 2
- Note: Trifluridine causes epithelial toxicity if used >2 weeks; ganciclovir is less toxic 2
Allergic Conjunctivitis
For allergic conjunctivitis, topical antihistamines with mast cell-stabilizing properties are the treatment of choice. 2, 7
Treatment algorithm:
- Simple measures first: Sunglasses as allergen barriers, cold compresses, refrigerated artificial tears 2, 7
- Mild cases: Over-the-counter topical antihistamine/vasoconstrictor agents OR second-generation H1-receptor antagonists 2
- Moderate cases: Topical medications with combined antihistamine and mast cell-stabilizing properties (preferred for both acute and chronic disease) 2
- Persistent/recurrent cases: Mast cell stabilizers 2, 7
- Severe refractory cases: Add brief course (1-2 weeks) of low side-effect profile topical corticosteroids 2, 7
Important caveat: Chronic use of vasoconstrictor agents causes rebound vasodilation upon discontinuation 2
Warning: Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 2
Corticosteroid Use: Critical Precautions
When topical corticosteroids are necessary, monitor intraocular pressure (IOP) periodically and perform pupillary dilation to evaluate for glaucoma and cataract formation. 2
- Taper corticosteroids once inflammation is controlled 2
- Consider corticosteroids with poor ocular penetration (fluorometholone) or site-specific agents (rimexolone, loteprednol) to reduce risk of elevated IOP and cataract formation 2
Mandatory Ophthalmology Referral
Refer immediately to an ophthalmologist for any of the following red flags: 2, 7
- 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
Hospitalization is mandatory for neonatal conjunctivitis and may be necessary for severe gonococcal conjunctivitis. 2, 7
Infection Control and Patient Education
Bacterial conjunctivitis is highly contagious—strict hygiene measures are essential: 5
- Frequent handwashing 5
- Avoid touching eyes 5
- Do not share towels, pillowcases, or makeup 5, 2
- Patients should not wear contact lenses if signs/symptoms of bacterial conjunctivitis are present 1, 2, 6
Common Pitfalls to Avoid
- Never use topical antibiotics or corticosteroids indiscriminately—they can cause toxicity and worsen viral infections 2, 7
- Do not use topical corticosteroids for viral conjunctivitis—they prolong adenoviral infections and worsen HSV 2
- Do not forget to treat sexual contacts in sexually transmitted conjunctivitis 2
- Always consider sexual abuse in children with gonococcal or chlamydial infections 1, 2
- Avoid contaminating eye drop bottles—instruct patients not to touch dropper tip to any surface 6