What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment of conjunctivitis must be tailored to the specific etiology: viral conjunctivitis requires only supportive care, bacterial conjunctivitis benefits from topical antibiotics in moderate-to-severe cases, and allergic conjunctivitis responds to topical antihistamines with mast cell-stabilizing properties. 1, 2

Initial Diagnostic Approach

The first step is determining the type of conjunctivitis based on clinical presentation:

Viral Conjunctivitis typically presents with:

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 3
• Often starts unilateral but becomes sequentially bilateral 3
• Preauricular lymphadenopathy common 3
• May have concurrent upper respiratory infection 3

Bacterial Conjunctivitis characteristically shows:

• Mucopurulent discharge with matted eyelids upon waking 3, 4
• Papillary (not follicular) reaction 3
• More common in children 4
• Preauricular lymphadenopathy less common unless hypervirulent organisms 3

Allergic Conjunctivitis features:

• Itching as the most consistent distinguishing symptom 3, 5
• Bilateral presentation with watery discharge 3
• No preauricular lymphadenopathy or matted eyelids 3

Treatment by Etiology

Viral Conjunctivitis

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

Supportive care includes:

• Artificial tears for symptomatic relief 3, 4
• Cold compresses 2, 4
• Topical antihistamines for symptom relief 3
• Patient education about high contagiousness for 10-14 days from symptom onset 3

Critical caveat: Topical corticosteroids should be avoided as they can prolong adenoviral infections and worsen HSV infections. 2, 3 If severe subepithelial infiltrates develop causing vision impairment, low-potency corticosteroids (fluorometholone, loteprednol, or rimexolone) may be considered under close ophthalmology supervision with regular IOP monitoring. 1, 3

For HSV conjunctivitis specifically:

• Topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 1
• Oral antivirals: acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 1
• Never use topical corticosteroids alone—they potentiate HSV infection 1

Bacterial Conjunctivitis

Mild cases are self-limited and may not require antibiotics. 2, 5 However, for moderate-to-severe cases:

• Broad-spectrum topical antibiotic for 5-7 days, applied 4 times daily 2, 6
• Fluoroquinolones (moxifloxacin, gatifloxacin) are effective against common pathogens including Streptococcus 6, 7
• Azithromycin: 1 drop twice daily (8-12 hours apart) for 2 days, then once daily for 5 days 8
• No specific antibiotic has proven superiority—choose based on cost and convenience 3

Return for re-evaluation if no improvement after 3-4 days. 2, 6

Special bacterial cases requiring systemic treatment:

• Gonococcal conjunctivitis: Requires systemic antibiotics plus daily follow-up until resolution; hospitalization may be necessary 1, 2
• Chlamydial conjunctivitis: Requires systemic antibiotics (>50% of infants have infection at other sites); sexual contacts must be treated concurrently 1, 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can treat chlamydial conjunctivitis 1, 2

Allergic Conjunctivitis

First-line treatment: topical antihistamines with mast cell-stabilizing properties 2, 3

Environmental modifications:

• Wear sunglasses as barriers to airborne allergens 2
• Cold compresses and refrigerated artificial tears 2
• Avoid eye rubbing 3

For persistent/recurrent cases:

• Mast cell stabilizers for prophylaxis 2
• Brief course (1-2 weeks) of low-potency topical corticosteroids for severe cases only 2, 3
• Allergen-specific immunotherapy, particularly beneficial in children 3

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present:

• Visual loss or decreased vision 2, 3
• Moderate or severe pain 1, 2
• Severe purulent discharge 1, 2
• Corneal involvement 1, 2
• Conjunctival scarring 1, 2
• Lack of response to therapy 1, 2
• Recurrent episodes 1, 2
• History of HSV eye disease 1, 2
• History of immunocompromise 1, 2
• Neonatal conjunctivitis (mandatory hospitalization) 1, 2

Common Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately—they prolong adenoviral infections, worsen HSV infections, and cause IOP elevation and cataracts 2, 3
• Avoid topical antibiotics for viral conjunctivitis—they cause unnecessary toxicity without benefit 3
• Discontinue contact lens wear during any infectious conjunctivitis 3, 8
• Chronic vasoconstrictor use causes rebound hyperemia 3
• Consider child abuse in children with sexually transmitted conjunctivitis 1

Prevention and Patient Education

For infectious conjunctivitis:

• Frequent handwashing with soap and water 3
• Avoid sharing towels, pillowcases, and makeup 6
• Disinfect surfaces with EPA-registered hospital disinfectant 3
• Avoid touching eyes 6

Follow-Up Recommendations

• Bacterial conjunctivitis: Return if no improvement after 3-4 days 2, 6
• Viral conjunctivitis: Return if symptoms persist beyond 2-3 weeks (if not on corticosteroids) 1, 3
• Severe cases with corneal involvement: Follow-up within 1 week 6
• Patients on topical corticosteroids: Regular IOP monitoring and pupillary dilation to evaluate for glaucoma and cataract 1, 3