What is the treatment for conjunctivitis?

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 clinical features that guide classification include:

• Viral conjunctivitis: Watery discharge, bilateral presentation, preauricular lymphadenopathy, often associated with upper respiratory symptoms 3, 4
• Bacterial conjunctivitis: Mucopurulent discharge with eyelids matted shut on awakening, lack of itching, unilateral or bilateral presentation 3, 5
• Allergic conjunctivitis: Itching (most consistent sign), watery discharge, bilateral presentation, chemosis, history of atopy 5, 6

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, 5

For moderate to severe bacterial conjunctivitis, prescribe broad-spectrum topical antibiotics for 5-7 days applied 4 times daily. 7, 2

Recommended first-line agents include:

• Fluoroquinolones (moxifloxacin 0.5% or gatifloxacin): Effective against common pathogens including Streptococcus and Staphylococcus species; moxifloxacin dosed 3 times daily for 7 days per FDA labeling 7, 8
• Aminoglycosides (tobramycin): Alternative effective option 7
• Povidone-iodine 1.25% ophthalmic solution: May be used when antibiotic access is limited 2

Instruct patients to return for re-evaluation if no improvement occurs after 3-4 days of antibiotic treatment. 7, 2, 9

Special Bacterial Infections Requiring Systemic Treatment

Gonococcal conjunctivitis requires systemic antibiotic therapy, not just topical treatment, with daily follow-up until complete resolution. 1, 2, 9

Additional management includes:

• Saline lavage for comfort and faster resolution 1, 2
• If corneal involvement is present, add topical treatment as for bacterial keratitis 1
• Treat sexual contacts concurrently and screen for concomitant sexually transmitted infections 1, 2, 9
• Consider sexual abuse in children presenting with gonococcal infection 1, 2
• Rule out Neisseria meningitidis before confirming N. gonorrhoeae 1

Chlamydial conjunctivitis requires systemic antibiotic therapy because more than 50% of infected infants have concurrent infection at other sites (nasopharynx, genital tract, lungs). 1, 2, 9

Management considerations:

• No data support adding topical therapy to systemic treatment 1
• Treatment failure rates can reach 19%, necessitating re-evaluation after treatment 1, 2
• Treat sexual contacts concurrently 1, 2, 9
• Consider sexual abuse in children 1, 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 1, 2, 9

Viral Conjunctivitis

Viral conjunctivitis requires only supportive care in most cases, as it is self-limited and resolves without specific treatment. 2, 3, 4

Supportive measures include:

• Artificial tears for comfort 3
• Cold compresses 2, 3
• Topical antihistamines for symptomatic relief 3

Instruct patients to return if symptoms persist beyond 2-3 weeks. 2

Critical: Avoid topical corticosteroids as they can prolong adenoviral infections and worsen HSV infections. 2

HSV Conjunctivitis (Requires Specific Antiviral Treatment)

For HSV conjunctivitis, prescribe either topical or oral antiviral therapy. 2

Topical options:

• Ganciclovir 0.15% gel three to five times daily 2
• Trifluridine 1% solution five to eight times daily (note: causes epithelial toxicity if used >2 weeks) 2

Oral options:

• Acyclovir 200-400 mg five times daily 2
• Valacyclovir 500 mg two to three times daily 2
• Famciclovir 250 mg twice daily 2

Follow-up within 1 week of initiating treatment is recommended. 2

Allergic Conjunctivitis

For mild allergic conjunctivitis, start with simple environmental measures and over-the-counter topical antihistamine/vasoconstrictor combinations. 2, 9

Simple measures include:

• Wearing sunglasses as barriers to airborne allergens 2, 9
• Cold compresses 2, 9
• Refrigerated artificial tears 2, 9

For moderate cases or when over-the-counter agents fail, prescribe topical medications with combined antihistamine and mast cell-stabilizing properties—these are the treatment of choice for both acute and chronic allergic conjunctivitis. 2, 9

For persistent or recurrent cases, use mast cell stabilizers as maintenance therapy. 2, 9

For severe cases inadequately controlled by the above, add a brief 1-2 week course of topical corticosteroids with a low side-effect profile (fluorometholone, rimexolone, or loteprednol). 2, 9

When using topical corticosteroids:

• Monitor intraocular pressure periodically 2
• Perform pupillary dilation to evaluate for cataract formation 2
• Taper once inflammation is controlled 2
• Prefer corticosteroids with poor ocular penetration or site-specific formulations to minimize IOP elevation and cataract risk 2

Critical Safety Considerations

Avoid indiscriminate use of topical antibiotics or corticosteroids, as they can induce toxicity and worsen certain infections. 2, 9

Additional pitfalls to avoid:

• Chronic vasoconstrictor use causes rebound vasodilation upon discontinuation 2
• Oral antihistamines may worsen dry eye syndrome 2
• Topical trifluridine inevitably causes epithelial toxicity if used >2 weeks 2

Infection Control Measures

Bacterial conjunctivitis is highly contagious; counsel patients on strict hygiene measures. 7

Specific instructions:

• Frequent handwashing 7, 3
• Avoid touching eyes 7
• Do not share towels, pillowcases, or makeup 7, 2
• Advise patients not to wear contact lenses if signs or symptoms of bacterial conjunctivitis are present 1, 2, 8

Mandatory Ophthalmology Referral Criteria

Refer immediately to an ophthalmologist for any of the following red flags: 1, 2, 9

• Visual loss 1, 2, 9
• Moderate or severe pain 1, 2, 9
• Severe purulent discharge 1, 2, 9
• Corneal involvement 1, 2, 9
• Conjunctival scarring 1, 2, 9
• Lack of response to therapy 1, 2, 9
• Recurrent episodes 1, 2, 9
• History of HSV eye disease 1, 2, 9
• History of immunocompromise 1, 2, 9

Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis. 2, 9

Follow-Up Recommendations

• Bacterial conjunctivitis: Return if no improvement after 3-4 days of treatment 7, 2, 9
• Viral conjunctivitis: Return if symptoms persist beyond 2-3 weeks 2
• Severe cases with corneal involvement or membranous conjunctivitis: Schedule follow-up within 1 week 7
• Gonococcal conjunctivitis: Daily follow-up until resolution 1, 2, 9
• Chlamydial conjunctivitis: Re-evaluate after treatment due to high failure rates 1, 2

All follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy. 7