What is the treatment for conjunctivitis (pink eye)?

Treatment for Pink Eye (Conjunctivitis)

Treatment depends entirely on the underlying cause—viral, bacterial, or allergic—with most cases being self-limited but specific therapies available to reduce symptom duration and prevent complications.

Determining the Cause

The first critical step is identifying the type of conjunctivitis, as this dictates management:

• Bacterial conjunctivitis presents with mucopurulent discharge, matted eyelids upon waking, and lack of itching 1, 2
• Viral conjunctivitis presents with watery discharge, burning/gritty sensation, and is highly contagious 3, 1
• Allergic conjunctivitis presents with bilateral itching (the most consistent sign), watery discharge, and seasonal pattern 4, 2

Bacterial Conjunctivitis Treatment

For uncomplicated bacterial conjunctivitis, most cases resolve spontaneously in 1-2 weeks without treatment, but topical antibiotics can shorten duration and allow earlier return to work/school 2.

Antibiotic Options:

• Topical erythromycin ointment or bacitracin ointment applied 1-3 times daily to the conjunctival sac 5, 6
• Delayed antibiotic prescribing (giving prescription but instructing patient to wait 2-3 days before filling) achieves similar symptom control as immediate prescribing 1

Critical Exceptions Requiring Immediate Treatment:

• Contact lens wearers: Always treat with antibiotics and refer to ophthalmology to evaluate for corneal ulcers 3, 1
• Sexually transmitted infections (gonorrhea/chlamydia): Require systemic antibiotics in addition to topical therapy 2
• Neonatal conjunctivitis: Requires special evaluation and treatment 1

Viral Conjunctivitis Treatment

There is no proven effective treatment to eradicate adenovirus, so management is entirely supportive 7.

Supportive Care:

• Artificial tears for lubrication 7, 1
• Cold compresses 7, 1
• Topical antihistamines for symptom relief 7, 1
• Avoid antibiotics as they provide no benefit and risk toxicity 7

When to Consider Topical Corticosteroids:

• Only for severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis 7
• Use low side-effect profile steroids (fluorometholone, rimexolone, or loteprednol) 7
• Requires close monitoring with baseline and periodic IOP measurement and pupillary dilation to evaluate for glaucoma and cataract 7
• Taper slowly once inflammation controlled 7

Infection Control:

• Strict hand hygiene is essential 1
• Patients should minimize contact with others for 10-14 days from symptom onset in the last affected eye 7

Allergic Conjunctivitis Treatment

Dual-action topical agents (olopatadine, ketotifen, epinastine, azelastine) are first-line treatment due to rapid onset and ability to both treat acute symptoms and prevent future episodes 4.

Stepwise Treatment Algorithm:

Step 1: First-Line Therapy

• Dual-action antihistamine/mast cell stabilizer drops (olopatadine, ketotifen, epinastine, or azelastine) 4
• Cold compresses and refrigerated preservative-free artificial tears 4
• Allergen avoidance (sunglasses, hypoallergenic bedding, frequent clothes washing) 4

Step 2: If No Improvement in 48 Hours

• Add brief course (1-2 weeks maximum) of loteprednol etabonate 4
• Must perform baseline and periodic IOP measurement plus pupillary dilation 4

Step 3: For Severe/Refractory Cases

• Topical cyclosporine 0.05% (at least 4 times daily) or tacrolimus 4
• Cyclosporine 0.1% is FDA-approved specifically for vernal keratoconjunctivitis 4
• For eyelid involvement: pimecrolimus cream 1% or tacrolimus ointment (0.03% for ages 2-15; 0.03% or 0.1% for ages 16+) 7, 4

Critical Pitfalls to Avoid:

• Never use punctal plugs in allergic conjunctivitis—they prevent flushing of allergens 4
• Avoid chronic vasoconstrictor use—causes rebound hyperemia (conjunctivitis medicamentosa) 4
• Avoid oral antihistamines as primary treatment—they worsen dry eye syndrome 4
• Avoid eye rubbing—can lead to keratoconus, especially in atopic patients 4

When to Refer to Ophthalmology

Immediate referral is indicated for 1:

• Neonatal conjunctivitis
• Severe pain or decreased vision
• Recent ocular surgery
• Vesicular rash on eyelids or nose (suggests herpes)
• History of rheumatologic disease
• Immunocompromised state
• Contact lens wearer with suspected bacterial conjunctivitis
• No improvement after 10 days of treatment 8

Special Considerations for Vernal/Atopic Keratoconjunctivitis

Topical corticosteroids are usually necessary to control severe symptoms in these conditions 7.

• Start with environmental modifications and dual-action antihistamines 7
• Progress to topical cyclosporine 2% (or 0.05% four times daily) to reduce steroid dependence 7
• For sight-threatening disease unresponsive to topical therapy, consider supratarsal corticosteroid injection 7
• Systemic immunosuppression (montelukast, oral cyclosporine/tacrolimus) rarely warranted 7
• Warning: Tacrolimus/pimecrolimus may increase susceptibility to herpes simplex keratitis 7