What are the recommended eyedrops for treating conjunctivitis?

Eyedrops for Conjunctivitis

The best eyedrop for conjunctivitis depends entirely on the etiology: topical fluoroquinolones (moxifloxacin or gatifloxacin) for bacterial conjunctivitis, second-generation topical antihistamines with mast-cell stabilizing properties for allergic conjunctivitis, and supportive care with artificial tears for viral conjunctivitis. 1

Bacterial Conjunctivitis

First-Line Treatment

• Topical fluoroquinolones are the recommended first-line antibiotics for bacterial conjunctivitis. 1, 2
• No evidence demonstrates superiority of any specific topical antibiotic agent over another, so choice can be based on dosing convenience, cost, and local resistance patterns. 3, 1

Specific Fluoroquinolone Options

• FDA-approved fluoroquinolones include moxifloxacin 0.5%, gatifloxacin 0.3%, levofloxacin 1.5%, ciprofloxacin 0.3%, ofloxacin 0.3%, and besifloxacin 0.6%. 2, 4, 5
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have superior coverage of gram-positive pathogens compared to earlier generations. 2
• Moxifloxacin is dosed as one drop three times daily for 7 days. 4
• Gatifloxacin is dosed as one drop every two hours while awake (up to 8 times) on Day 1, then one drop two to four times daily on Days 2-7. 5

Severe Bacterial Conjunctivitis

• For severe cases with copious purulent discharge, obtain conjunctival cultures and Gram staining before initiating treatment. 1, 6
• Consider a loading dose of fluoroquinolone every 5-15 minutes followed by hourly applications for severe infections. 2
• Methicillin-resistant S. aureus (MRSA) should be considered in patients from nursing homes or with community-acquired infections; compounded topical vancomycin may be needed for resistant cases. 1

Special Bacterial Pathogens

• Gonococcal conjunctivitis is a hyperacute, vision-threatening condition requiring immediate systemic therapy in addition to topical antibiotics. 3
• Chlamydial conjunctivitis requires systemic therapy because more than 50% of infants may have infection at other sites (nasopharynx, genital tract, lungs). 3
• There are no data supporting the use of topical therapy in addition to systemic therapy for chlamydial conjunctivitis. 3

Pediatric Considerations

• Fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are FDA-approved for children older than 12 months. 1, 2, 6
• Administer topical antibiotic four times daily for 5-7 days in mild to moderate cases. 6
• Single-use tubes of 0.5% erythromycin ophthalmic ointment are the standard prophylactic agent to prevent ophthalmia neonatorum. 3

Follow-Up and Monitoring

• Patients should return for evaluation in 3-4 days if no improvement is noted. 3, 6
• If no improvement occurs after 3-4 days, consider culture and sensitivity testing and potential change in therapy. 2

Viral Conjunctivitis

General Management

• No proven effective treatment exists for eradication of adenovirus infection. 1
• Symptomatic treatment includes artificial tears, topical antihistamines, and cold compresses. 1
• Indiscriminate use of topical antibiotics should be avoided as viral conjunctivitis will not respond to antibacterial agents. 3, 1

Topical Corticosteroids for Adenoviral Conjunctivitis

• Topical corticosteroids may be considered in severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close monitoring. 1
• Patients with severe disease who have corneal epithelial ulceration or membranous conjunctivitis should be re-evaluated within 1 week. 3
• For corneal subepithelial infiltrates causing blurring, photophobia, and decreased vision, topical corticosteroids at the minimum effective dose may be considered. 3
• Use corticosteroids with poor ocular penetration (fluorometholone, loteprednol) to minimize risk of elevated IOP or cataract formation. 3
• Cyclosporine drops (0.05% to 1% compounded) have been found helpful as an alternative in reducing subepithelial infiltrates. 3

Herpes Simplex Virus (HSV) Conjunctivitis

• Topical options include ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily. 3, 1
• Oral antivirals include acyclovir (200-400 mg five times daily), valacyclovir (500 mg two or three times daily), or famciclovir (250 mg twice daily). 3, 1
• Topical corticosteroids potentiate HSV infection and should be avoided. 3, 1
• Topical trifluridine inevitably causes epithelial toxicity if used for more than 2 weeks. 3
• Topical ganciclovir is less toxic to the ocular surface than trifluridine. 3
• Oral antivirals alone may not be adequate in preventing progression of HSV blepharoconjunctivitis; addition of topical antiviral treatment has been effective. 3

Varicella Zoster Virus (VZV) Conjunctivitis

• Topical antibiotics may be used to prevent secondary infection as vesicles undergo necrosis before healing. 3
• Topical antivirals alone have not been shown helpful in treating VZV conjunctivitis but may be used as additive treatment in unresponsive patients. 3

Allergic Conjunctivitis

First-Line Treatment

• Second-generation topical antihistamines with mast-cell stabilizing properties are first-line therapy for mild allergic conjunctivitis. 1
• Adjunctive measures include cold compresses, refrigerated preservative-free artificial tears, and sunglasses as an allergen barrier. 1

Escalation for Persistent Symptoms

• A brief 1-2 week course of low side-effect profile topical corticosteroids can be added if symptoms persist. 1
• Monitor intraocular pressure and evaluate for cataract when using topical corticosteroids. 1

Vernal Conjunctivitis

• For acute exacerbations of vernal conjunctivitis, topical corticosteroids are usually necessary to control severe symptoms and signs. 3

Critical Referral Indications

Patients should be referred to an ophthalmologist for: 3, 1

• 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

Common Pitfalls to Avoid

• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage, as they potentiate infection. 1
• Avoid prolonged use of topical trifluridine beyond 2 weeks due to inevitable epithelial toxicity. 3
• Do not delay systemic antibiotics for gonococcal conjunctivitis, as this can lead to poor outcomes including corneal perforation. 1
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis. 3, 1
• Increasing fluoroquinolone resistance has been reported, particularly with MRSA; consider local resistance patterns when selecting therapy. 2