What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment Algorithm by Etiology

Treatment must be tailored to the specific cause of conjunctivitis: viral cases require only supportive care, bacterial cases may benefit from topical antibiotics in moderate-to-severe presentations, and allergic cases respond to topical antihistamines with mast cell-stabilizing properties. 1

Viral Conjunctivitis

• Avoid antibiotics entirely—they provide no benefit and may cause toxicity. 2
• Viral conjunctivitis is self-limited, typically resolving within 5-14 days without specific antimicrobial treatment. 2
• Provide supportive care with artificial tears for symptomatic relief, cold compresses, and topical antihistamines if needed. 2
• Educate patients about high contagiousness and encourage minimizing contact with others for 10-14 days from symptom onset. 2
• For severe cases with pseudomembranes or subepithelial infiltrates, topical corticosteroids may be considered, but require close ophthalmology follow-up for monitoring intraocular pressure and cataract formation. 2
• Critical pitfall: Corticosteroids can prolong adenoviral infections and worsen HSV infections—use with extreme caution. 2

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and may resolve without treatment, though topical antibiotics may decrease duration. 2
• For moderate-to-severe bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic. 2
• Apply bacitracin ophthalmic ointment or erythromycin ophthalmic ointment approximately 1 cm in length directly into the conjunctival sac 1-3 times daily (bacitracin) or up to six times daily (erythromycin), depending on severity. 3, 4, 5, 4
• No evidence demonstrates superiority of any particular topical antibiotic agent—choose the most convenient or least expensive option. 2
• Instruct patients to return for evaluation if no improvement is seen after 3-4 days of treatment. 1

Allergic Conjunctivitis

• Topical antihistamines with mast cell-stabilizing properties are the first-line treatment of choice. 1, 2
• Recommend simple environmental measures: wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears. 1
• For persistent or recurrent cases, mast cell stabilizers can be used. 1
• In severe cases, add a brief 1-2 week course of topical corticosteroids with a low side-effect profile. 1
• Allergen-specific immunotherapy is beneficial in reducing symptoms, particularly in children. 2

Special Situations Requiring Systemic Antibiotics

• Gonococcal conjunctivitis requires systemic antibiotics and daily follow-up until resolution. 1
• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis. 1
• Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of infants with this condition may have infection at other sites. 1
• Sexual contacts of patients with sexually transmitted conjunctivitis should be treated concurrently. 1
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis. 1

Clinical Features to Guide Diagnosis

• Bacterial conjunctivitis: Mucopurulent discharge with matted eyelids upon waking, papillary reaction, lack of itching, absence of preauricular lymphadenopathy. 2, 3
• Viral conjunctivitis: Watery discharge, follicular reaction on inferior tarsal conjunctiva, preauricular lymphadenopathy, often starts unilateral but becomes sequentially bilateral, may have concurrent upper respiratory infection. 2
• Allergic conjunctivitis: Itching is the most consistent and distinguishing feature, bilateral presentation, watery discharge, absence of preauricular lymphadenopathy and matted eyelids. 2

Immediate Ophthalmology Referral Indications

Refer immediately for any of the following red flags: 1, 2

• Visual loss or decreased vision
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised state
• Membrane or pseudomembrane formation
• Neonatal conjunctivitis

Prevention and Patient Education

• Emphasize proper hand hygiene with soap and water to prevent transmission. 2
• Advise against sharing personal items like towels, pillows, or cosmetics. 1
• Contact lens wearers must suspend use until complete resolution. 1
• Disinfect surfaces with EPA-registered hospital disinfectant. 2

Critical Pitfalls to Avoid

• Never use topical antibiotics or corticosteroids indiscriminately—they can induce toxicity, prolong adenoviral infections, and worsen HSV infections. 1, 2
• In children with sexually transmitted conjunctivitis, always consider and report potential child abuse. 1
• Chronic or recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma) and requires further evaluation. 2