What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment must be tailored to the specific etiology of conjunctivitis, with bacterial cases requiring topical antibiotics, allergic cases requiring antihistamines with mast cell stabilizers, and viral cases managed supportively. 1, 2

Initial Classification by Clinical Presentation

Determine the type of conjunctivitis based on discharge characteristics and associated symptoms:

• Bacterial conjunctivitis presents with mucopurulent discharge and eyelids matted shut upon waking, more common in children 3, 4
• Viral conjunctivitis presents with watery discharge and is the most common overall cause, accounting for 80% of acute infectious conjunctivitis 3, 5
• Allergic conjunctivitis presents with itching as the most consistent sign, along with watery discharge 3, 4

Bacterial Conjunctivitis Treatment

Mild Cases

Mild bacterial conjunctivitis is self-limited and does not require antibiotics in immunocompetent adults, as most uncomplicated cases resolve spontaneously in 1-2 weeks. 2, 4

Moderate to Severe Cases

For moderate to severe bacterial conjunctivitis, prescribe broad-spectrum topical antibiotics for 5-7 days applied 4 times daily: 6, 2

• Fluoroquinolones are first-line agents: moxifloxacin 0.5% or gatifloxacin are effective against common pathogens including Streptococcus and Staphylococcus species 6, 7, 8
• Alternative option: aminoglycosides such as tobramycin 6
• Instruct patients to return if no improvement after 3-4 days 1, 6, 2

Special Bacterial Pathogens

Gonococcal conjunctivitis requires systemic antibiotics, not just topical treatment: 9, 1, 2

• Daily follow-up is mandatory until complete resolution 9, 1
• Add saline lavage for comfort and faster resolution 9, 2
• If corneal involvement is present, treat as bacterial keratitis 9
• Treat sexual contacts concurrently and consider sexual abuse in children 9, 1, 2

Chlamydial conjunctivitis requires systemic antibiotics because >50% of infants have infection at other sites (nasopharynx, genital tract, lungs): 9, 1, 2

• Topical therapy alone is insufficient 9
• Re-evaluate after treatment due to 19% treatment failure rate 9, 2
• Treat sexual contacts concurrently and consider sexual abuse in children 9, 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 9, 1, 2

For MRSA infections, particularly in nursing home residents, consider compounded topical vancomycin guided by culture results. 9

Viral Conjunctivitis Treatment

Viral conjunctivitis requires supportive care only, as it is self-limited: 2, 3

• Artificial tears, cold compresses, and topical antihistamines for symptom relief 3
• Avoid topical corticosteroids as they prolong adenoviral infections and worsen HSV infections 1, 2
• Instruct patients to return if symptoms persist beyond 2-3 weeks 2
• Emphasize strict hand hygiene and avoiding sharing personal items to prevent transmission 3, 5

HSV Conjunctivitis (Specific Exception)

For herpes simplex virus conjunctivitis, use antiviral therapy: 2

• Topical options: ganciclovir 0.15% gel 3-5 times daily (preferred due to less toxicity) or trifluridine 1% solution 5-8 times daily 2
• Oral options: acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 2
• Avoid topical corticosteroids as they potentiate HSV infection 2
• Follow-up within 1 week 2

Allergic Conjunctivitis Treatment

Start with simple conservative measures: 1, 2

• Sunglasses as barriers to airborne allergens 1, 2
• Cold compresses and refrigerated artificial tears 1, 2
• Identify and avoid triggering allergens 1

For mild cases, use over-the-counter topical antihistamine/vasoconstrictor agents or second-generation H1-receptor antagonists. 2

For both acute and chronic allergic conjunctivitis, topical antihistamines with mast cell-stabilizing properties are the treatment of choice. 1, 2, 3, 4

For persistent or recurrent cases, use mast cell stabilizers. 1, 2

For severe cases not adequately controlled, add a brief 1-2 week course of topical corticosteroids with low side-effect profile (fluorometholone, rimexolone, or loteprednol). 1, 2

Critical Corticosteroid Monitoring

If topical corticosteroids are used, monitor intraocular pressure and perform pupillary dilation periodically to evaluate for glaucoma and cataract. 2

• Taper corticosteroids once inflammation is controlled 2
• Site-specific corticosteroids (rimexolone, loteprednol) are less likely to cause elevated IOP or cataract formation 2

Contact Lens Management

Instruct all patients with conjunctivitis to discontinue contact lens wear until complete resolution. 1, 2

Mandatory Ophthalmology Referral Criteria

Refer immediately to ophthalmology if any of the following red flags are present: 1, 2

• Visual loss 1, 2
• 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 (hospitalization mandatory) 1, 2

Critical Pitfalls to Avoid

Do not use topical antibiotics or corticosteroids indiscriminately, as they can induce toxicity, prolong adenoviral infections, and worsen HSV infections. 1, 2

Avoid chronic use of vasoconstrictor agents, which cause rebound vasodilation upon discontinuation. 2

Do not use topical trifluridine for more than 2 weeks, as it inevitably causes epithelial toxicity. 2

Always consider and report sexual abuse in children presenting with gonococcal or chlamydial conjunctivitis. 9, 1

Treat sexual contacts concurrently in all cases of sexually transmitted conjunctivitis to prevent reinfection. 9, 1, 2