What is the treatment for pink eye (conjunctivitis) in an adult?

Treatment for Pink Eye (Conjunctivitis) in Adults

Treatment depends entirely on the etiology: bacterial conjunctivitis receives topical antibiotics (though mild cases are self-limited), viral conjunctivitis requires only supportive care, and allergic conjunctivitis is treated with dual-action topical antihistamine/mast cell stabilizers as first-line therapy. 1

Determining the Type of Conjunctivitis

Before treating, identify the etiology based on clinical presentation:

• Bacterial conjunctivitis: Mucopurulent discharge with eyelids matted shut upon waking, lack of itching, no history of prior conjunctivitis 2, 3
• Viral conjunctivitis: Watery discharge, often with preauricular lymphadenopathy, highly contagious 2
• Allergic conjunctivitis: Itching is the most consistent sign, watery discharge, bilateral presentation 3, 4

Bacterial Conjunctivitis Treatment

Mild Bacterial Conjunctivitis

Mild bacterial conjunctivitis is self-limited and typically resolves spontaneously without treatment in immunocompetent adults. 5

• Topical antibiotics provide earlier clinical remission (days 2-5) compared to placebo, but this advantage lessens over time 5
• A 5-7 day course of broad-spectrum topical antibiotic is standard when treatment is chosen 1
• No specific antibiotic demonstrates superiority over another, so select based on cost and convenience 5, 1
• Options include topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) or bacitracin ointment applied 1-3 times daily 1, 6
• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics when access is limited 5

Moderate to Severe Bacterial Conjunctivitis

Copious purulent discharge, pain, and marked inflammation require cultures and Gram staining before initiating treatment. 5, 1

• Obtain conjunctival cultures if gonococcal infection is suspected 5
• Consider MRSA, especially in nursing home residents or community-acquired infections—these organisms resist many topical antibiotics 5
• Compounded topical vancomycin may be necessary for resistant cases 5

Gonococcal Conjunctivitis

Systemic antibiotic therapy is mandatory for gonococcal conjunctivitis, with daily monitoring until resolution. 5, 1

• Saline lavage promotes comfort 5
• Delayed referral leads to poor outcomes 1

Viral Conjunctivitis Treatment

No proven effective treatment exists for eradicating adenovirus infection; management is supportive only. 5, 1

Adenoviral Conjunctivitis (Epidemic Keratoconjunctivitis)

• Avoid antibiotics as they provide no benefit and risk adverse effects 5, 1
• Supportive care includes artificial tears, cold compresses, topical antihistamines, and oral analgesics 5
• Educate patients that the condition is highly contagious for 10-14 days from symptom onset in the last affected eye 5
• Strict hand hygiene with soap and water prevents transmission 1
• Avoid close contact for 7-14 days and discard multiple-dose eyedrop containers 1

Topical corticosteroids are helpful only in severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close follow-up due to prolonged viral shedding in animal models 5

• Povidone-iodine 0.6% alone or with dexamethasone 0.1% is under investigation for reducing viral titers and shortening clinical course 5

Herpes Simplex Virus (HSV) Conjunctivitis

Topical ganciclovir 0.15% gel or trifluridine 1% solution is recommended for HSV conjunctivitis. 1

• Oral antivirals (acyclovir 800 mg five times daily, valacyclovir 1000 mg every 8 hours, or famciclovir 500 mg three times daily for 7 days) may be beneficial in acute/subacute disease 5
• Never use topical corticosteroids without antiviral coverage as they potentiate HSV infection 1
• Prolonged trifluridine use (>2 weeks) causes epithelial toxicity 1

Molluscum Contagiosum

Treatment requires removal of eyelid lesions through incision and curettage, excision, or cryotherapy. 5

• Conjunctivitis may take weeks to resolve after lesion elimination 5
• Multiple or large lesions in adults suggest immunocompromised state 5

Allergic Conjunctivitis Treatment

Dual-action agents (olopatadine, ketotifen, epinastine, azelastine) are first-line treatment due to rapid onset and ability to both treat acute symptoms and prevent future episodes. 7

First-Line Therapy

• Topical antihistamine/mast cell stabilizers provide immediate relief and ongoing protection 7, 1
• Store drops in refrigerator for additional cooling relief upon instillation 7
• Adjunctive measures: cold compresses, refrigerated preservative-free artificial tears to dilute allergens, sunglasses as allergen barrier 7, 1
• Allergen avoidance: hypoallergenic bedding, frequent clothes washing, bathing before bedtime 7

Second-Line Therapy

If symptoms persist after 48 hours on dual-action drops, add a brief 1-2 week course of loteprednol etabonate. 7, 1

• Baseline and periodic intraocular pressure (IOP) measurement plus pupillary dilation required to monitor for glaucoma and cataract 7, 1
• Mast cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) are better for prophylactic use due to slow onset 7
• Topical NSAIDs (ketorolac) provide temporary relief of itching 7

Third-Line Therapy for Severe/Refractory Cases

Topical cyclosporine 0.05% (at least four times daily) or tacrolimus can be considered for cases unresponsive to above treatments. 7, 1

• Cyclosporine 0.1% is FDA-approved specifically for vernal keratoconjunctivitis in children and adults 5, 7
• These agents allow reduced steroid use 5, 7
• Tacrolimus or pimecrolimus may increase susceptibility to herpes simplex keratitis 5, 7

Special Considerations for Vernal/Atopic Keratoconjunctivitis

Topical corticosteroids are usually necessary to control severe symptoms and signs in vernal keratoconjunctivitis. 5, 7

• For eyelid involvement in patients ≥2 years: pimecrolimus cream 1% or tacrolimus ointment (0.03% for ages 2-15; 0.03% or 0.1% for ages ≥16) 5, 7
• Supratarsal corticosteroid injection for severe sight-threatening disease unresponsive to topical therapy 5
• Systemic options (rarely warranted): montelukast, oral cyclosporine, oral tacrolimus 5, 7

Critical Pitfalls to Avoid

• Never use punctal plugs in allergic conjunctivitis—they prevent flushing of allergens and inflammatory mediators 7
• Avoid chronic vasoconstrictor use—over-the-counter antihistamine/vasoconstrictor combinations cause rebound vasodilation (conjunctivitis medicamentosa) 7
• Avoid oral antihistamines as primary treatment—they worsen dry eye syndrome and impair the tear film's protective barrier 5, 7
• Avoid indiscriminate antibiotic use—topical antibiotics induce toxicity and are not indicated for viral or allergic conjunctivitis 1
• Avoid eye rubbing in allergic conjunctivitis—this worsens symptoms and increases keratoconus risk, especially in atopic patients 5, 7

When to Refer to Ophthalmology

Immediate referral is indicated for: 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
• Immunocompromised state
• Neonatal conjunctivitis (requires systemic treatment coordinated with pediatrician) 1

Follow-Up Strategy

• Frequency based on disease severity, etiology, and treatment response 5, 7
• If corticosteroids used chronically: baseline and periodic IOP measurement plus pupillary dilation to evaluate for glaucoma and cataract 5, 7
• Monitor for keratoconus in allergic/atopic patients—adequate allergy control and preventing eye rubbing decrease ectasia progression 5, 7