Conjunctivitis Management
Treatment Algorithm by Type
Treatment of conjunctivitis must be tailored to the specific etiology—bacterial, viral, or allergic—with antibiotics reserved for bacterial cases, supportive care for viral infections, and topical antihistamines with mast cell stabilizers for allergic disease. 1
Bacterial Conjunctivitis
Mild Cases
- Most mild bacterial conjunctivitis is self-limited and resolves spontaneously without antibiotics in immunocompetent adults 2
- Consider delayed antibiotic prescribing, which provides similar symptom control to immediate treatment 3
Moderate to Severe Cases
- Prescribe broad-spectrum topical antibiotics for 5-7 days 2
- First-line options for children >12 months: topical fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) 4 times daily for 5-7 days 4
- Moxifloxacin 0.5% is FDA-approved: instill one drop in affected eye 3 times daily for 7 days 5
- Clean eyelids and lashes with warm water and gentle soap to remove crusts before applying medication 2
- Return for evaluation if no improvement after 3-4 days of treatment 1, 2
Special Bacterial Pathogens Requiring Systemic Therapy
Gonococcal Conjunctivitis:
- Requires systemic antibiotics plus topical treatment—topical therapy alone is inadequate 1, 2
- Neonates: ceftriaxone 125 mg IM plus topical antibiotics 4
- Daily follow-up until resolution is mandatory 1
- Saline lavage promotes comfort and faster resolution 2
- Treat sexual contacts concurrently and evaluate for child abuse in pediatric cases 1, 4
- Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 1
Chlamydial Conjunctivitis:
- Systemic antibiotic therapy is required, as >50% of patients have infection at other sites 1, 2
- Topical antibiotics provide no additional benefit beyond systemic treatment 4
- In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1
- Treat sexual contacts concurrently 1
- Re-evaluate after treatment due to 19% treatment failure rate 2
- Evaluate for child abuse in pediatric cases 4
Antibiotic Resistance Considerations
- Methicillin-resistant S. aureus (MRSA) is an increasing concern and may require alternative antibiotics such as vancomycin 4
- Obtain conjunctival cultures before treatment if severe purulent discharge is present 4
Viral Conjunctivitis
- Supportive care only—no specific antiviral treatment for most cases 1, 6
- Artificial tears, cold compresses, and topical antihistamines for symptom relief 1
- Avoid topical corticosteroids as they prolong adenoviral infections and worsen HSV infections 1, 2
- Strict hand hygiene is essential to prevent transmission 3
- Return if symptoms persist beyond 2-3 weeks 2
- If herpetic dendrites are present, refer to ophthalmology for trifluridine treatment 7
Allergic Conjunctivitis
First-Line Measures
- Wear sunglasses as barriers to airborne allergens 1, 2
- Apply cold compresses 1, 2
- Use refrigerated artificial tears 1, 2
Pharmacologic Treatment
- Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic allergic conjunctivitis 1, 2, 3
- For persistent or recurrent cases, use mast cell stabilizers like cromolyn sodium 2
- For severe cases not adequately controlled, add a brief course (1-2 weeks) of topical corticosteroids with low side-effect profile 1, 2
- Avoid oral antihistamines as they may worsen dry eye syndrome and impair the tear film's protective barrier 2
Corticosteroid Monitoring
- Monitor intraocular pressure (IOP) periodically and perform pupillary dilation to evaluate for glaucoma and cataract 2
- Taper corticosteroids once inflammation is controlled 2
- Consider fluorometholone, rimexolone, or loteprednol, which are less likely to cause elevated IOP or cataract formation 2
Contact Lens-Related Conjunctivitis
- Discontinue contact lens wear until the cornea returns to normal 2
- Consider a brief (1-2 weeks) course of topical corticosteroids plus longer-term topical cyclosporine 0.05% 2
- For giant papillary conjunctivitis, replace lenses more frequently, decrease wearing time, use preservative-free lens care systems, or switch to daily disposable lenses 2
- Consider alternatives to contact lenses (eyeglasses or refractive surgery) once resolved 2
Red Flags Requiring Immediate Ophthalmology Referral
Refer immediately for any of the following: 1, 2
- Visual loss
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement or infiltrates
- 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 (birth to 28 days) 4
Critical Pitfalls to Avoid
- Never use topical corticosteroids indiscriminately—they prolong adenoviral infections and worsen HSV infections 1, 2
- Avoid chronic use of vasoconstrictor agents, which cause rebound vasodilation 2
- In pediatric cases of sexually transmitted conjunctivitis, always evaluate for child abuse and report appropriately 1, 4
- Do not use combination antibiotic-corticosteroid preparations unless conjunctivitis is proven to be nonherpetic 7
- Patients should not wear contact lenses if signs or symptoms of bacterial conjunctivitis are present 5