What is the treatment for bilateral conjunctivitis?

Treatment of Bilateral Conjunctivitis

Treatment depends entirely on identifying the underlying etiology, as viral, bacterial, and allergic conjunctivitis require fundamentally different management approaches. 1

Initial Diagnostic Approach

The key clinical features that differentiate etiologies include:

• Viral conjunctivitis: Watery to serofibrinous discharge, bilateral presentation (may start unilateral), follicular reaction on inferior tarsal conjunctiva, preauricular lymphadenopathy, often with concurrent upper respiratory symptoms 2, 3
• Bacterial conjunctivitis: Mucopurulent discharge, matted eyelids on waking, absence of itching, no history of prior conjunctivitis 4, 5
• Allergic conjunctivitis: Severe itching (most consistent sign), mucoid discharge, chemosis, eyelid edema, papillary reaction, allergen exposure history 1, 5

Always examine the cornea with fluorescein staining in any case of purulent conjunctivitis to detect early corneal involvement. 2

Viral Conjunctivitis Management

Most viral conjunctivitis is self-limited, resolving within 5-14 days, and requires only supportive care. 2, 3, 4

Supportive measures include:

• Cool compresses 1
• Artificial tears for symptom relief 1, 4
• Topical antihistamines for comfort 1, 4
• Strict hand hygiene to prevent transmission 4

Monitor for progression to epidemic keratoconjunctivitis with fluorescein staining, as subepithelial infiltrates can cause long-term visual sequelae. 2, 3

Critical Red Flags Requiring Immediate Referral:

• Herpes simplex virus: Can progress to keratitis, stromal keratitis, corneal scarring, perforation, uveitis, and retinitis 2
• Varicella zoster virus: Vesicular dermatomal rash, severe pain, risk of corneal scarring and uveitis 2
• Pseudomembrane formation: Higher risk of conjunctival scarring, symblepharon, and lacrimal stenosis 2

Bacterial Conjunctivitis Management

For uncomplicated bacterial conjunctivitis, delayed antibiotic prescribing has similar symptom control as immediate prescribing, as most cases resolve in 1-2 weeks without treatment. 4, 5

When antibiotics are indicated:

• Topical antibiotics (e.g., bacitracin ointment applied to conjunctival sac 1-3 times daily) shorten duration and allow earlier return to work/school 6, 5
• Culture-guided therapy for chronic cases associated with blepharitis, recurrent styes, or meibomianitis 7

Life-Threatening Bacterial Infections Requiring Immediate Systemic Treatment:

Gonococcal conjunctivitis can cause corneal perforation within 24-48 hours and requires immediate systemic antibiotics plus topical therapy. 2

Chlamydial conjunctivitis (distinctive sign: follicles on bulbar conjunctiva and semilunar fold) requires systemic antibiotics. 2

Any purulent conjunctivitis in a neonate is an emergency until gonococcal and chlamydial causes are ruled out; gonococcal infection can lead to septicemia, meningitis, and death. 2

Allergic Conjunctivitis Management

Topical antihistamines with mast cell-stabilizing activity are the treatment of choice for allergic conjunctivitis. 4, 5

Treatment algorithm:

• First-line: Environmental modification, cool compresses, ocular lubricants, topical antihistamines/mast cell stabilizers 1
• Avoid: Topical vasoconstrictors (may worsen dry eye and allergic conjunctivitis); punctal plugs (prevent flushing of allergens) 1
• Acute exacerbations: Short-term topical corticosteroids for severe symptoms 1
• Steroid-sparing agents: Topical cyclosporine 0.05% (more frequent dosing) or 2% for severe cases, topical tacrolimus 0.1% for refractory cases 1
• Severe refractory disease: Allergen-specific immunotherapy (subcutaneous or sublingual) 1

Vernal/Atopic Conjunctivitis Specific Management:

For severe sight-threatening atopic keratoconjunctivitis unresponsive to topical therapy, supratarsal corticosteroid injection or systemic immunosuppression (cyclosporine, tacrolimus, montelukast) may be warranted. 1

Adequate control of allergy and eye rubbing is critical to prevent keratoconus progression. 1

Monitoring Requirements

• If corticosteroids used chronically: Baseline and periodic IOP measurement and dilated exam to monitor for glaucoma and cataract 1
• Immunocompromised patients: Higher risk for severe complications and atypical presentations requiring closer monitoring 2
• Contact lens wearers with conjunctivitis: Must be treated with antibiotics due to higher risk of complications 5