What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

Treatment depends entirely on the underlying cause—viral conjunctivitis requires only supportive care, bacterial conjunctivitis may benefit from topical antibiotics to shorten duration, and allergic conjunctivitis responds best to dual-action topical antihistamine/mast cell stabilizers like olopatadine or ketotifen. 1, 2

Viral Conjunctivitis (Most Common Overall)

No specific antiviral treatment is effective or necessary for most cases. 1

Supportive Management

• Artificial tears, cold compresses, and oral analgesics provide symptomatic relief 1
• Topical antihistamines may reduce discomfort 1
• Avoid topical antibiotics—they provide no benefit and risk toxicity 1
• Patients should minimize contact with others for 10-14 days from symptom onset in the last affected eye 1

When to Consider Topical Corticosteroids

• Reserve for severe cases only: marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis 1
• Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize IOP elevation and cataract risk 1
• Debride membranes if present to prevent permanent cicatricial changes 1
• Monitor IOP and perform pupillary dilation periodically when using any corticosteroid 1
• Taper slowly once inflammation is controlled 1

Emerging Treatments Under Investigation

• Povidone-iodine 0.4-0.6% (alone or with dexamethasone 0.1%) shows promise in reducing viral titers and shortening clinical course 1
• Off-label topical ganciclovir 0.15% gel may benefit specific adenovirus serotypes but needs further study 1

Bacterial Conjunctivitis (Second Most Common Infectious Cause)

Most cases are self-limited and resolve in 1-2 weeks without treatment, but topical antibiotics shorten duration and allow earlier return to school/work. 3, 4

Clinical Features Suggesting Bacterial Etiology

• Mattering and adherence of eyelids on waking 3
• Lack of itching 3
• No history of prior conjunctivitis 3

Topical Antibiotic Options

• Polymyxin-bacitracin ointment applied 1-3 times daily 5, 4
• Erythromycin ointment for superficial infections 6
• Topical antibiotics achieve clinical cure in 62% by days 3-5 versus 28% with placebo, and 91% by days 8-10 versus 72% with placebo 4
• Bacterial eradication occurs in 71% by days 3-5 and 79% by days 8-10 with antibiotics versus 19% and 31% with placebo 4

Special Situations Requiring Systemic Treatment

• Gonococcal or chlamydial conjunctivitis: requires systemic antibiotics in addition to topical therapy 3, 1
• Contact lens wearers: always treat with antibiotics and refer for evaluation of corneal ulcers 7
• Giant fornix syndrome: obtain conjunctival cultures (usually Staphylococcus aureus, including MRSA) before starting prolonged systemic anti-staphylococcal antibiotics plus intensive topical antibiotics and corticosteroids 1

Allergic Conjunctivitis (Up to 40% of Population)

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. 2

First-Line Approach

• Allergen avoidance: sunglasses as barrier, hypoallergenic bedding, eyelid cleansers, frequent clothes washing, shower before bedtime 1, 2
• Cold compresses and refrigerated preservative-free artificial tears dilute allergens and inflammatory mediators 1, 2
• Dual-action topical agents (antihistamine + mast cell stabilizer) are most effective 2
• Store drops in refrigerator for additional cooling relief 2

Second-Line Options

• Mast cell stabilizers alone (cromolyn, lodoxamide, nedocromil, pemirolast) for prophylaxis—slow onset limits use in acute symptoms 2
• Topical NSAIDs (ketorolac) for temporary relief of itching 2

Third-Line for Severe Cases

• Brief 1-2 week course of low side-effect topical corticosteroids (loteprednol etabonate) for inadequate symptom control 1, 2
• Baseline and periodic IOP measurement plus pupillary dilation required when using any corticosteroid 2
• Topical cyclosporine 0.05% or tacrolimus for severe refractory cases, particularly vernal or atopic keratoconjunctivitis 1, 2

Critical Pitfalls to Avoid

• Never use punctal plugs—they prevent flushing of allergens and inflammatory mediators 2
• Avoid chronic vasoconstrictor use—causes rebound vasodilation (conjunctivitis medicamentosa) 2
• Avoid oral antihistamines as primary treatment—they worsen dry eye syndrome and impair tear film 1, 2
• Avoid indiscriminate antibiotic use—not indicated and causes toxicity 2

Medication-Induced/Preservative-Induced Conjunctivitis

Discontinue the offending agent—resolution occurs over weeks to months. 1

• Brief course of preservative-free topical corticosteroid ointment or cream if severe inflammation present 1
• Nonpreserved artificial tears or low-dose topical corticosteroids may help 1
• Monitor for subepithelial fibrosis 1

When to Refer

• Severe pain, decreased vision, or painful pupillary reaction—suggests serious intraocular condition 8
• Contact lens wearers with conjunctivitis—evaluate for corneal ulcers 7
• Allergic conjunctivitis uncontrolled with topical medications—consider allergist consultation for immunotherapy 2
• Vernal or atopic keratoconjunctivitis—may require ophthalmology for supratarsal corticosteroid injections or systemic immunosuppression 2