What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Determine the Etiology First

Treatment must be tailored to the specific cause—viral, bacterial, or allergic—as antibiotics are ineffective and potentially harmful for viral conjunctivitis, while allergic conjunctivitis requires antihistamines rather than antimicrobials. 1

Key Clinical Differentiators

Viral conjunctivitis typically presents with:

• Watery discharge (not purulent) 2
• Follicular reaction on inferior tarsal conjunctiva 2
• Preauricular lymphadenopathy 2
• Often starts unilateral but becomes sequentially bilateral 2
• May have concurrent upper respiratory infection 2
• Subconjunctival hemorrhages may be present 2

Bacterial conjunctivitis characteristically shows:

• Mucopurulent discharge with matted eyelids upon waking 1, 3
• Papillary (not follicular) reaction 2
• Lack of itching 3
• Can be unilateral or bilateral 2
• Preauricular lymphadenopathy less common unless hypervirulent organisms 2

Allergic conjunctivitis is distinguished by:

• Itching as the most consistent and distinguishing feature 1, 2
• Watery discharge 2
• Bilateral presentation 2
• Absence of preauricular lymphadenopathy and matted eyelids 2
• Often seasonal or perennial pattern 2
• May have concurrent allergic rhinitis or asthma 2

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Treatment Algorithm by Etiology

Viral Conjunctivitis

Avoid antibiotics entirely—they provide no benefit and may cause toxicity. 1, 4

Supportive care only:

• Artificial tears for comfort and to dilute viral particles 4, 5
• Cold compresses to reduce inflammation 4, 5
• Topical antihistamines for itching relief 4
• Oral analgesics for pain 4

Patient education is critical:

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 4
• Practice strict hand hygiene with soap and water 2
• Avoid sharing towels, pillows, or cosmetics 1
• Disinfect surfaces with EPA-registered hospital disinfectants or 1:10 dilution of household bleach 4
• Discontinue contact lens wear until complete resolution 1, 2

For severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing blurred vision:

• Consider topical corticosteroids (fluorometholone, rimexolone, or loteprednol preferred) 4
• Mandatory close ophthalmology follow-up required 4
• Monitor intraocular pressure and perform periodic pupillary dilation 4
• Taper slowly to minimum effective dose 4
• Never use corticosteroids without ruling out HSV, as they can worsen HSV infections and cause corneal scarring 4

Special viral etiologies:

• HSV conjunctivitis: Topical ganciclovir 0.15% gel or trifluridine 1% solution; oral antivirals (acyclovir, valacyclovir, or famciclovir) for severe cases 4
• VZV conjunctivitis: Topical antibiotics to prevent secondary bacterial infection; oral antivirals for persistent disease 4
• Molluscum contagiosum: Physical removal of eyelid lesions via incision and curettage, excision, or cryotherapy 4

Follow-up:

• Re-evaluate within 1 week for severe disease 4
• Return if symptoms persist beyond 2-3 weeks without corticosteroid treatment 1

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Bacterial Conjunctivitis

Mild cases are self-limited and may not require antibiotics, but moderate-to-severe cases benefit from topical antibiotics to shorten duration and allow earlier return to work/school. 1, 3

For moderate-to-severe bacterial conjunctivitis:

• 5-7 day course of broad-spectrum topical antibiotic 1, 2
• No specific agent has proven superiority—choose based on convenience and cost 2
• Options include moxifloxacin 0.5% (1 drop 3 times daily for 7 days) 6 or azithromycin 1% (1 drop twice daily for 2 days, then once daily for 5 days) 7

Return for evaluation if no improvement after 3-4 days of treatment 1

Special considerations requiring systemic antibiotics:

• Gonococcal conjunctivitis: Requires systemic antibiotics PLUS topical therapy; hospitalization necessary for parenteral therapy; daily follow-up until resolution; treat sexual contacts concurrently 1, 2
• Chlamydial conjunctivitis: Requires systemic antibiotics (topical alone is inadequate); more than 50% of infants have infection at other sites; treat sexual contacts; re-evaluate after treatment 1, 2
• In children with sexually transmitted conjunctivitis, consider child abuse and report appropriately 1

Neonatal conjunctivitis requires immediate ophthalmology referral and may need hospitalization 2, 4

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Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) are first-line treatment. 1, 2

Environmental modifications:

• Wear sunglasses as barriers to airborne allergens 1
• Apply cold compresses 1
• Use refrigerated artificial tears 1
• Avoid eye rubbing 2
• Identify and avoid allergen triggers 1

For persistent or recurrent cases:

• Mast cell stabilizers can be used 1

For severe cases:

• Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile 1, 2
• Requires monitoring for intraocular pressure elevation and cataract formation 2

For refractory cases:

• Consider allergen-specific immunotherapy, particularly beneficial in children 2
• Multidisciplinary approach with allergists may be helpful 2

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Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if ANY of the following are present: 1, 2

• Visual loss or decreased vision
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• 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 (mandatory referral)

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Common Pitfalls to Avoid

Never use topical antibiotics indiscriminately for viral conjunctivitis—they cause unnecessary toxicity and do not shorten disease course. 1, 4

Never use topical corticosteroids without close ophthalmology follow-up—they can prolong adenoviral infections, worsen HSV infections, elevate intraocular pressure, and cause cataracts. 1, 2, 4

Never miss gonococcal conjunctivitis—it can cause corneal perforation and requires immediate systemic treatment. 2

Never allow contact lens wear during any form of infectious conjunctivitis. 1, 2

Avoid vasoconstrictor eye drops chronically—they cause rebound hyperemia. 2

In chronic or recalcitrant conjunctivitis, consider underlying malignancy (sebaceous or squamous cell carcinoma) and pursue further evaluation. 2