What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment Algorithm by Etiology

Treatment of conjunctivitis must be tailored to the specific cause—viral, bacterial, or allergic—with viral cases requiring only supportive care, bacterial cases potentially benefiting from topical antibiotics in moderate-to-severe presentations, and allergic cases responding to topical antihistamines with mast cell-stabilizing activity. 1

Viral Conjunctivitis

Viral conjunctivitis is self-limited and requires no prescription medication—avoid antibiotics entirely as they provide no benefit and may cause unnecessary toxicity. 1, 2

Supportive Care Measures:

• Artificial tears applied frequently throughout the day for symptomatic relief and to flush viral particles 2
• Cold compresses applied to closed eyelids to reduce discomfort and inflammation 1, 2
• Topical antihistamines may be used if itching is prominent 1, 2
• Disease typically resolves spontaneously within 5-14 days without specific antimicrobial treatment 3, 2

Critical Pitfall:

• Never use topical corticosteroids in primary care for routine viral conjunctivitis—they can prolong viral shedding, worsen herpes simplex infections if misdiagnosed, and require intraocular pressure monitoring 1, 3, 2
• Corticosteroids are reserved only for severe cases with corneal involvement under ophthalmology supervision 3, 2

Infection Control:

• Patients remain highly contagious for 10-14 days from symptom onset 1, 2
• Emphasize frequent handwashing with soap and water as the single most important preventive measure 1, 2
• Avoid sharing towels, washcloths, pillows, or any items that contact the face 1, 2
• Disinfect frequently touched surfaces with EPA-registered hospital disinfectant 1, 3
• Children can return to school after 24-48 hours once symptoms are improving and purulent discharge has resolved 2

Bacterial Conjunctivitis

For mild bacterial conjunctivitis, treatment is optional as most cases are self-limited and resolve within 1-2 weeks; however, topical antibiotics may shorten duration and allow earlier return to work or school. 1, 3, 4

Treatment Approach:

• Moderate-to-severe cases: 5-7 day course of broad-spectrum topical antibiotic 1, 3
• No evidence demonstrates superiority of any particular topical antibiotic agent—choose the most convenient or least expensive option 3
• FDA-approved options include:
  • Moxifloxacin 0.5%: 1 drop three times daily for 7 days 5
  • Azithromycin 1%: 1 drop twice daily for 2 days, then once daily for 5 days 6

Follow-up:

• Patients should return for evaluation if no improvement is seen after 3-4 days of treatment 1

Special Considerations:

• Gonococcal conjunctivitis requires systemic antibiotics in addition to topical therapy, with daily follow-up until resolution and hospitalization for severe cases 1, 3
• Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of infants may have infection at other sites 1, 3
• Sexual contacts of patients with sexually transmitted conjunctivitis should be treated concurrently 1, 3
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 1

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for allergic conjunctivitis. 1, 3

First-Line Treatment:

• Topical antihistamines with mast cell-stabilizing activity (e.g., olopatadine, ketotifen) 1, 3
• Environmental modifications: wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 3
• Avoid eye rubbing 3

Escalation for Persistent Cases:

• Mast cell stabilizers can be used for persistent or recurrent cases 1
• Short course of topical corticosteroids (1-2 weeks) with a low side-effect profile may be added in severe cases 1, 3
• Allergen-specific immunotherapy is beneficial in reducing symptoms, particularly in children 3

Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present: 1, 3

• Visual loss or decreased vision
• Moderate or severe pain (beyond mild irritation)
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of herpes simplex virus eye disease
• Immunocompromised state
• Vesicular rash on eyelids or nose
• Membrane or pseudomembrane formation

Critical Pitfalls to Avoid

• Never prescribe "just in case" antibiotics for viral conjunctivitis—this increases antibiotic resistance without benefit 2
• Avoid indiscriminate use of topical corticosteroids—they can prolong adenoviral infections, worsen HSV infections, and cause increased intraocular pressure and cataracts 1, 3
• Contact lens wear should be avoided during any form of infectious conjunctivitis 3, 5, 6
• In children with sexually transmitted conjunctivitis, consider child abuse and make appropriate reports 1
• Chronic and/or recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma) and requires further evaluation 3