What are the management options for conjunctivitis?

Management of Conjunctivitis

Determine Etiology First

The management of conjunctivitis depends entirely on identifying whether the cause is viral, bacterial, or allergic, as treatment differs fundamentally between these etiologies. 1

Key Clinical Differentiators

Viral conjunctivitis typically presents with:

• Watery discharge with abrupt onset 1
• Follicular reaction on inferior tarsal conjunctiva 1
• Preauricular lymphadenopathy 1
• Often starts unilateral but becomes sequentially bilateral 1
• Concurrent upper respiratory infection common 1

Bacterial conjunctivitis characteristically shows:

• Mucopurulent or purulent discharge with matted eyelids 1
• Papillary (not follicular) reaction 1
• Can be unilateral or bilateral 1
• May have concurrent otitis media, sinusitis, or pharyngitis in children 1

Allergic conjunctivitis is distinguished by:

• Itching as the most consistent and distinguishing feature 1
• Bilateral presentation 1
• Watery discharge 1
• Absence of preauricular lymphadenopathy and matted eyelids 1
• Often seasonal or perennial pattern 1

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Treatment Algorithm by Etiology

Viral Conjunctivitis

Avoid antibiotics entirely for viral conjunctivitis, as they provide no benefit and may cause unnecessary toxicity. 1

Supportive care only:

• Artificial tears for symptomatic relief 1
• Cold compresses 1
• Topical antihistamines for symptomatic relief 1

Patient education is critical:

• Highly contagious for 10-14 days from symptom onset 1
• Strict hand hygiene with soap and water 1
• Avoid sharing towels, pillows, or personal items 1
• Disinfect surfaces with EPA-registered hospital disinfectant 1

For severe cases with marked chemosis and lid swelling:

• Consider short course of topical corticosteroids with extreme caution 1
• Requires close ophthalmology follow-up for monitoring intraocular pressure and cataract formation 1
• May prolong viral shedding and worsen HSV infections 1
• Re-evaluate within 1 week if severe 1

Duration: Self-limited, typically resolving within 5-14 days 1

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Bacterial Conjunctivitis

Mild bacterial conjunctivitis:

• Usually self-limited and may resolve without treatment 1
• Topical antibiotics may decrease duration but are not mandatory 1, 2

Moderate to severe bacterial conjunctivitis:

• 5-7 day course of broad-spectrum topical antibiotic is recommended 1
• No evidence demonstrates superiority of any particular topical antibiotic 1
• Choose based on convenience and cost 1

FDA-approved topical fluoroquinolones for children >12 months include:

• Levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, or besifloxacin 3
• Administer 4 times daily for 5-7 days 3
• Moxifloxacin produces clinical cure in 66-69% by Day 5-6 with microbiological success rates of 84-94% 4

Follow-up:

• Return for evaluation if no improvement after 3-4 days 5, 3
• Consider alternative diagnoses or resistant organisms if no response 3

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Allergic Conjunctivitis

First-line treatment:

• Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1, 5
• Most effective for ocular symptoms 1

Environmental modifications:

• Wear sunglasses as barriers to airborne allergens 1, 5
• Cold compresses and refrigerated artificial tears 1, 5
• Avoid eye rubbing 1
• Identify and avoid allergen triggers 5

For persistent or recurrent cases:

• Mast cell stabilizers can be used 5

For severe refractory cases:

• Brief 1-2 week course of topical corticosteroids with low side-effect profile 1, 5

For severe cases:

• Consider allergen-specific immunotherapy, more beneficial in children than adults 1
• Multidisciplinary approach with pediatricians, internists, and allergists 1

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Special Situations Requiring Systemic Treatment

Gonococcal Conjunctivitis

Requires immediate systemic antibiotics in addition to topical therapy:

• Presents with marked eyelid edema, bulbar conjunctival injection, and purulent discharge 1
• Can lead to corneal infiltrate, ulcer, or perforation 1
• Hospitalization necessary for parenteral therapy 1
• Daily follow-up until resolution 5
• Treat sexual contacts concurrently 5
• In children, mandatory consideration of sexual abuse 3

Chlamydial Conjunctivitis

Requires systemic antibiotic therapy:

• Topical therapy alone is inadequate 1, 5
• More than 50% of infants may have infection at other sites 5
• Evaluate and treat sexual partners 1, 5
• In children, consider sexual abuse 3
• PCR or immunofluorescent antibody testing for confirmation 1
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 5

Herpes Simplex Virus Conjunctivitis

Distinctive features:

• Usually unilateral (bilateral in atopic, pediatric, or immunocompromised patients) 1
• Vesicular rash or ulceration of eyelids 1
• Dendritic epithelial keratitis of cornea 1
• Requires ophthalmology referral 1

Neonatal Conjunctivitis

Always requires immediate treatment and evaluation:

• Risk of serious complications including corneal perforation, septicemia, and meningitis 3
• Hospitalization mandatory 5
• Gonococcal (1-7 days after birth): systemic ceftriaxone 125 mg IM plus topical antibiotics with daily follow-up 3

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Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present:

• Visual loss or decreased vision 1, 5
• Moderate or severe pain 1, 5
• Severe purulent discharge 1, 5
• Corneal involvement 1, 5, 3
• Conjunctival scarring 1, 5
• Lack of response to therapy after 3-4 days 1, 5
• Recurrent episodes 1, 5
• History of HSV eye disease 1, 5
• Immunocompromised state 1, 5
• Pseudomembranes or membrane formation 1

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Common Pitfalls to Avoid

Indiscriminate antibiotic use:

• Viral conjunctivitis will not respond to antibacterial agents 1
• Can cause unnecessary toxicity 1, 5
• May lead to bacterial resistance 3

Inappropriate corticosteroid use:

• Should not be used without close ophthalmology follow-up 1
• Can prolong adenoviral infections 1, 5
• Worsen HSV infections 1, 5
• Cause increased intraocular pressure and cataracts 1
• Requires regular IOP monitoring and periodic pupillary dilation 1

Contact lens wear:

• Avoid during any form of infectious conjunctivitis 1
• Suspend use until complete resolution 5

Inadequate patient education:

• Failure to educate about contagiousness leads to community spread 1

Missing gonococcal conjunctivitis:

• Can cause corneal perforation and requires immediate systemic treatment 1

Failing to assess for child abuse:

• Sexually transmitted conjunctivitis in children mandates consideration of abuse and appropriate reporting 5

Chronic/recalcitrant conjunctivitis:

• May indicate underlying malignancy (sebaceous or squamous cell carcinoma) requiring further evaluation 1