What are the treatment options for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

Treatment for pink eye depends entirely on the underlying cause: topical broad-spectrum antibiotics for bacterial conjunctivitis, topical antihistamines with mast cell-stabilizing properties for allergic conjunctivitis, and supportive care only for viral conjunctivitis. 1, 2

Initial Classification by Clinical Presentation

The first step is determining the type of conjunctivitis based on key clinical features:

• Bacterial conjunctivitis: Yellow crusting around the eyes, mucopurulent discharge, eyelids matted shut upon waking, absence of itching 3, 4
• Viral conjunctivitis: Watery discharge, burning/gritty sensation, often preceded by upper respiratory infection 4, 5
• Allergic conjunctivitis: Bilateral itching (most consistent sign), watery discharge, seasonal pattern 6, 7

Treatment by Type

Bacterial Conjunctivitis

Mild cases are self-limited and resolve spontaneously in 1-2 weeks without treatment in immunocompetent adults 3, 6

Moderate to severe cases (copious purulent discharge, marked inflammation):

• Prescribe a 5-7 day course of broad-spectrum topical antibiotic 1, 3
• Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective against common pathogens including S. aureus, S. pneumoniae, and H. influenzae 2
• Alternative options include bacitracin ointment applied 1-3 times daily 8 or erythromycin ointment 9
• No single antibiotic has proven superiority over another; choice can be based on dosing convenience, cost, and local resistance patterns 2
• Instruct patients to clean eyelids with warm water before applying medication 3
• Advise return if no improvement after 3-4 days 1, 3

Special bacterial cases requiring systemic antibiotics:

• Gonococcal conjunctivitis: Ceftriaxone 250 mg IM single dose plus azitromicin 1 g oral single dose; requires daily follow-up until resolution 1, 2
• Chlamydial conjunctivitis: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days; treat sexual contacts concurrently 1, 3, 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can substitute for chlamydial treatment 10, 1

Viral Conjunctivitis

No specific antiviral treatment exists for adenoviral conjunctivitis (80% of viral cases) 5, 7

Supportive care includes:

• Refrigerated preservative-free artificial tears 4 times daily to dilute viral particles 2
• Cold compresses 1, 3
• Topical antihistamines for symptomatic relief of itching 2
• Avoid topical antibiotics as they provide no benefit and risk toxicity 3, 2
• Avoid topical corticosteroids as they can prolong adenoviral infections 1, 3

Herpes simplex virus (HSV) conjunctivitis requires specific treatment:

• Topical ganciclovir 0.15% gel OR topical trifluridine 1% solution 2
• Oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used 2
• Never use topical corticosteroids without antiviral coverage as they potentiate HSV infection 2

Allergic Conjunctivitis

First-line treatment:

• Topical antihistamines with mast cell-stabilizing properties (e.g., olopatadine, ketotifen) are the treatment of choice 1, 3, 2
• Simple measures: sunglasses as allergen barriers, cold compresses, refrigerated artificial tears 1, 3

Persistent or recurrent cases:

• Mast cell stabilizers (cromolyn sodium) for prophylaxis 1, 3

Severe cases:

• Brief 1-2 week course of low side-effect profile topical corticosteroids (fluorometholone, loteprednol, or rimexolone) 1, 3
• Monitor intraocular pressure and for cataract formation if corticosteroids are used 3, 2

Infection Control Measures

• Strict handwashing with soap and water to prevent transmission 2
• Avoid sharing towels, pillows, or cosmetics 1
• Discontinue contact lens wear until complete resolution 1, 3
• Discard multiple-dose eyedrop containers to avoid cross-contamination 2
• Viral conjunctivitis patients should avoid close contact for 7-14 days from symptom onset 2

Mandatory Ophthalmology Referral

Immediate referral is required for: 10, 1, 3

• Visual loss
• 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
• Neonatal conjunctivitis (mandatory hospitalization) 1, 2

Critical Pitfalls to Avoid

• Failing to treat sexual contacts concurrently in gonococcal or chlamydial conjunctivitis leads to reinfection 1, 3
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis; reporting may be mandatory 10, 1
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage worsens infection 3, 2
• Indiscriminate antibiotic use in viral conjunctivitis causes unnecessary toxicity 1, 3
• Prolonged trifluridine use (>2 weeks) causes epithelial toxicity 2
• Chronic vasoconstrictor use causes rebound vasodilation 3
• Oral antihistamines may worsen dry eye syndrome 3