Treatment of Conjunctivitis
Treatment of conjunctivitis must be tailored to the specific etiology: viral conjunctivitis requires only supportive care, bacterial conjunctivitis may benefit from topical antibiotics in moderate-to-severe cases, and allergic conjunctivitis responds to topical antihistamines with mast cell-stabilizing properties. 1
Initial Assessment and Red Flags
Before initiating treatment, immediately refer to ophthalmology if any of the following are present 1:
- Visual loss
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement
- Conjunctival scarring
- History of HSV eye disease
- Immunocompromised state
- Lack of response to initial therapy
- Recurrent episodes
In children with gonococcal or chlamydial conjunctivitis, sexual abuse must be considered and appropriate reporting initiated. 2
Viral Conjunctivitis
Viral conjunctivitis is the most common cause overall (80% of acute cases) and requires only supportive care, as it is self-limiting. 3, 4
Supportive measures include 1, 5:
- Cold compresses
- Refrigerated artificial tears
- Topical antihistamines for symptomatic relief
- Strict hand hygiene to prevent transmission
Avoid topical antibiotics and corticosteroids in viral conjunctivitis, as they can prolong adenoviral infections and worsen HSV infections. 1
Bacterial Conjunctivitis
Uncomplicated Cases
Most uncomplicated bacterial conjunctivitis is self-limiting and resolves in 1-2 weeks without treatment. 3 Clinical features suggesting bacterial etiology include matted eyelids on waking, mucopurulent discharge, and absence of itching 3.
For moderate-to-severe cases, topical antibiotics shorten duration and allow earlier return to work/school 6, 3:
- First-line: Broad-spectrum fluoroquinolone (moxifloxacin 0.5%) three times daily for 5-7 days 6
- Alternative: Aminoglycosides or bacitracin ointment 1-3 times daily 7
- Clean eyelids with warm water before applying medication 6
Patients should return in 3-4 days if no improvement occurs. 2, 1
Special Bacterial Etiologies Requiring Systemic Treatment
Gonococcal conjunctivitis requires systemic antibiotics plus daily follow-up until resolution. 2, 1 Add saline lavage for comfort and topical antibiotics if corneal involvement is present 2. Sexual contacts must be treated concurrently 1.
Chlamydial conjunctivitis requires systemic antibiotics because >50% of infants have infection at other sites (nasopharynx, genital tract, lungs). 2, 1 Topical therapy adds no benefit 2. Sexual contacts must be treated simultaneously 1. In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 2, 1.
MRSA Considerations
In nursing home residents or cases not responding to standard therapy, consider MRSA and obtain cultures to guide therapy, which may require compounded vancomycin. 2, 6
Allergic Conjunctivitis
Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for allergic conjunctivitis. 1 Itching is the most consistent sign 3.
Treatment algorithm 1:
- First-line: Simple measures including sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears
- Second-line: Topical antihistamines with mast cell-stabilizing properties
- Persistent/recurrent cases: Add dedicated mast cell stabilizers
- Severe cases: Brief course (1-2 weeks) of low side-effect profile topical corticosteroids
Identify and avoid triggering allergens 1.
Contact Lens Wearers
Discontinue contact lens use until complete resolution in all cases of conjunctivitis. 1 Contact lens wearers with bacterial conjunctivitis require antibiotic treatment due to risk of serious complications 3.
Prevention and Hygiene
Strict hand hygiene is essential to prevent transmission. 5 Do not share towels, pillows, or cosmetics 1.
Common Pitfalls to Avoid
- Never use topical corticosteroids indiscriminately, as they prolong adenoviral infections and worsen HSV infections 1
- Do not prescribe topical antibiotics for viral conjunctivitis 1
- Always consider and report suspected child abuse in children with sexually transmitted conjunctivitis 1
- Do not miss gonococcal or chlamydial conjunctivitis, which require systemic treatment 2, 1