What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment of conjunctivitis must be tailored to the specific etiology—viral conjunctivitis requires only supportive care without antibiotics, bacterial conjunctivitis may benefit from topical antibiotics in moderate-to-severe cases, and allergic conjunctivitis responds to topical antihistamines with mast cell-stabilizing activity. 1

Initial Diagnostic Approach

The key to appropriate treatment is accurate differentiation of conjunctivitis type based on clinical features:

Viral Conjunctivitis Features

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 2
• Often starts unilateral but becomes sequentially bilateral 2
• Preauricular lymphadenopathy commonly present 2
• May have concurrent upper respiratory infection 2
• Subconjunctival hemorrhages and chemosis may be present 2

Bacterial Conjunctivitis Features

• Mucopurulent discharge with matted eyelids on waking 2
• Papillary (not follicular) reaction 2
• Preauricular lymphadenopathy less common unless hypervirulent organisms 2
• May have concurrent otitis media, sinusitis, or pharyngitis in children 2

Allergic Conjunctivitis Features

• Itching is the most consistent and distinguishing feature 2
• Bilateral presentation with watery discharge 2
• No preauricular lymphadenopathy or matted eyelids 2
• Often seasonal or perennial pattern with concurrent allergic rhinitis or asthma 2

Treatment by Etiology

Viral Conjunctivitis Management

Avoid antibiotics entirely—they provide no benefit and may cause unnecessary toxicity. 1, 2

Supportive care measures:

• Artificial tears applied frequently throughout the day for symptomatic relief 1, 3
• Cold compresses to closed eyelids to reduce discomfort and inflammation 1, 3
• Topical antihistamines may be used if itching is prominent 1, 3
• Self-limited course, typically resolving within 5-14 days 2, 3

Patient education on contagiousness:

• Encourage frequent handwashing with soap and water 1, 3
• Avoid touching or rubbing eyes 3
• Do not share towels, washcloths, pillows, or face-contacting items 1, 3
• Disinfect frequently touched surfaces with EPA-registered hospital disinfectant 1, 3
• Patients remain contagious for 10-14 days from symptom onset 1, 3
• Children may return to school after 24-48 hours once symptoms are improving and discharge is minimal 3

Topical corticosteroids:

• Should be avoided in routine mild cases 3
• May be considered only for severe cases with corneal involvement or pseudomembranes under ophthalmology supervision 1, 2
• Can prolong viral shedding and worsen HSV infections if misdiagnosed 1, 2, 3
• Require regular monitoring of intraocular pressure and periodic pupillary dilation 1, 2

Bacterial Conjunctivitis Management

Mild bacterial conjunctivitis is usually self-limited and may resolve without specific treatment. 2

For moderate-to-severe bacterial conjunctivitis:

• Prescribe a 5-7 day course of broad-spectrum topical antibiotic 2
• No evidence demonstrates superiority of any particular topical antibiotic agent 2
• Moxifloxacin 0.5%: one drop in affected eye 3 times daily for 7 days 4
• Azithromycin 1%: one drop twice daily (8-12 hours apart) for first 2 days, then once daily for next 5 days 5
• Topical antibiotics may decrease duration of infection and allow earlier return to school or work 2, 6

Special considerations requiring systemic antibiotics:

• Gonococcal conjunctivitis requires systemic antibiotics in addition to topical therapy 1, 2

• Daily follow-up until resolution is mandatory 1

• Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 1

• Can lead to corneal perforation if untreated 2

• Chlamydial conjunctivitis requires systemic antibiotic therapy 1, 2

• More than 50% of infants may have infection at other sites 1

• Sexual contacts must be treated concurrently 1, 2

• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1

Follow-up:

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

Allergic Conjunctivitis Management

Topical antihistamines with mast cell-stabilizing properties are the treatment of choice. 1, 2

Environmental modifications:

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

Pharmacologic treatment:

• First-line: topical antihistamines with mast cell-stabilizing activity (e.g., olopatadine, ketotifen) 1, 2
• For persistent or recurrent cases: mast cell stabilizers 1
• Oral antihistamines are less effective than topical agents for ocular symptoms 2

Severe or refractory cases:

• Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile may be added 1, 2
• Allergen-specific immunotherapy is beneficial, particularly in children 2
• Multidisciplinary approach with pediatricians, internists, and allergists recommended 2

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 (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
• Symptoms persisting beyond 2-3 weeks

Common Pitfalls to Avoid

Do not prescribe antibiotics for viral conjunctivitis—this increases antibiotic resistance without benefit. 1, 2, 3

Do not use topical corticosteroids indiscriminately:

• Can prolong adenoviral infections 1, 2
• Can worsen HSV infections if misdiagnosed 1, 2, 3
• Require close ophthalmology follow-up for IOP monitoring 1, 2, 3

Do not allow contact lens wear during any form of infectious conjunctivitis. 1, 2

Do not miss sexually transmitted conjunctivitis in children—this mandates consideration of abuse and appropriate reporting. 1

Do not keep children home from school indefinitely—transmission risk drops significantly after 24-48 hours with good hygiene. 3

Avoid chronic use of topical vasoconstrictor agents—can cause rebound hyperemia. 2