Treatment of Conjunctivitis
Treatment of conjunctivitis must be directed at 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 activity. 1
Immediate Red Flags Requiring Ophthalmology Referral
Before initiating treatment, rule out conditions requiring urgent specialist evaluation:
- Visual loss or decreased vision 1, 2
- Moderate or severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 3, 1
- Severe purulent discharge (raises concern for gonococcal infection) 1
- Corneal involvement (fluorescein staining shows epithelial defects) 3, 1
- Conjunctival scarring 3, 1
- Lack of response to therapy after 3-4 days 1
- History of HSV eye disease 3, 1
- Immunocompromised state 3, 1
- Recurrent episodes 3
Viral Conjunctivitis
Clinical Features
- Watery discharge with follicular reaction on inferior tarsal conjunctiva 2
- Preauricular lymphadenopathy 3, 2
- Often starts unilateral but becomes sequentially bilateral 2
- May have concurrent upper respiratory infection 3
- Subconjunctival hemorrhages and chemosis are distinctive findings 2
Treatment Approach
Viral conjunctivitis is self-limited and requires only supportive care—antibiotics provide no benefit and should be avoided. 1, 2
- Artificial tears (refrigerated for additional cooling relief) 3, 1
- Cold compresses 3, 1
- Topical antihistamines for symptomatic relief 2
- Patient education: highly contagious for 10-14 days from symptom onset 2
- Strict hand hygiene and avoid sharing towels/pillows 2
Critical Pitfall
Never use topical corticosteroids indiscriminately—they prolong adenoviral infections and can worsen HSV infections. 3, 1, 2 Corticosteroids may be considered only in severe cases with pseudomembranes or marked chemosis, but require close ophthalmology follow-up for monitoring intraocular pressure and cataract formation 2.
Bacterial Conjunctivitis
Clinical Features
- Mucopurulent discharge with matted eyelids on waking 2, 4
- Papillary reaction (not follicular) 2
- Lack of itching and absence of preauricular lymphadenopathy (unless hypervirulent organisms) 2, 4
- May be associated with otitis media, sinusitis, or pharyngitis in children 2
Treatment Approach
Mild bacterial conjunctivitis is self-limited and may resolve without antibiotics, but moderate-to-severe cases benefit from a 5-7 day course of broad-spectrum topical antibiotics. 1, 2
- Topical antibiotics: No single agent is superior—choose based on cost and convenience 2
- Re-evaluate if no improvement after 3-4 days 1
Special Bacterial Pathogens
Gonococcal Conjunctivitis
Gonococcal conjunctivitis requires immediate systemic antibiotics (ceftriaxone) plus topical therapy, with daily follow-up until resolution—this is a vision-threatening emergency that can cause corneal perforation. 1, 7, 2
- Hospitalization may be necessary for parenteral therapy 3, 1
- Treat sexual contacts concurrently 3, 1
- Mandatory hospitalization for neonates 3, 1
Chlamydial Conjunctivitis
Chlamydial conjunctivitis requires systemic antibiotic therapy because topical treatment alone is inadequate—more than 50% of infants have infection at other sites. 1, 2
- Systemic antibiotics mandatory 1
- Treat sexual contacts concurrently 3, 1
- In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 3, 1
- Consider sexual abuse in children with sexually transmitted conjunctivitis 3, 1
Allergic Conjunctivitis
Clinical Features
- Itching is the most consistent and distinguishing feature 2, 4
- Bilateral presentation with watery discharge 2
- No preauricular lymphadenopathy or matted eyelids 2
- May have concurrent allergic rhinitis or asthma 2
Treatment Approach
Topical antihistamines with mast cell-stabilizing activity are first-line treatment for allergic conjunctivitis. 1, 2
Environmental Modifications
- Wear sunglasses as barrier to airborne allergens 3, 1
- Cold compresses and refrigerated artificial tears 3, 1
- Avoid eye rubbing 3
- Hypoallergenic bedding, frequent clothes washing, showering before bedtime 3
Pharmacologic Treatment
- First-line: Topical antihistamines with mast cell-stabilizing properties (olopatadine, ketotifen) 1, 2
- For persistent/recurrent cases: Mast cell stabilizers 3, 1
- Severe cases: Brief 1-2 week course of topical corticosteroids with low side-effect profile 3, 1, 2
- Oral antihistamines may worsen dry eye syndrome and should be used cautiously 3
Critical Pitfall
Chronic use of vasoconstrictor agents causes rebound vasodilation once stopped. 2
Infection Control Measures
Hand washing is the single most important measure to prevent transmission of infectious conjunctivitis. 3, 2
- Avoid sharing towels, pillows, or cosmetics 1
- Contact lens wearers must discontinue use until complete resolution 1
- Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 3
- Return to school/work depends on type and severity—viral conjunctivitis patients should minimize contact for 10-14 days 2
Follow-Up Recommendations
- Bacterial conjunctivitis: Return if no improvement after 3-4 days of antibiotics 1
- Viral conjunctivitis: Return if symptoms persist beyond 2-3 weeks 2
- Severe cases with corneal involvement: Re-evaluate within 1 week 2
- Patients on topical corticosteroids: Regular monitoring of intraocular pressure and periodic pupillary dilation 2
Critical Pitfalls to Avoid
- Never use antibiotics for viral conjunctivitis—they provide no benefit and cause unnecessary toxicity 1, 2
- Never use topical corticosteroids without ruling out HSV—they worsen herpetic infections 3, 1, 2
- Never miss gonococcal conjunctivitis—it requires immediate systemic treatment to prevent corneal perforation 2
- Never forget to consider sexual abuse in children with sexually transmitted conjunctivitis 3, 1
- Chronic/recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma) and requires further evaluation 2