What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis (Pink Eye)

Most cases of conjunctivitis are viral and self-limiting, requiring only supportive care with artificial tears and cold compresses, while bacterial conjunctivitis can be treated with topical antibiotics (though many cases resolve without treatment), and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing properties. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, immediately refer to ophthalmology if any of the following are present:

• Visual loss or decreased vision 1, 2
• Moderate to severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 1, 2
• Corneal involvement (fluorescein staining showing epithelial defects) 1, 2
• Severe purulent discharge 1, 2
• Conjunctival scarring or membrane formation 1, 2
• History of HSV eye disease 1, 2
• Immunocompromised state 1, 2
• Lack of response to therapy after 3-4 days 1, 2
• Recurrent episodes 1, 2

Treatment by Type

Viral Conjunctivitis (Most Common)

Viral conjunctivitis accounts for 80% of acute conjunctivitis cases and requires only supportive care—no antibiotics. 3, 4

Treatment approach:

• Artificial tears for symptomatic relief 2, 5
• Cold compresses 2, 5
• Topical antihistamines for symptomatic relief (not for treatment, but comfort) 2
• Avoid topical corticosteroids as they can prolong adenoviral infections and worsen HSV infections 2

Key clinical features:

• Watery discharge (not mucopurulent) 5
• Preauricular lymphadenopathy 2
• Often concurrent upper respiratory infection 2

Critical infection control:

• Hand washing is the single most important preventive measure 2
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 2
• Avoid sharing towels, pillows, or personal items 2, 6
• Patients may return to work/school after 24-48 hours if symptoms improving 6

Bacterial Conjunctivitis

For uncomplicated bacterial conjunctivitis, initiate empiric broad-spectrum topical antibiotic therapy for 5-7 days, selecting the most convenient or least expensive option since no clinical evidence suggests superiority of any particular antibiotic. 2, 6

FDA-approved topical antibiotics:

• Erythromycin ophthalmic ointment applied 1-3 times daily 7
• Bacitracin ophthalmic ointment applied 1-3 times daily 8

Alternative when antibiotic access is limited:

• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics 2, 6

Key clinical features:

• Mucopurulent discharge with eyelids matted shut on waking 5, 3
• More common in children 5
• Lack of itching 3

Follow-up:

• Instruct patients to return in 3-4 days if no improvement noted 1, 2, 6
• Most uncomplicated cases resolve in 1-2 weeks 3

Important caveat: Many cases of bacterial conjunctivitis are self-limiting and resolve without antibiotics in 1-2 weeks, but topical antibiotics decrease duration and allow earlier return to school/work 3

Gonococcal Conjunctivitis (Medical Emergency)

Gonococcal conjunctivitis requires immediate systemic antibiotics plus topical therapy, with daily follow-up until resolution. 1, 2

• Systemic antibiotic therapy is mandatory (see specific regimens in guidelines) 1
• Saline lavage promotes comfort and rapid resolution 1
• Hospitalization may be necessary, and is mandatory for neonatal cases 2
• If corneal involvement present, treat as bacterial keratitis 1
• Treat sexual contacts concurrently 1, 2
• Consider sexual abuse in children 1

Chlamydial Conjunctivitis

Chlamydial conjunctivitis requires systemic antibiotic therapy because more than 50% of infants have infection at other sites (nasopharynx, genital tract, lungs). 1, 2

• Systemic antibiotics are indicated (topical therapy alone is insufficient) 1
• Treatment failure rate can be as high as 19%—re-evaluate following treatment 1
• Treat sexual contacts concurrently 1, 2
• Consider sexual abuse in children 1
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1, 2

Key clinical features:

• Follicular conjunctivitis persisting for several weeks 1

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for allergic conjunctivitis. 2

Treatment algorithm:

1. First-line therapy:

   • Topical antihistamines with mast cell-stabilizing activity 2
   • Simple environmental measures: wearing sunglasses as barriers to airborne allergens 2
   • Cold compresses 2
   • Refrigerated artificial tears 2

2. For persistent or recurrent cases:

   • Mast cell stabilizers 2

3. For severe cases:

   • Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile 2

Key clinical features:

• Itching is the most consistent sign 3
• Watery discharge 5
• Encountered in up to 40% of population 3

Critical Pitfalls to Avoid

• Do not use indiscriminate topical antibiotics or corticosteroids as they can induce toxicity, prolong adenoviral infections, and worsen HSV infections 2
• Do not use systemic antibiotics for uncomplicated bacterial conjunctivitis 6
• Consider culture and sensitivity testing in moderate to severe cases or treatment failures, particularly if gonococcal infection suspected 6
• Failing to assess for child abuse is critical—sexually transmitted conjunctivitis in children mandates consideration of abuse and appropriate reporting 2
• If corticosteroids are used, baseline and periodic IOP measurement and pupillary dilation should be performed to evaluate for glaucoma and cataract 1

Contact Lens Wearers

• Discontinue contact lens use until complete resolution 2
• Consider switching to daily-wear disposables or changing contact lens polymer 1