Treatment of Conjunctivitis
Treatment Must Be Tailored to the Specific Etiology
The treatment of conjunctivitis depends entirely on identifying whether the cause is viral, bacterial, or allergic, as each requires a fundamentally different approach: viral cases receive supportive care only, bacterial cases may benefit from topical antibiotics in moderate-to-severe presentations, and allergic cases respond to topical antihistamines with mast cell-stabilizing activity. 1
Viral Conjunctivitis: Supportive Care Only
Primary Management
- Viral conjunctivitis is self-limited and requires no antimicrobial treatment - the majority of cases resolve within 5-14 days without intervention 1, 2
- Provide symptomatic relief with artificial tears (refrigerated for added comfort), cold compresses, and topical antihistamines for itching 1, 2
- Avoid topical antibiotics entirely - they provide no benefit and may cause unnecessary toxicity 2
Critical Warning About Corticosteroids
- Never use topical corticosteroids indiscriminately - they can prolong adenoviral shedding, worsen herpes simplex virus infections, and cause elevated intraocular pressure and cataracts 1, 2
- Corticosteroids may be considered only in severe cases with marked chemosis, lid swelling, or subepithelial infiltrates, but require close ophthalmology follow-up with regular IOP monitoring 2
Infection Control
- Hand washing is the single most important preventive measure - patients should minimize contact with others for 10-14 days from symptom onset 1, 2
- Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 1
- Avoid sharing towels, pillows, or cosmetics 1
Bacterial Conjunctivitis: Selective Antibiotic Use
Mild Cases
- Mild bacterial conjunctivitis is usually self-limited and may resolve without treatment in 1-2 weeks 1, 3
- Topical antibiotics may decrease duration but are not mandatory for uncomplicated cases 1, 3
Moderate-to-Severe Cases
- Prescribe a 5-7 day course of broad-spectrum topical antibiotic (e.g., fluoroquinolones, polymyxin B/trimethoprim) 2
- No specific topical antibiotic has proven superiority - choose based on convenience and cost 2
- Typical dosing: 1-2 drops every 2-4 hours for days 1-2, then four times daily for days 3-7 4
Follow-Up
- Patients should return if no improvement after 3-4 days of antibiotic treatment 1
Special Bacterial Pathogens Requiring Systemic Treatment
Gonococcal Conjunctivitis
- Requires immediate systemic antibiotics (ceftriaxone) plus topical therapy - this is a medical emergency 1, 5
- Hospitalization may be necessary for parenteral therapy with daily follow-up until resolution 1, 5
- Can cause corneal perforation if untreated 2
- Sexual contacts must be treated concurrently 1
Chlamydial Conjunctivitis
- Requires systemic antibiotic therapy - topical treatment alone is inadequate, as >50% of infants have infection at other sites 1, 2
- Evaluate and treat sexual contacts 1, 2
- In low-resource settings, povidone-iodine 1.25% ophthalmic solution can be used 1
Meningococcal Conjunctivitis
- All suspected cases require immediate systemic antibiotics (ceftriaxone) to prevent invasive meningococcal disease 5
- Add topical fluoroquinolone (moxifloxacin 0.5% or levofloxacin 0.5%) four times daily for 5-7 days 5
- Close contacts require antibiotic chemoprophylaxis 5
Allergic Conjunctivitis: Antihistamines and Environmental Modifications
First-Line Treatment
- Topical antihistamines with mast cell-stabilizing activity (olopatadine, ketotifen) are the treatment of choice 1, 2
- These agents are more effective than oral antihistamines for ocular symptoms 2
Adjunctive Measures
- Environmental modifications: wear sunglasses as barriers to airborne allergens, use cold compresses, apply refrigerated artificial tears 1
- Avoid eye rubbing 2
- Identify and avoid triggering allergens 1
Persistent or Severe Cases
- Mast cell stabilizers can be used for persistent or recurrent cases 1
- Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile may be added in severe cases 1, 2
- Consider allergen-specific immunotherapy for refractory cases, particularly in children 2
Contact Lens Wearers: Special Considerations
- Discontinue contact lens wear immediately until complete resolution of any form of conjunctivitis 1, 3
- Contact lens-associated bacterial conjunctivitis should be treated with antibiotics 3
Immediate Ophthalmology Referral Required For:
- Visual loss or decreased vision 1, 2
- Moderate or severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 1, 2
- Severe purulent discharge 1
- Corneal involvement (fluorescein staining showing epithelial defects) 1, 2
- Conjunctival scarring 1
- Lack of response to therapy 1
- Recurrent episodes 1
- History of herpes simplex virus eye disease 1, 2
- Immunocompromised state 1, 2
- Neonatal conjunctivitis (mandatory hospitalization) 1, 5
Key Clinical Differentiators
Viral vs. Bacterial
- Viral: watery discharge, follicular reaction on inferior tarsal conjunctiva, preauricular lymphadenopathy, often concurrent upper respiratory infection 1, 2
- Bacterial: mucopurulent discharge with matted eyelids on waking, papillary (not follicular) reaction, lack of itching 2, 3
Allergic
- Bilateral presentation with itching as the most consistent feature, watery discharge, absence of preauricular lymphadenopathy and matted eyelids 2
Critical Pitfalls to Avoid
- Never use combination antibiotic-corticosteroid preparations unless conjunctivitis is proven to be non-herpetic 6
- Do not miss sexually transmitted conjunctivitis in children - mandates consideration of sexual abuse and appropriate reporting 1
- Chronic/recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma) and requires further evaluation 2