What is the recommended treatment for a patient presenting with conjunctivitis (pink eye)?

Treatment for Pink Eye (Conjunctivitis)

Treatment depends entirely on the underlying cause—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 stabilizers. 1, 2

Determining the Etiology

Before treating, identify the type based on these key clinical features:

Viral Conjunctivitis

• Watery discharge with follicular reaction on the 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 are distinctive findings 2

Bacterial Conjunctivitis

• Mucopurulent discharge with matted eyelids upon waking 2, 3
• Papillary (not follicular) reaction 2
• Lack of itching 3
• May have concurrent otitis media, sinusitis, or pharyngitis in children 2

Allergic Conjunctivitis

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

Treatment by Etiology

Viral Conjunctivitis

Avoid antibiotics entirely—they provide no benefit and may cause toxicity. 4

• Supportive care only: artificial tears (preferably refrigerated and preservative-free) 4 times daily to dilute viral particles and inflammatory mediators 2, 4
• Cold compresses for symptomatic relief 1, 4
• Topical antihistamines may relieve itching and discomfort 2, 4
• Patient education is critical: highly contagious for 10-14 days from symptom onset; strict hand hygiene with soap and water, avoid sharing towels/pillows, disinfect surfaces 2, 4
• For severe cases with marked chemosis, lid swelling, or membranous conjunctivitis: consider short course (1-2 weeks) of topical corticosteroids with close ophthalmology follow-up for IOP monitoring 1, 4

Special consideration for HSV conjunctivitis:

• Topical ganciclovir 0.15% gel or trifluridine 1% solution 4
• Oral antivirals (acyclovir, valacyclovir, or famciclovir) 4
• Never use topical corticosteroids without antiviral coverage—they potentiate HSV infection 4

Bacterial Conjunctivitis

Mild cases are self-limited and may resolve without treatment, but topical antibiotics shorten duration. 2

• For moderate-to-severe cases: 5-7 day course of broad-spectrum topical antibiotic 2, 4
• Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) are effective against common pathogens including S. aureus, S. pneumoniae, and H. influenzae 4
• No evidence demonstrates superiority of any specific agent—choose based on dosing convenience, cost, and local resistance patterns 4
• Consider MRSA in nursing home patients or community-acquired infections; may require compounded vancomycin 4

Special considerations requiring systemic therapy:

• Gonococcal conjunctivitis: Ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose; requires daily monitoring until resolution and can cause corneal perforation if untreated 4
• Chlamydial conjunctivitis: Azithromycin 1 g oral single dose or doxycycline 100 mg oral twice daily for 7 days; topical therapy alone is inadequate 4
• Both require evaluation and treatment of sexual partners 2, 4

Allergic Conjunctivitis

Second-generation topical antihistamines with mast cell-stabilizing properties are first-line treatment. 1, 4

• Environmental modifications: sunglasses as allergen barrier, cold compresses, refrigerated preservative-free artificial tears, avoid eye rubbing 1
• Topical antihistamine/mast cell stabilizers (olopatadine, ketotifen) 1, 4
• If symptoms persist: brief 1-2 week course of low side-effect profile topical corticosteroids with IOP monitoring 1, 4
• Avoid chronic use of vasoconstrictor agents—associated with rebound vasodilation 1
• Oral antihistamines may worsen dry eye syndrome and impair tear film 1

Critical Red Flags Requiring Immediate Ophthalmology Referral

• Visual loss or decreased vision 2, 4
• Moderate or severe pain 2, 4
• Severe purulent discharge 2, 4
• Corneal involvement 2, 4
• History of HSV eye disease 2, 4
• Immunocompromised state 2, 4
• Neonatal conjunctivitis (requires systemic treatment) 4
• Contact lens wearers (evaluate for corneal ulcer) 2

Common Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately—they prolong adenoviral infections, worsen HSV infections, and can cause elevated IOP and cataracts 2, 4
• Do not miss gonococcal conjunctivitis—delayed referral leads to corneal perforation and vision loss 4
• Avoid antibiotics for viral conjunctivitis—no benefit and contributes to resistance 4
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 4
• Discontinue contact lens wear during any infectious conjunctivitis 2

Follow-Up Recommendations

• Severe viral conjunctivitis: re-evaluate within 1 week 2
• Patients not on corticosteroids: return if symptoms persist beyond 2-3 weeks 2
• Patients on topical corticosteroids: regular IOP monitoring and periodic pupillary dilation 1, 2
• Gonococcal conjunctivitis: daily monitoring until resolution 4