What are the differences in management and treatment for a patient presenting with conjunctivitis of various etiologies, including viral, bacterial, allergic, or irritant-induced causes?

Conjunctivitis: Differences and Management

Immediate Diagnostic Approach

The most critical first step is distinguishing true conjunctivitis from vision-threatening conditions, then classifying by etiology (viral, bacterial, or allergic) based on discharge character, presence of follicles versus papillae, and associated symptoms. 1, 2

Red Flags Requiring Urgent Ophthalmology Referral

Before proceeding with conjunctivitis management, immediately refer if any of the following are present: 3, 2

• Visual loss or decreased vision 3
• Moderate to severe pain 3
• Severe purulent discharge 3
• Corneal involvement 3
• History of herpes simplex virus eye disease 3
• Immunocompromised state 3
• Recent ocular surgery 3
• Vesicular rash on eyelids or nose 3

Distinguishing Features by Etiology

Viral Conjunctivitis

Clinical presentation: 3, 2

• Watery discharge (not purulent) 3
• Follicular reaction on inferior tarsal conjunctiva 3, 2
• Abrupt onset, often starts unilateral but becomes sequentially bilateral within days 3, 2
• Preauricular lymphadenopathy (especially with adenovirus) 3
• Concurrent upper respiratory infection common 3
• Subconjunctival hemorrhages, chemosis, eyelid swelling may be present 3
• Self-limited course: 5-14 days 3

Bacterial Conjunctivitis

Clinical presentation: 3, 2

• Mucopurulent discharge with matted eyelids on waking 3, 2
• Papillary reaction (not follicular) 3, 2
• Unilateral or bilateral 3
• Lack of itching 4
• May be associated with otitis media, sinusitis, or pharyngitis in children 3
• Preauricular lymphadenopathy less common unless hypervirulent organism 3

Special high-risk bacterial forms requiring immediate systemic treatment: 3, 2

• Gonococcal conjunctivitis: Marked eyelid edema, severe hyperpurulent discharge, rapid progression, risk of corneal perforation—requires hospitalization for parenteral therapy 3, 2
• Chlamydial conjunctivitis: Follicular reaction in adults, requires systemic treatment and evaluation of sexual partners 3, 2

Allergic Conjunctivitis

Clinical presentation: 3, 2

• Itching is the most consistent and distinguishing feature 3, 2
• Bilateral presentation 3
• Watery discharge with mild mucous component 2
• Eyelid edema, periorbital hyperpigmentation 2
• Absence of preauricular lymphadenopathy 3
• Absence of matted eyelids 3
• Often seasonal or perennial depending on allergen 3
• May have concurrent allergic rhinitis or asthma 3

Management by Etiology

Viral Conjunctivitis Management

Avoid antibiotics entirely—they provide no benefit and may cause toxicity. 3

Treatment approach: 3

• Supportive care only: Artificial tears for symptomatic relief 3
• Cold compresses 5
• Topical antihistamines for symptomatic relief 3
• Patient education is critical: Highly contagious for 10-14 days from symptom onset 3
• Strict hand hygiene with soap and water 3
• Avoid sharing towels, pillows, personal items 3
• Disinfect surfaces with EPA-registered hospital disinfectant 3

For severe cases with marked chemosis and lid swelling: 3

• Consider short course of topical corticosteroids only with close ophthalmology follow-up 3
• Critical warning: Corticosteroids may prolong viral shedding, worsen HSV infections, cause elevated intraocular pressure and cataracts 3
• Requires regular monitoring of intraocular pressure and periodic pupillary dilation 3

Follow-up: 3

• Re-evaluate within 1 week if severe 3
• Return if symptoms persist beyond 2-3 weeks 3

Bacterial Conjunctivitis Management

Mild bacterial conjunctivitis is usually self-limited and may resolve without treatment, but topical antibiotics may decrease duration. 3

Treatment approach: 3

• For moderate to severe cases: 5-7 day course of broad-spectrum topical antibiotic 3
• No specific antibiotic is superior—choose the most convenient or least expensive option 3, 4
• Delayed antibiotic prescribing has similar symptom control as immediate prescribing 5
• Most uncomplicated cases resolve in 1-2 weeks 4

Special bacterial forms requiring systemic treatment: 3, 2

• Gonococcal: Hospitalization for parenteral therapy, daily follow-up until resolution, treatment of sexual contacts 3
• Chlamydial: Systemic therapy (topical alone is inadequate), treatment of sexual contacts, re-evaluation after treatment 3, 2
• Contact lens-related: Avoid contact lens wear during any infectious conjunctivitis 3

Important consideration: 3

• MRSA is increasingly isolated, but fluoroquinolones remain effective 3

Allergic Conjunctivitis Management

Topical antihistamines with mast cell-stabilizing activity are first-line treatment. 3, 2

Treatment approach: 3, 2

• First-line: Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 3
• Environmental modifications: 3
  • Wear sunglasses as barrier to airborne allergens 3
  • Use cold compresses and refrigerated artificial tears 3
  • Avoid eye rubbing 3
• Allergen avoidance 3
• Oral antihistamines as additional option (less effective than topical for ocular symptoms) 3

For refractory cases: 3

• Short-term corticosteroids: brief 1-2 week course with low side-effect profile 3
• Allergen-specific immunotherapy beneficial, especially in children 3
• Multidisciplinary approach with pediatricians, internists, and allergists 3

Common Pitfalls to Avoid

Critical errors that worsen outcomes: 3, 2

• Never use antibiotics indiscriminately for viral conjunctivitis—causes unnecessary toxicity without benefit 3
• Never use topical corticosteroids without close ophthalmology follow-up—risk of elevated intraocular pressure, cataracts, prolonged viral shedding, and worsening HSV infections 3
• Do not miss gonococcal conjunctivitis—can cause corneal perforation and requires immediate systemic treatment 3
• Chronic/recalcitrant conjunctivitis may indicate underlying malignancy (sebaceous or squamous cell carcinoma)—requires further evaluation 3
• Recognize dry eye and blepharitis as the most frequent causes of conjunctival inflammation—treat the underlying problem, not just the conjunctivitis 1, 2
• Avoid chronic use of topical vasoconstrictors—causes rebound effect 3
• Inadequate patient education about contagiousness leads to community spread 3

When Symptoms Persist or Worsen

Re-evaluate and consider ophthalmology referral if: 3, 6

• Lack of response to therapy 3
• Recurrent episodes 3
• Symptoms persist beyond 2-3 weeks 3, 7
• Conjunctival scarring develops 3