Treatment and Management of Conjunctivitis
Most conjunctivitis is self-limited and requires only supportive care, but specific etiologies—particularly gonococcal, chlamydial, and immune-mediated forms—demand immediate targeted therapy to prevent vision-threatening complications. 1
Initial Diagnostic Approach
The first priority is distinguishing conjunctivitis from vision-threatening conditions and identifying cases requiring urgent intervention. 1
Key red flags requiring immediate ophthalmology referral: 2, 3
- Visual loss or moderate-to-severe pain
- Corneal involvement on fluorescein staining
- Copious purulent discharge (suggests gonococcal infection)
- History of recent ocular surgery
- Immunocompromised state
- Lack of response after 3-4 days of appropriate therapy
Perform slit-lamp biomicroscopy with fluorescein staining to evaluate for corneal involvement, which fundamentally changes management. 4, 2
Hyperacute Purulent Conjunctivitis (Gonococcal)
This is a medical emergency requiring immediate systemic antibiotics without waiting for culture results. 5
Clinical Recognition
- Copious purulent discharge with marked eyelid edema 5
- Rapid onset (within 24 hours) 5
- Preauricular lymphadenopathy 5
- Critical finding: Superior corneal infiltrates or ulcers that can progress to perforation within 24 hours 5
Immediate Management
Systemic therapy (do not rely on topical antibiotics alone): 5
- Ceftriaxone 1g IM/IV immediately 5
- Add azithromycin 1g PO single dose (or doxycycline 100mg twice daily for 7 days) for presumed chlamydial coinfection 5
- Consider saline lavage to reduce bacterial load 5
Obtain conjunctival cultures and Gram stain but initiate treatment immediately. 2
Special Populations
- Neonates (1-7 days after birth): Represents ophthalmia neonatorum; requires same systemic therapy 1, 5
- Children: Consider and document sexual abuse 1, 5, 2
- Sexually active adults: Screen for concurrent genital infection and treat partners 5
Follow-up within 24-48 hours to assess treatment response and monitor for corneal complications. 5
Chlamydial Conjunctivitis
Inclusion Conjunctivitis (Serotypes D-K)
Clinical features: 1
- Follicular conjunctivitis with follicles on bulbar conjunctiva and semilunar fold (distinctive finding) 1
- Chronic course with corneal pannus and subepithelial infiltrates 1
- Sexually transmitted; highly communicable 1
Treatment requires systemic antibiotics: 1, 5
- Azithromycin 1g PO single dose, OR
- Doxycycline 100mg twice daily for 7 days
- Treat sexual partners 1
Trachoma (Serotypes A, B, C)
- Endemic in areas without adequate water/sanitation 1
- Requires systemic azithromycin for mass drug administration programs 1
- Leading infectious cause of global blindness if untreated 1
Bacterial Conjunctivitis (Non-Gonococcal)
Most cases are self-limited, resolving in 1-2 weeks without treatment. 3, 6
Clinical Features Suggesting Bacterial Etiology
- Mucopurulent discharge with eyelids matted shut on waking 3, 6
- Lack of itching 6
- No history of recurrent conjunctivitis 6
- More common in children 3
Treatment Strategy
Delayed antibiotic prescribing is appropriate for uncomplicated cases and provides similar symptom control to immediate prescribing. 3, 6
Indications for topical antibiotics: 1, 3
- Desire for earlier return to school/work 6
- Contact lens wearers (requires treatment) 6
- Immunocompromised patients 3
No evidence supports superiority of any specific topical antibiotic. 1
FDA-approved topical options: 7, 8
- Bacitracin ophthalmic ointment: Apply to conjunctival sac 1-3 times daily 7
- Erythromycin ophthalmic ointment: Apply to conjunctival sac 8
Critical pitfall: Indiscriminate antibiotic use should be avoided as viral conjunctivitis will not respond and mild bacterial cases are self-limited. 1
Viral Conjunctivitis
Viral conjunctivitis is the most common overall cause of infectious conjunctivitis and typically requires only supportive care. 6, 9
Clinical Features
- Watery discharge (not purulent) 3
- More common in adults 3
- Adenovirus accounts for approximately 80% of viral cases 9
- Preauricular lymphadenopathy may be present 9
Supportive Management
Infection Control (Critical for Epidemic Adenoviral Conjunctivitis)
The ophthalmologist plays a critical role in breaking the chain of transmission: 1
- Counsel patients on frequent handwashing 1
- Use separate towels 1
- Avoid close contact during contagious period 1
- Disinfect tonometers with dilute bleach (1:10 sodium hypochlorite) 1
- Do not use 70% isopropyl alcohol, 3% hydrogen peroxide, or ethyl alcohol for tonometer disinfection 1
- Disinfect surfaces with EPA-registered hospital disinfectant 1
Herpes simplex viral conjunctivitis requires specific diagnosis before using corticosteroid eye solutions, as steroids are contraindicated in HSV. 9
Allergic Conjunctivitis
Affects up to 40% of the population; itching is the most consistent sign. 6
Treatment
Topical antihistamines with mast cell-stabilizing activity are first-line therapy. 3, 6
Clinical Features
Contact Lens-Related Conjunctivitis
Requires discontinuation of contact lens wear. 1
Clinical Features
- Ranges from mild to diffuse conjunctival injection 1
- Papillary hypertrophy of superior tarsal conjunctiva (Giant Papillary Conjunctivitis) 1
- May take months to resolve even with treatment and lens withdrawal 1
Risk Factors
- Soft contact lenses, infrequent replacement, prolonged wearing time, poor hygiene 1
Potential Complications
- Corneal neovascularization, superior limbal stem cell deficiency 1
Immune-Mediated Conjunctivitis Requiring Early Detection
These conditions require systemic treatment and early detection is critical: 1
Ocular Mucous Membrane Pemphigoid (OMMP)
- Bilateral bulbar conjunctival injection with papillary reaction 1
- Progressive conjunctival scarring 1
- Requires systemic immunosuppression 1
Graft-Versus-Host Disease (GVHD)
- Important to detect early for systemic management 1
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
- Bilateral conjunctival involvement with potential for severe mucocutaneous necrosis 4
- Conjunctival scarring and subepithelial fibrosis 4
Juvenile Dermatomyositis
- Limbic-sparing conjunctivitis is characteristic 4
- May present with systemic manifestations including weakness and elevated liver enzymes 4
Medication-Induced Conjunctivitis
Obtain comprehensive medication history including recent antibiotics, anticonvulsants, or topical eye medications. 4
Clinical Features
- Conjunctival injection, punctal edema, inferior fornix follicles 1
- Contact dermatitis of eyelids with erythema and scaling 1
- Most common with multiple eye medications and frequent dosing 1
Topical corticosteroids should be avoided indiscriminately as they can worsen certain conditions. 1
Prevention
Herpes Zoster vaccination should be strongly recommended in patients 50 years or older. 1