What are the treatment options for conjunctivitis?

Treatment of Conjunctivitis

Treatment must be tailored to the specific etiology: topical fluoroquinolones (moxifloxacin, levofloxacin) for bacterial conjunctivitis, topical antihistamines with mast cell-stabilizing properties for allergic conjunctivitis, and supportive care only for viral conjunctivitis. 1, 2

Initial Classification by Clinical Features

The first step is determining the type of conjunctivitis based on discharge and associated symptoms:

• Yellow crusting and mucopurulent discharge strongly indicates bacterial conjunctivitis 2
• Watery discharge with preauricular lymphadenopathy suggests viral conjunctivitis 1, 3
• Severe itching is the hallmark of allergic conjunctivitis 1, 4

Bacterial Conjunctivitis Treatment

Mild to Moderate Cases

• Mild bacterial conjunctivitis is self-limited in immunocompetent adults and may not require antibiotics, as spontaneous resolution typically occurs within 1-2 weeks 2, 5
• For moderate to severe cases, prescribe a 5-7 day course of broad-spectrum topical fluoroquinolones such as moxifloxacin 0.5% three times daily 2, 5, 6
• Moxifloxacin demonstrates 84-94% microbiological eradication rates and 66-69% clinical cure rates by day 5-6 6
• Instruct patients to clean eyelids with warm water before applying medication to remove crusts 2
• Patients must return if no improvement occurs after 3-4 days, as this suggests resistant organisms or alternative diagnosis 1, 2

Severe or Resistant Cases

• Obtain conjunctival cultures and Gram staining before treatment if gonococcal infection is suspected or if there is copious purulent discharge 2, 5
• Consider MRSA in nursing home patients or community-acquired infections; compounded vancomycin may be necessary 5

Sexually Transmitted Conjunctivitis (Critical)

Gonococcal Conjunctivitis

• Requires systemic antibiotics, not just topical therapy: ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose 1, 2, 5
• Daily follow-up is mandatory until complete resolution to prevent corneal perforation and vision loss 1, 2
• Hospitalization may be necessary for severe cases and is mandatory for neonatal gonococcal conjunctivitis 1, 2
• Saline lavage promotes comfort and faster resolution 2

Chlamydial Conjunctivitis

• Systemic antibiotics are required because >50% of patients have infection at other sites (genital, respiratory) 1, 2, 5
• Treatment options: azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 5
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used 1, 2
• Re-evaluation after treatment is essential due to 19% treatment failure rate 2

Critical Considerations for STI-Related Conjunctivitis

• Sexual contacts must be treated concurrently and informed about possible concomitant disease 1, 2
• In children, consider sexual abuse and report appropriately 1, 5

Viral Conjunctivitis Treatment

• No antibiotics should be prescribed as they provide no benefit and contribute to resistance 5, 4
• Supportive care only: refrigerated preservative-free artificial tears 4 times daily, cold compresses, and topical antihistamines for symptomatic relief 1, 5, 3
• Artificial tears help dilute viral particles and inflammatory mediators 5
• Patients should return if symptoms persist beyond 2-3 weeks 2

Herpes Simplex Virus (HSV) Conjunctivitis

• Topical ganciclovir 0.15% gel OR trifluridine 1% solution is recommended 5, 7
• Oral antivirals (acyclovir, valacyclovir, famciclovir) may also be used 5
• Never use topical corticosteroids without antiviral coverage as they potentiate HSV infection and can cause corneal perforation 1, 2, 5
• Prolonged trifluridine use (>2 weeks) causes epithelial toxicity 5

Adenoviral Conjunctivitis

• No proven effective treatment for viral eradication exists 5
• In severe cases with marked chemosis, lid swelling, or membranous conjunctivitis, topical corticosteroids may help but require close ophthalmology monitoring 5

Allergic Conjunctivitis Treatment

First-Line Therapy

• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic allergic conjunctivitis 1, 2, 5
• Simple adjunctive measures: wearing sunglasses as allergen barriers, cold compresses, and refrigerated artificial tears 1, 2

Persistent or Recurrent Cases

• Mast cell stabilizers (cromolyn sodium) can be used for prophylaxis 1, 2
• For severe cases uncontrolled by antihistamines: add a brief 1-2 week course of low side-effect profile topical corticosteroids (fluorometholone, loteprednol, rimexolone) 1, 2
• Monitor intraocular pressure and for cataract formation if corticosteroids are used 2, 5
• Taper corticosteroids once inflammation is controlled 2

Contact Lens-Related Conjunctivitis

• Discontinue contact lens wear immediately until the cornea returns to normal 2
• For giant papillary conjunctivitis: consider more frequent lens replacement, decreased wearing time, preservative-free solutions, or daily disposable lenses 2
• Brief topical corticosteroids (1-2 weeks) plus longer-term cyclosporine 0.05% may be prescribed 2

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present: 1, 2, 5

• Visual loss or decreased vision
• Moderate to severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma)
• Severe purulent discharge (possible gonococcal infection)
• Corneal involvement (fluorescein staining shows epithelial defects)
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised state
• Neonatal conjunctivitis (requires systemic treatment)

Infection Control Measures

• Hand hygiene with soap and water is the single most important preventive measure 1, 5
• Avoid close contact for 7-14 days from symptom onset in viral conjunctivitis 5
• Do not share towels, pillows, or cosmetics 1
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 bleach solution 1
• Discard multiple-dose eyedrop containers to avoid cross-contamination 5

Critical Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately as they prolong adenoviral infections, worsen HSV infections, and can cause corneal perforation 1, 2, 5
• Avoid topical antibiotics in viral conjunctivitis as they provide no benefit and induce toxicity 1, 2
• Chronic use of vasoconstrictor agents causes rebound vasodilation 2
• Oral antihistamines may worsen dry eye syndrome 2
• Failure to treat sexual contacts in STI-related conjunctivitis perpetuates transmission 2
• Delayed referral for gonococcal conjunctivitis leads to vision loss 5