What is the treatment for conjunctivitis in individuals of all ages?

Treatment of Conjunctivitis

Treatment of conjunctivitis must be tailored to the specific etiology, with most viral and mild bacterial cases being self-limited, but certain conditions—particularly gonococcal, chlamydial, and immune-mediated forms—requiring immediate systemic therapy to prevent vision-threatening complications. 1, 2

Initial Diagnostic Approach

The first priority is identifying red flag features that require urgent ophthalmology referral within 24 hours 3:

• Visual loss or decreased visual acuity 3
• Moderate to severe ocular pain 3
• Corneal involvement (opacity, loss of transparency) 3
• Severe purulent discharge (hyperacute presentation) 2, 3
• History of herpes simplex virus eye disease 3
• Immunocompromised state 3
• Contact lens wear (raises concern for keratitis) 3

Viral Conjunctivitis (Most Common Overall)

Viral conjunctivitis does not respond to antibacterial agents and should not be treated with antibiotics. 1, 3, 4

Management:

• Supportive care only: preservative-free artificial tears 4 times daily and cold compresses 3, 4, 5
• Topical antihistamine eye drops for symptomatic relief 3
• Patient education on hygiene: frequent handwashing, separate towels, avoid close contact during contagion period 1, 5
• Adenovirus accounts for approximately 80% of viral conjunctivitis cases 6
• Typically starts unilaterally but becomes sequentially bilateral within days 3

Critical Pitfall:

Indiscriminate use of topical antibiotics should be avoided as viral conjunctivitis will not respond and antibiotics provide no benefit while potentially causing harm 1, 3

Bacterial Conjunctivitis

Most uncomplicated bacterial conjunctivitis cases are self-limited, resolving in 1-2 weeks without treatment. 4, 5

Clinical Features Suggesting Bacterial Etiology:

• Mucopurulent discharge with eyelids matted shut on waking 4, 5
• Lack of itching 4
• No history of prior conjunctivitis 4
• More common in children 5

Treatment Options:

• Delayed antibiotic prescribing has similar symptom control as immediate prescribing 5
• When antibiotics are used: broad-spectrum topical antibiotic (e.g., erythromycin ophthalmic ointment, bacitracin) 3, 7, 8
• Topical antibiotics decrease duration and allow earlier return to school/work 4
• No evidence demonstrates superiority of any specific topical antibiotic agent 1

Hyperacute Bacterial Conjunctivitis (EMERGENCY)

Gonococcal conjunctivitis requires immediate systemic antibiotics without waiting for culture results due to risk of corneal perforation within 24 hours. 1, 2

Clinical Presentation:

• Copious purulent discharge, marked eyelid edema, preauricular lymphadenopathy 1, 2
• Superior corneal infiltrates or ulcers that can rapidly progress to perforation 1, 2
• Manifests 1-7 days after birth in neonates 1, 2
• Consider sexual abuse in children 1

Immediate Treatment:

• Ceftriaxone 1g IM/IV (first-line systemic therapy) 2
• Add treatment for Chlamydia coinfection: azithromycin 1g orally single dose OR doxycycline 100mg twice daily for 7 days 2
• Saline lavage of infected eye to reduce bacterial load 2
• Topical antibiotics alone are inadequate 2

Critical Pitfalls:

• Delaying systemic antibiotics while waiting for culture results can result in corneal perforation and permanent vision loss 2
• Missing corneal involvement on initial slit-lamp examination leads to poor outcomes 2
• Failing to treat sexual partners and screen for other sexually transmitted infections 2

Chlamydial Conjunctivitis

Chlamydial conjunctivitis requires systemic treatment and evaluation/treatment of sexual partners. 1, 3, 4

Clinical Features:

• Follicular conjunctivitis on bulbar conjunctiva and semilunar fold 1
• Chronic inflammation that can persist 3-12 months untreated in neonates 1
• Caused by Chlamydia trachomatis serotypes D-K 1

Treatment:

• Systemic antibiotics required (azithromycin 1g single dose OR doxycycline 100mg twice daily for 7 days) 2, 3
• Topical therapy alone is insufficient 3, 4
• Treat sexual partners 3
• CDC recommends retesting approximately 3 months after treatment 2

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity are the treatment of choice for allergic conjunctivitis. 3, 4, 5

Clinical Features:

• Itching is the most consistent sign 4, 5
• Watery discharge 5
• Environmental or seasonal triggers 3

Treatment:

• Olopatadine or ketotifen: 1 drop in affected eye(s) twice daily 3
• Environmental modifications 3
• Short course of low-potency topical corticosteroid (loteprednol etabonate) for severe cases with baseline and periodic IOP monitoring 3

Critical Pitfall:

Topical corticosteroids require regular IOP monitoring and pupillary dilation to evaluate for glaucoma or cataracts 3

Contact Lens-Related Conjunctivitis

Contact lens-related conjunctivitis requires withdrawal of contact lenses and may take months to resolve. 1

Management:

• Discontinue contact lens wear immediately 1
• Address underlying causes: mechanical irritation, chronic hypoxia, preservatives 1
• Improve lens hygiene and replacement schedule 1
• Ophthalmology referral indicated as contact lens wear raises concern for keratitis 3

Ophthalmology Referral Criteria

Refer to ophthalmology for: 3, 5

• Lack of response to therapy after 3-4 days 3
• Recurrent episodes 3
• Conjunctival scarring 3
• Corneal involvement 3
• Neonatal conjunctivitis 5
• Recent ocular surgery 5
• Vesicular rash on eyelids or nose (herpes zoster) 5
• History of rheumatologic disease 5

Special Populations

Neonates:

• Erythromycin ophthalmic ointment for prophylaxis of ophthalmia neonatorum due to N. gonorrhoeae or C. trachomatis 8
• For infants born to mothers with clinically apparent gonorrhea: aqueous crystalline penicillin G 50,000 units IM/IV (term infants) or 20,000 units (low birth weight); topical prophylaxis alone is inadequate 8

Immunocompromised Patients:

• Require urgent ophthalmology consultation within 24 hours 3
• Higher risk for serious complications 3