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

Treatment and Management of Conjunctivitis

Immediate Diagnostic Priorities

The first critical step is to identify hyperacute bacterial conjunctivitis (especially gonococcal) and initiate systemic antibiotics immediately, as this can progress to corneal perforation within 24 hours if untreated. 1

Red Flags Requiring Urgent Action

• Copious purulent discharge with marked eyelid edema: Start ceftriaxone 1g IM/IV immediately without waiting for cultures, plus azithromycin 1g PO single dose (or doxycycline 100mg twice daily for 7 days) to cover concurrent chlamydial infection 1
• Corneal involvement on fluorescein staining: Requires aggressive therapy and ophthalmology referral 2
• Neonates with conjunctivitis: Gonococcal infection manifests 1-7 days after birth and requires immediate systemic antibiotics 1
• Sexual abuse consideration: Must be documented in children with gonococcal or chlamydial conjunctivitis 3, 2

Critical Pitfall

Topical antibiotics alone are inadequate for gonococcal conjunctivitis and can lead to corneal perforation and permanent vision loss 1

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General Management Principles

Indiscriminate use of topical antibiotics should be avoided, as viral conjunctivitis will not respond to antibacterial agents and mild bacterial conjunctivitis is typically self-limited. 3

Viral Conjunctivitis (Most Common in Adults)

• Supportive care only: Artificial tears, cold compresses, and topical antihistamines for symptom relief 4
• Infection control is paramount: Counsel patients to wash hands frequently, use separate towels, avoid close contact during contagion period 3
• No antibiotics indicated: 80% of acute conjunctivitis is viral, primarily adenovirus 5
• Expected course: Self-limited, typically resolves without intervention 6

Bacterial Conjunctivitis (More Common in Children)

Clinical presentation: Mucopurulent discharge with eyelids matted shut on waking, lack of itching, no history of prior conjunctivitis 4, 6

Treatment Options:

• Delayed antibiotic prescribing: Provides similar symptom control as immediate prescribing and is a reasonable approach 4
• If antibiotics used: No evidence demonstrates superiority of any specific topical antibiotic 3
  • Erythromycin ophthalmic ointment: Apply to conjunctival sac 1-3 times daily 7
  • Bacitracin ophthalmic ointment: Apply to conjunctival sac 1-3 times daily 8
• Expected course: Most uncomplicated cases resolve in 1-2 weeks without treatment 6

Exceptions Requiring Systemic Treatment:

• Chlamydial conjunctivitis: Requires systemic antibiotics (azithromycin 1g PO single dose or doxycycline 100mg twice daily for 7 days) in addition to topical therapy 3, 1
• Contact lens wearers: Must be treated with antibiotics due to risk of serious complications 6

Allergic Conjunctivitis

Itching is the hallmark symptom distinguishing allergic from infectious conjunctivitis. 4, 6

• First-line treatment: Topical antihistamines with mast cell-stabilizing activity 4, 6
• Presentation: Watery discharge, bilateral involvement, history of atopy 4

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Special Populations and Situations

Neonatal Conjunctivitis (Ophthalmia Neonatorum)

• Gonococcal prophylaxis: Erythromycin ophthalmic ointment is indicated for prevention 7
• If gonococcal infection confirmed: Systemic penicillin G (50,000 units for term infants, 20,000 units for low birth weight) is required; topical prophylaxis alone is inadequate 7
• Chlamydial infection: Manifests 5-19 days after birth and can cause nasopharyngeal, genital, or pulmonary infection in up to 50% of cases 3

Contact Lens-Related Conjunctivitis

• Management: Discontinue contact lens wear immediately 3
• Resolution timeline: May take months or longer even with treatment 3
• Risk factors: Soft lenses, infrequent replacement, prolonged wearing time, poor hygiene 3
• Potential complications: Corneal neovascularization, limbal stem cell deficiency 3

Giant Papillary Conjunctivitis (GPC)

• Primary intervention: Remove inciting factor (contact lenses, exposed sutures, prostheses) 3
• Clinical finding: Papillary hypertrophy of superior tarsal conjunctiva with mucoid discharge 3

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Mandatory Ophthalmology Referral Criteria

Immediate referral is warranted for: 2, 4

• Visual loss or moderate-to-severe pain
• Severe purulent discharge suggesting gonococcal infection
• Corneal involvement on fluorescein staining
• Lack of response after 3-4 days of appropriate therapy
• Immunocompromised state
• Recent ocular surgery
• Vesicular rash on eyelids or nose (herpes zoster)
• History of rheumatologic disease
• Recurrent episodes or history of HSV eye disease

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Critical Systemic Conditions to Detect Early

Certain forms of conjunctivitis indicate serious underlying systemic disease requiring immediate systemic treatment: 3

• Ocular mucous membrane pemphigoid (OMMP): Bilateral papillary conjunctivitis with potential for cicatricial changes 3
• Graft-versus-host disease (GVHD): Requires systemic immunosuppression 3
• Limbic-sparing conjunctivitis: Characteristic of juvenile dermatomyositis 9
• Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Bilateral involvement with severe mucocutaneous necrosis 9

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Infection Control Measures

For Healthcare Settings:

• Tonometer disinfection: Use dilute bleach (sodium hypochlorite) at 1:10 concentration; 70% isopropyl alcohol is no longer recommended 3
• Surface disinfection: Use EPA-registered hospital disinfectant per label directions 3

For Patients:

• Hand hygiene: Frequent handwashing is essential to prevent transmission 3, 4
• Avoid contamination: Instruct patients on proper technique when applying ointments to avoid gross contamination 8
• Isolation measures: Use separate towels, avoid close contact during contagious period 3

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Prevention

Herpes zoster vaccination should be strongly recommended in patients 50 years or older to prevent herpes zoster ophthalmicus. 3