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 corneal perforation can occur 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 immediate ophthalmology referral and aggressive therapy 2
• Neonates with conjunctivitis: Gonococcal infection manifests 1-7 days after birth and requires systemic ceftriaxone; topical antibiotics alone are inadequate 1, 3
• Sexual abuse consideration: Must be documented in children/adolescents with gonococcal or chlamydial conjunctivitis 4, 2

General Management Principles

Avoid indiscriminate use of topical antibiotics or corticosteroids, as viral conjunctivitis will not respond to antibacterials and mild bacterial conjunctivitis is typically self-limited. 4

Viral Conjunctivitis (Most Common - 80% of Acute Cases)

• Supportive care only: Artificial tears, cold compresses, and topical antihistamines for symptom relief 5, 6
• Strict hygiene measures: Frequent handwashing, separate towels, avoid close contact during contagion period to break transmission chain 4
• No antibiotics indicated: Most cases resolve spontaneously in 1-2 weeks 7, 6
• Infection control: Dilute bleach (1:10 sodium hypochlorite) for tonometer disinfection; EPA-registered hospital disinfectants for surfaces 4

Bacterial Conjunctivitis

Delayed antibiotic prescribing has similar symptom control as immediate prescribing for uncomplicated cases. 5

When to Treat with Antibiotics:

• Mucopurulent discharge with matted eyelids (strongest predictor of bacterial etiology) 5, 7
• Contact lens wearers: Requires antibiotic treatment due to risk of serious complications 7
• Gonococcal/chlamydial infection: Requires systemic antibiotics (see above) 4, 1
• Lack of improvement after 3-4 days: Consider antibiotic therapy 2

Topical Antibiotic Options (No Superior Agent):

• Bacitracin ointment: Apply to conjunctival sac 1-3 times daily 8
• Erythromycin ointment: For superficial infections; also used for neonatal prophylaxis 3
• Duration: Most uncomplicated cases resolve in 1-2 weeks with or without treatment 7

Allergic Conjunctivitis (Up to 40% of Population)

Topical antihistamines with mast cell-stabilizing activity are the treatment of choice. 5, 7

• Key diagnostic feature: Itching is the most consistent sign 5, 7
• Treatment: Topical antihistamines and mast cell stabilizers alleviate symptoms effectively 7
• Supportive measures: Cold compresses, artificial tears 5

Contact Lens-Related Conjunctivitis

• Immediate contact lens discontinuation: May take months to resolve even with treatment 4
• Risk factors to address: Poor hygiene, prolonged wearing time, infrequent replacement, allergenic solutions 4
• Potential complications: Corneal neovascularization, limbal stem cell deficiency, superior epitheliopathy 4

Critical Conditions Requiring Systemic Treatment

Chlamydial Conjunctivitis (Inclusion)

• Neonates: Manifests 5-19 days after birth; up to 50% have associated systemic infection 4
• Adults: Chronic follicular conjunctivitis with bulbar follicles; requires systemic antibiotics for concurrent STI 4
• Treatment: Azithromycin 1g PO or doxycycline 100mg twice daily for 7 days 1

Immune-Mediated Conjunctivitis

• Ocular mucous membrane pemphigoid (OMMP): Requires early detection and systemic immunosuppression 4
• Graft-versus-host disease (GVHD): Treat underlying systemic disorder 4
• Stevens-Johnson Syndrome: Bilateral involvement with severe mucocutaneous necrosis; requires immediate systemic management 9

Mandatory Ophthalmology Referral

• Visual loss or moderate-to-severe pain 2
• Corneal involvement on fluorescein staining 2
• Severe purulent discharge suggesting gonococcal infection 2
• Lack of response after 3-4 days of appropriate therapy 2
• Immunocompromised state or history of HSV eye disease 2
• Recurrent episodes or chronic unilateral conjunctivitis (rule out neoplasm) 4
• Conjunctival scarring or symblepharon formation 4

Prevention Strategies

• Herpes zoster vaccination: Strongly recommended for patients ≥50 years old 4
• Neonatal prophylaxis: Erythromycin ointment for prevention of ophthalmia neonatorum 3
• Patient education: Hand hygiene, avoid sharing towels, stay home during contagious period 4

Common Pitfalls to Avoid

• Delaying systemic antibiotics in hyperacute conjunctivitis: Can result in corneal perforation and permanent vision loss 1
• Using topical antibiotics alone for gonococcal conjunctivitis: Inadequate treatment 1
• Missing corneal involvement: Always perform fluorescein staining 2
• Failing to treat sexual partners: Essential for STI-related conjunctivitis 1
• Overlooking underlying systemic disease: Dry eye and blepharitis are the most frequent causes of conjunctival inflammation; treat the underlying problem 4