What is the treatment for a patient with conjunctivitis?

Treatment of Conjunctivitis

Treatment must be tailored to the specific etiology—bacterial conjunctivitis receives topical antibiotics (5-7 days of broad-spectrum agents like moxifloxacin), viral conjunctivitis requires only supportive care with artificial tears and cold compresses, and allergic conjunctivitis is treated with topical antihistamines with mast cell-stabilizing properties as first-line therapy. 1, 2

Immediate Red Flags Requiring Ophthalmology Referral

Before initiating treatment, identify patients who need immediate specialist evaluation 3, 1:

• Visual loss or decreased vision 3, 1
• Moderate or severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 3, 1
• Severe purulent discharge (possible gonococcal infection) 3, 1
• Corneal involvement (fluorescein staining showing epithelial defects) 3, 1
• Conjunctival scarring 3, 1
• Lack of response to therapy after 3-4 days 1, 2
• Recurrent episodes 3, 1
• History of HSV eye disease 3, 1
• Immunocompromised state 3, 1

Bacterial Conjunctivitis

Mild to Moderate Cases

• Mild bacterial conjunctivitis is self-limited and may resolve without antibiotics, but topical therapy shortens duration and allows earlier return to work/school 1, 2, 4
• Prescribe a 5-7 day course of broad-spectrum topical antibiotic (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) 1, 2
• No single topical antibiotic demonstrates superiority over others—choose based on cost, dosing convenience, and local resistance patterns 2, 4
• Moxifloxacin is effective against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 5
• Instruct patients to return if no improvement after 3-4 days 1, 2

Severe Cases with Copious Purulent Discharge

• Obtain conjunctival cultures and Gram staining before initiating treatment 2
• Consider MRSA in nursing home patients or community-acquired infections 2
• Compounded topical vancomycin may be needed for resistant organisms 2

Gonococcal Conjunctivitis (Medical Emergency)

• Requires systemic antibiotics plus topical therapy 1, 2
• Adult treatment: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 2
• Neonatal treatment: Ceftriaxone 25-50 mg/kg IV or IM single dose 2
• Hospitalization is mandatory for neonatal cases and may be necessary for severe adult cases 3, 1
• Daily follow-up until resolution is required—can cause corneal perforation if untreated 1, 2
• Treat sexual contacts concurrently 1, 2

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy—topical treatment alone is inadequate as >50% of infants have infection at other sites 1, 2
• Adult treatment: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 2
• Neonatal treatment: Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided in 4 doses for 14 days 2
• In low-to-middle income countries with limited antibiotic access: Povidone-iodine 1.25% ophthalmic solution 1
• Treat sexual contacts concurrently and screen for concurrent genital infections 1, 2
• Consider sexual abuse in children with chlamydial or gonococcal conjunctivitis—mandatory reporting in many jurisdictions 3, 2

Viral Conjunctivitis

Adenoviral Conjunctivitis (Most Common)

• No proven effective antiviral treatment exists for adenovirus—management is supportive only 2, 6
• Supportive care includes:
  • Refrigerated preservative-free artificial tears 4 times daily (dilutes viral particles and inflammatory mediators) 2, 6
  • Cold compresses for comfort 1, 2
  • Topical antihistamines for symptomatic relief of itching 2, 6
• Avoid topical antibiotics—they provide no benefit and may cause toxicity 1, 2, 6
• Self-limited course, typically resolving within 5-14 days 6
• Strict hand hygiene with soap and water to prevent transmission—avoid close contact for 7-14 days from symptom onset 1, 2

Severe Adenoviral Cases with Marked Chemosis, Lid Swelling, or Pseudomembranes

• Consider a brief 1-2 week course of low side-effect profile topical corticosteroids 1, 2
• Requires close ophthalmology monitoring for intraocular pressure and cataract formation 2, 6
• Warning: Corticosteroids can prolong adenoviral infections and viral shedding 1, 2

Herpes Simplex Virus (HSV) Conjunctivitis

• Topical ganciclovir 0.15% gel OR topical trifluridine 1% solution 2
• Oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used 2
• NEVER use topical corticosteroids without antiviral coverage—they potentiate HSV infection and can cause corneal perforation 1, 2, 6
• Do not use topical trifluridine for more than 2 weeks—causes epithelial toxicity 2
• Immediate ophthalmology referral for any patient with history of HSV eye disease 3, 1

Varicella Zoster Virus (VZV) Conjunctivitis

• Topical antivirals alone are not helpful 2
• May require topical antibiotics to prevent secondary bacterial infection in children with chickenpox-associated conjunctivitis 2

Allergic Conjunctivitis

First-Line Treatment

• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice (olopatadine, ketotifen, alcaftadine, bepotastine) 1, 2, 6
• These dual-action agents provide faster relief than mast cell stabilizers alone 1, 2

Adjunctive Measures

• Environmental modifications: 1, 2
  • Wear sunglasses as barriers to airborne allergens
  • Apply cold compresses
  • Use refrigerated preservative-free artificial tears
  • Avoid eye rubbing
  • Identify and avoid allergen triggers

Persistent or Recurrent Cases

• Mast cell stabilizers can be used for prophylaxis 1
• For severe cases: Add a brief 1-2 week course of topical corticosteroids with low side-effect profile 1, 2
• Monitor intraocular pressure and perform periodic pupillary dilation if using corticosteroids 2, 6
• Allergen-specific immunotherapy is beneficial, especially in children 6
• Consider multidisciplinary approach with allergists for severe cases 6

Giant Papillary Conjunctivitis (Contact Lens-Related)

• Discontinue contact lens use 2
• Use topical anti-inflammatory agents 2
• Monitor intraocular pressure if corticosteroids are used 2

Special Populations

Neonatal Conjunctivitis (Ophthalmia Neonatorum)

• Hospitalization is mandatory 3, 1
• Requires systemic treatment coordinated with a pediatrician 3, 2
• Immediate pediatric consultation for suspected HSV—risk of life-threatening systemic infection 2

Pediatric Viral Conjunctivitis

• Primarily managed with supportive care alone—no proven effective antiviral for adenovirus 2
• Artificial tears, cold compresses, and frequent handwashing 2
• Avoid topical antibiotics to prevent unnecessary adverse effects and resistance 2

Contact Lens Wearers

• Suspend contact lens use until complete resolution 1, 6
• Requires antibiotic treatment due to risk of Pseudomonas and other serious pathogens 4
• Discard multiple-dose eyedrop containers to avoid cross-contamination 2

Critical Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately—they prolong adenoviral infections, worsen HSV infections, and can cause increased intraocular pressure and cataracts 1, 2, 6
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage 2, 6
• Do not miss gonococcal conjunctivitis—requires immediate systemic treatment to prevent corneal perforation 2, 6
• Avoid topical antibiotics in viral conjunctivitis—they provide no benefit and may cause toxicity 1, 2, 6
• Do not use doxycycline or quinolones in pregnant women—use erythromycin or azithromycin for chlamydial coverage 2
• Failure to consider sexual abuse in children with sexually transmitted conjunctivitis has serious consequences 3, 2
• Delayed referral for patients with red flags leads to poor outcomes including vision loss 2

Infection Control Measures

• Hand washing with soap and water is the single most important measure to prevent transmission 1, 2
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 1
• Do not share towels, pillows, or cosmetics 1
• Avoid close contact for 7-14 days from symptom onset in viral conjunctivitis 2, 6