What are the treatment options for conjunctivitis?

Treatment of Conjunctivitis

Immediate Triage: Red Flags Requiring Urgent Ophthalmology Referral

If any of the following are present, refer immediately to ophthalmology before initiating treatment: 1, 2

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

Treatment Algorithm by Etiology

Bacterial Conjunctivitis

For mild to moderate bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic (e.g., moxifloxacin 0.5% three times daily). 1, 2, 3 This accelerates clinical and microbiological remission in days 2-5, reduces transmissibility, and allows earlier return to school/work. 3

Clinical features suggesting bacterial etiology: 4, 5

• Mucopurulent discharge with eyelids matted shut on waking
• Lack of itching
• No history of previous conjunctivitis
• More common in children

Antibiotic selection: 2, 3

• First-line: Topical fluoroquinolones (moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin, ofloxacin) provide superior coverage against Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 2, 3, 6
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have better gram-positive coverage, including some MRSA strains 3
• Alternative options: Polymyxin B/trimethoprim, erythromycin, gentamicin, or tobramycin 2, 3
• No evidence demonstrates superiority of any specific agent for uncomplicated cases, so choose based on cost and convenience 2, 3

Special circumstances requiring systemic antibiotics: 1, 2

• Gonococcal conjunctivitis: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose; requires daily monitoring until resolution and hospitalization may be necessary 1, 2, 3
• Chlamydial conjunctivitis: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days; topical therapy alone is insufficient 1, 2, 3
• MRSA conjunctivitis: May require compounded topical vancomycin, as MRSA is resistant to most commercially available topical antibiotics 2, 3
• Contact lens wearers: Use fluoroquinolones due to higher risk of Pseudomonas infection 3

Critical follow-up: Advise patients to return if no improvement after 3-4 days of treatment. 1, 2, 3

Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—do NOT prescribe antibiotics. 1, 2, 4 Most cases are self-limited and resolve without treatment.

Clinical features suggesting viral etiology: 1, 4, 5

• Watery discharge
• Preauricular lymphadenopathy
• Concurrent upper respiratory infection
• Follicular reaction in inferior fornix
• More common in adults

Supportive treatment: 1, 2

• Refrigerated preservative-free artificial tears 4 times daily (dilutes viral particles and inflammatory mediators)
• Cold compresses for comfort
• Topical antihistamines for symptomatic relief of itching (NOT for viral eradication)

Exception—HSV conjunctivitis: 2

• Topical ganciclovir 0.15% gel OR topical trifluridine 1% solution 2
• Oral antivirals: Acyclovir, valacyclovir, or famciclovir 2
• NEVER use topical corticosteroids in HSV conjunctivitis without antiviral coverage—they potentiate infection 1, 2

Infection control: 1, 2

• Strict handwashing with soap and water
• Avoid close contact for 7-14 days from symptom onset
• Discard multiple-dose eyedrop containers to prevent cross-contamination
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach

Allergic Conjunctivitis

For allergic conjunctivitis, prescribe topical antihistamines with mast cell-stabilizing properties as first-line treatment. 1, 2 These are the treatment of choice for allergic conjunctivitis.

Clinical features suggesting allergic etiology: 4, 5, 7

• Itching (most consistent sign)
• Watery discharge
• Concurrent allergic rhinitis or asthma
• Allergen exposure history

Treatment algorithm: 1, 2

1. First-line: Topical antihistamines with mast cell-stabilizing activity (e.g., olopatadine, ketotifen) 1, 2
2. Adjunctive measures: Cold compresses, refrigerated preservative-free artificial tears, wearing sunglasses as allergen barrier 1, 2
3. Persistent/recurrent cases: Add mast cell stabilizers 1
4. Severe cases: Brief 1-2 week course of low side-effect profile topical corticosteroids (e.g., loteprednol); monitor intraocular pressure and for cataract formation 1, 2

Environmental modifications: Identify and avoid allergen triggers. 1

Critical Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately—they prolong adenoviral infections, worsen HSV infections, and can induce toxicity 1, 2
• Never prescribe antibiotics for viral conjunctivitis—this promotes resistance and provides no benefit 2, 3
• Never use topical therapy alone for gonococcal or chlamydial conjunctivitis—systemic antibiotics are mandatory 1, 2, 3
• Always treat sexual contacts concurrently in sexually transmitted conjunctivitis 1
• Always consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2
• Never allow contact lens wear until complete resolution of conjunctivitis 1

Special Populations

Neonates: 1, 2

• Gonococcal: Ceftriaxone 25-50 mg/kg IV or IM single dose; hospitalization mandatory
• Chlamydial: Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided in 4 doses for 14 days; >50% have infection at other sites requiring systemic treatment

Pregnant women: 2

• Avoid doxycycline and quinolones
• Use erythromycin or azithromycin for chlamydial coverage

Contact lens wearers: 3

• Discontinue lens use until complete resolution
• Use fluoroquinolones due to Pseudomonas risk