Treatment and Management of Conjunctivitis
Immediate Diagnostic Approach
The treatment of conjunctivitis depends critically on identifying the etiology—viral, bacterial, or allergic—through specific clinical features, with viral cases requiring only supportive care, bacterial cases potentially benefiting from topical antibiotics in moderate-to-severe presentations, and allergic cases responding to topical antihistamines with mast cell stabilizers. 1, 2
Key Clinical Differentiators
Viral conjunctivitis presents with:
- Watery discharge with abrupt onset, often starting unilateral but becoming sequentially bilateral 2
- Follicular reaction on inferior tarsal conjunctiva (not papillae) 2
- Preauricular lymphadenopathy 2
- Concurrent upper respiratory infection symptoms 2
- Subconjunctival hemorrhages and chemosis may be present 2
Bacterial conjunctivitis presents with:
- Mucopurulent or purulent discharge with matted eyelids upon waking 2, 3
- Papillary reaction (not follicular) 2
- Absence of itching 3
- May be associated with otitis media, sinusitis, or pharyngitis in children 2
Allergic conjunctivitis presents with:
- Itching as the most consistent and distinguishing feature 2
- Bilateral presentation with watery discharge 2
- History of atopy, asthma, or eczema 2
- Absence of preauricular lymphadenopathy and matted eyelids 2
Treatment by Etiology
Viral Conjunctivitis
Avoid antibiotics entirely—they provide no benefit and may cause unnecessary toxicity. 2
Supportive care includes:
- Artificial tears for symptomatic relief 2, 4
- Cold compresses 2, 4
- Topical antihistamines for symptomatic relief (not curative) 2
Patient education is critical:
- Highly contagious for 10-14 days from symptom onset 2
- Strict hand hygiene with soap and water 2
- Avoid sharing towels, pillows, or personal items 2
- Disinfect surfaces with EPA-registered hospital disinfectant 2
For severe cases with marked chemosis, lid swelling, or pseudomembranes:
- Consider short course of topical corticosteroids (1-2 weeks) with close ophthalmology follow-up 2
- Critical caveat: Corticosteroids prolong viral shedding, worsen HSV infections, and risk elevated intraocular pressure and cataracts 2
- Requires regular IOP monitoring and periodic pupillary dilation 2
Self-limited course: Typically resolves within 5-14 days 2
Bacterial Conjunctivitis
Mild cases are usually self-limited and may resolve without treatment, but topical antibiotics may shorten duration. 2, 3
For moderate-to-severe cases:
- Prescribe 5-7 day course of broad-spectrum topical antibiotic 2
- No specific antibiotic is superior—choose the most convenient or least expensive option: 2
Dosing for erythromycin ointment: Apply directly into conjunctival sac; for blepharitis, remove scales/crusts and spread uniformly over lid margins 6, 5
MRSA considerations: Increasingly isolated, but fluoroquinolones remain effective 2
Hyperacute Bacterial Conjunctivitis (Gonococcal)
This is a medical emergency requiring immediate systemic antibiotics without waiting for culture results. 7
Clinical presentation:
- Copious purulent discharge with marked eyelid edema 1, 7
- Preauricular lymphadenopathy 1, 7
- Critical finding: Superior corneal infiltrate or ulcer that can progress to perforation within 24 hours 1, 7
Immediate management:
- Ceftriaxone 1g IM/IV (first-line systemic therapy) 7
- Add treatment for Chlamydia coinfection: azithromycin 1g orally single dose OR doxycycline 100mg twice daily for 7 days 7
- Saline lavage of infected eye to reduce bacterial load 7
- Topical antibiotics alone are inadequate 7
Special populations:
- Neonates: Manifests 1-7 days after birth; requires hospitalization for parenteral therapy 1, 7
- Children: Consider sexual abuse and document with standard culture 7
- Adults: Screen for concurrent genital infection and treat sexual partners 7
Follow-up: Close monitoring within 24-48 hours; retest approximately 3 months after treatment 7
Chlamydial Conjunctivitis
Requires systemic treatment—topical therapy alone is inadequate. 2
Clinical presentation:
- Follicular conjunctivitis with follicles on bulbar conjunctiva and semilunar fold 1
- Neonates: Manifests 5-19 days after birth with purulent/mucopurulent discharge (no follicles) 1
- Adults: Chronic inflammation with corneal pannus and limbal follicles 1
Management:
- Systemic antibiotics (azithromycin or doxycycline) 2
- Evaluate and treat sexual partners 2
- PCR or immunofluorescent antibody testing for confirmation 2
Allergic Conjunctivitis
Topical antihistamines with mast cell-stabilizing activity are first-line treatment. 2
Recommended agents:
Environmental modifications:
- Wear sunglasses as barrier to airborne allergens 2
- Cold compresses and refrigerated artificial tears 2
- Avoid eye rubbing 2
- Allergen avoidance 2
For refractory cases:
- Short-term topical corticosteroids (1-2 weeks) with low side-effect profile 2
- Consider allergen-specific immunotherapy (more beneficial in children than adults) 2
- Multidisciplinary approach with pediatricians, internists, and allergists 2
Oral antihistamines: Less effective than topical agents for ocular symptoms but may be used as adjunct 8
Red Flags Requiring Urgent Ophthalmology Referral
Refer immediately for: 2
- Visual loss or decreased vision
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement (infiltrate, ulcer, or scarring)
- Conjunctival scarring
- Lack of response to therapy after 2-3 weeks
- Recurrent episodes
- History of herpes simplex virus eye disease
- Immunocompromised state
- Recent ocular surgery
- Vesicular rash on eyelids or nose
- History of rheumatologic disease
Neonatal conjunctivitis: Requires prompt evaluation and may need hospitalization for parenteral therapy 2
Critical Pitfalls to Avoid
- Never prescribe antibiotics indiscriminately for viral conjunctivitis—this contributes to resistance and causes unnecessary toxicity 2
- Never use topical corticosteroids without close ophthalmology follow-up—risk of elevated IOP, cataracts, and worsening HSV infections 2
- Never delay systemic antibiotics for suspected gonococcal conjunctivitis while waiting for culture results—can result in corneal perforation and permanent vision loss 7
- Never use topical antibiotics alone for gonococcal or chlamydial conjunctivitis—systemic treatment is mandatory 2, 7
- Never allow contact lens wear during any form of infectious conjunctivitis 2
- Never miss corneal involvement on initial examination—requires careful slit-lamp biomicroscopy 1, 2
- Avoid chronic use of topical vasoconstrictors—can cause rebound hyperemia 2
Follow-Up Recommendations
Viral conjunctivitis:
- Re-evaluate within 1 week if severe with corneal involvement or pseudomembranes 2
- Return if symptoms persist beyond 2-3 weeks 2
Bacterial conjunctivitis:
Patients on topical corticosteroids:
- Regular IOP monitoring and periodic pupillary dilation 2
Chronic/recalcitrant conjunctivitis:
- May indicate underlying malignancy (sebaceous or squamous cell carcinoma)—requires further evaluation 2