What are the treatment options for conjunctivitis?

Treatment of Conjunctivitis

Treatment must be tailored to the specific etiology—bacterial conjunctivitis receives topical antibiotics (5-7 days of broad-spectrum fluoroquinolones), allergic conjunctivitis receives topical antihistamines with mast cell-stabilizing properties, and viral conjunctivitis receives supportive care only with artificial tears and cold compresses. 1, 2

Immediate Red Flags Requiring Ophthalmology Referral

Before initiating any treatment, you must immediately refer to ophthalmology if any of these are present:

• Visual loss suggests corneal involvement, uveitis, or serious pathology 1, 2
• Moderate to severe pain indicates possible keratitis, uveitis, or acute angle-closure glaucoma 1, 2
• Severe purulent discharge raises concern for gonococcal infection requiring systemic antibiotics 1, 2
• Corneal involvement on fluorescein staining (epithelial defects, infiltrates, ulcers) 1, 2
• Conjunctival scarring suggests severe or chronic disease 1, 2
• History of HSV eye disease increases recurrence risk 1, 2
• Immunocompromised state increases risk of atypical or severe infections 1, 2
• Lack of response after 3-4 days of appropriate therapy 1, 2
• Neonatal conjunctivitis requires systemic treatment and hospitalization 1, 2

Bacterial Conjunctivitis Treatment Algorithm

Mild Bacterial Conjunctivitis

• Often self-limited and resolves spontaneously in 1-2 weeks without treatment in immunocompetent adults 2, 3
• If treatment is chosen, prescribe 5-7 days of broad-spectrum topical antibiotic (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) applied 3 times daily 1, 2, 4
• No single antibiotic is superior to another, so choose based on cost, dosing convenience, and local resistance patterns 2

Moderate to Severe Bacterial Conjunctivitis

• Characterized by copious purulent discharge, pain, and marked inflammation 2
• Prescribe topical fluoroquinolones (moxifloxacin 0.5% three times daily for 7 days produces 66-69% clinical cure rates and 84-94% microbiological eradication) 4
• Obtain conjunctival cultures and Gram staining before treatment if gonococcal infection suspected 2
• Consider MRSA in nursing home patients or community-acquired infections—may require compounded vancomycin 2
• Instruct patients to clean eyelids with warm water and gentle soap before applying medication 5
• Re-evaluate in 3-4 days if no improvement 1, 2, 5

Gonococcal Conjunctivitis (Sexually Transmitted)

• Requires systemic antibiotics plus topical therapy—ceftriaxone 250 mg IM single dose PLUS azitromicina 1 g oral single dose 2, 5
• Daily monitoring until resolution is mandatory 1, 2
• Hospitalization may be necessary for severe cases and is mandatory for neonates 1, 5
• Treat sexual contacts concurrently and screen for concurrent genital infections 1, 2, 5
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 2
• Saline lavage promotes comfort and faster resolution 5

Chlamydial Conjunctivitis (Sexually Transmitted)

• Requires systemic antibiotics—azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 2, 5
• More than 50% of infants have infection at other sites, necessitating systemic therapy 1, 2
• For neonates: erythromycin base 50 mg/kg/day oral divided in 4 doses for 14 days 2
• Treat sexual contacts concurrently 1, 2, 5
• Re-evaluate after treatment due to 19% treatment failure rate 5
• In low-resource settings, povidone-iodine 1.25% ophthalmic solution can be used 1, 2

Viral Conjunctivitis Treatment

Adenoviral Conjunctivitis (Most Common)

• No proven effective antiviral treatment exists for adenovirus 2, 6
• Supportive care only: refrigerated preservative-free artificial tears 4 times daily, cold compresses, and topical antihistamines for symptomatic relief 1, 2, 6
• Avoid topical antibiotics—they provide no benefit and risk toxicity and resistance 2, 3, 6
• Avoid topical corticosteroids—they can prolong adenoviral infections 1, 2, 5
• Look for preauricular lymphadenopathy and concurrent upper respiratory infection as diagnostic clues 1
• Instruct patients to return if symptoms persist beyond 2-3 weeks 5

HSV Conjunctivitis

• Topical ganciclovir 0.15% gel OR topical trifluridine 1% solution is recommended 2, 7
• 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, 5
• Prolonged trifluridine use (>2 weeks) causes epithelial toxicity 2
• Immediate ophthalmology referral for any history of HSV eye disease 1, 2

Allergic Conjunctivitis Treatment

First-Line Treatment

• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice for both acute and chronic allergic conjunctivitis 1, 2, 5
• Simple measures: wear sunglasses as allergen barriers, apply cold compresses, use refrigerated artificial tears 1, 5
• Identify and avoid allergen triggers 1

Persistent or Recurrent Cases

• Add mast cell stabilizers (cromolyn sodium) for prophylaxis 1, 5
• For severe cases not controlled by above measures, add brief 1-2 week course of low side-effect profile topical corticosteroids (fluorometholone, loteprednol, or rimexolone) 1, 2, 5
• Monitor intraocular pressure and for cataract formation if using corticosteroids 2, 5
• Taper corticosteroids once inflammation is controlled 5

Contact Lens-Related (Giant Papillary Conjunctivitis)

• Discontinue contact lens wear until cornea returns to normal 2, 5
• Brief topical corticosteroids (1-2 weeks) plus longer-term topical cyclosporine 0.05% 5
• Consider daily disposable lenses, more frequent replacement, or switching to eyeglasses 5

Critical Pitfalls to Avoid

• Never use topical corticosteroids indiscriminately—they prolong adenoviral infections, worsen HSV infections, and can cause glaucoma and cataracts 1, 2, 5
• Never use topical antibiotics for viral conjunctivitis—they provide no benefit and risk toxicity and resistance 2, 3, 6
• Never use topical therapy alone for gonococcal or chlamydial conjunctivitis—systemic antibiotics are mandatory 1, 2, 5
• Never miss sexual abuse in children with sexually transmitted conjunctivitis 2
• Never delay referral for gonococcal conjunctivitis—it can cause corneal perforation and vision loss 2
• Chronic use of vasoconstrictor agents causes rebound vasodilation 5
• Oral antihistamines may worsen dry eye syndrome 5

Infection Control Measures

• Strict handwashing with soap and water is the single most important preventive measure 1, 6
• Avoid close contact for 7-14 days from symptom onset in viral conjunctivitis 2
• Do not share towels, pillows, or cosmetics 1
• Disinfect surfaces with EPA-registered disinfectant or 1:10 bleach solution 1
• Discard multiple-dose eyedrop containers to avoid cross-contamination 2
• Discontinue contact lens use until complete resolution 1