What is the recommended treatment for a dialysis patient with conjunctivitis?

Treatment of Conjunctivitis in Dialysis Patients

Dialysis patients with conjunctivitis should be treated according to the etiology (bacterial, viral, or allergic) using the same approach as the general population, with heightened vigilance for severe bacterial infections and prompt ophthalmology referral for any red flag symptoms. 1

Critical Red Flags Requiring Immediate Ophthalmology Referral

Before initiating treatment, assess for these urgent conditions that mandate same-day ophthalmology consultation in any patient, including those on dialysis:

• Visual loss or decreased vision suggests corneal involvement, uveitis, or other serious pathology 1, 2
• Moderate to severe pain indicates possible keratitis, uveitis, or acute angle-closure glaucoma 1, 2
• Severe purulent discharge may signal gonococcal infection requiring systemic antibiotics 1, 2
• Corneal involvement (epithelial defects on fluorescein staining) requires specialist management 1, 2
• History of HSV eye disease increases risk of recurrence and complications 1, 2
• Immunocompromised state (which dialysis patients may have) increases risk of atypical or severe infections 1, 2

Determining the Etiology

Bacterial Conjunctivitis Features:

• Mucopurulent discharge with matted eyelids on waking is the hallmark finding 1, 3
• Papillary reaction (not follicular) on tarsal conjunctiva 4
• Unilateral or bilateral presentation 1
• Absence of itching helps distinguish from allergic causes 3

Viral Conjunctivitis Features:

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 1, 4
• Preauricular lymphadenopathy is common 4, 2
• Concurrent upper respiratory infection often present 4
• Sequential bilateral involvement (starts unilateral, becomes bilateral) 4

Allergic Conjunctivitis Features:

• Itching is the most consistent and distinguishing feature 1, 4
• Bilateral presentation with watery discharge 4
• History of atopy, asthma, or eczema 4

Treatment Algorithm by Etiology

Bacterial Conjunctivitis

For mild to moderate bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic. 1

• Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) are effective against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 1, 5
• No specific antibiotic is superior to another, so choose based on cost and convenience 1, 4
• Gatifloxacin 0.5%: Instill one drop every 2 hours while awake (up to 8 times) on Day 1, then one drop 2-4 times daily on Days 2-7 5
• Mild bacterial conjunctivitis is often self-limited and may resolve without antibiotics, but topical therapy provides earlier clinical remission 1, 3

Important considerations for dialysis patients:

• Consider MRSA in dialysis patients, as they are at higher risk for healthcare-associated infections 1
• Obtain conjunctival cultures and Gram staining if severe purulent discharge suggests gonococcal infection 1
• Compounded topical vancomycin may be needed for MRSA cases 1

Special bacterial causes requiring systemic antibiotics:

• Gonococcal conjunctivitis: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose, with daily monitoring until resolution 1, 2
• Chlamydial conjunctivitis: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 1, 2
• Both require treatment of sexual partners and evaluation for concurrent genital infections 1, 2

Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—do not prescribe antibiotics. 1, 6

• Artificial tears (preferably preservative-free, refrigerated) 4 times daily to dilute viral particles and inflammatory mediators 1
• Cold compresses for comfort and to reduce inflammation 1, 6
• Topical antihistamines (second-generation) may be used for symptomatic relief of itching 1
• Strict hand hygiene with soap and water is critical to prevent transmission 1
• Avoid close contact for 7-14 days from symptom onset 1, 4

Critical pitfall: Never use topical antibiotics for viral conjunctivitis—they provide no benefit and may cause toxicity and resistance 1, 4, 6

HSV conjunctivitis requires antiviral therapy:

• Topical ganciclovir 0.15% gel OR topical trifluridine 1% solution 1
• Oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used 1
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage, as they potentiate infection 1, 4

Allergic Conjunctivitis

First-line treatment is topical antihistamines with mast cell-stabilizing activity. 1, 2

• Olopatadine or ketotifen are preferred agents 4, 2
• Environmental modifications: Wear sunglasses as allergen barrier, use cold compresses, refrigerated artificial tears 1, 2
• Avoid eye rubbing 4
• For persistent symptoms: Add mast cell stabilizers 2
• For severe cases: Brief 1-2 week course of low side-effect profile topical corticosteroids with monitoring of intraocular pressure 1, 4

Follow-Up Recommendations

• Bacterial conjunctivitis: Return if no improvement after 3-4 days of treatment 2
• Viral conjunctivitis: Return if symptoms persist beyond 2-3 weeks 4
• Any patient on topical corticosteroids: Regular monitoring of intraocular pressure and periodic pupillary dilation 4, 2

Common Pitfalls to Avoid

• Do not use combination antibiotic-steroid drops (like Tobradex) without definitively ruling out viral conjunctivitis, especially HSV, as corticosteroids can prolong adenoviral infections and worsen HSV infections 1, 4
• Do not prescribe antibiotics indiscriminately for viral conjunctivitis—this contributes to resistance and causes unnecessary toxicity 1, 4
• Do not miss gonococcal conjunctivitis—it can cause corneal perforation and requires immediate systemic treatment 1, 2
• Advise patients not to wear contact lenses during any form of infectious conjunctivitis 4, 5
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2