What is the appropriate treatment and management for a patient presenting with conjunctivitis?

Treatment and Management of Conjunctivitis

The appropriate treatment for conjunctivitis depends entirely on the etiology: viral conjunctivitis requires only supportive care with artificial tears and cold compresses, bacterial conjunctivitis benefits from a 5-7 day course of broad-spectrum topical antibiotics (such as moxifloxacin or polymyxin B/trimethoprim), and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing activity like olopatadine or ketotifen. 1

Initial Diagnostic Approach

The first critical step is determining the etiology through focused history and examination, as treatment differs fundamentally between viral, bacterial, and allergic causes. 1, 2

Key distinguishing features to assess:

• Discharge character: Watery discharge suggests viral or allergic etiology, while mucopurulent discharge with matted eyelids upon waking strongly indicates bacterial conjunctivitis 1, 3
• Itching: The most consistent and distinguishing feature of allergic conjunctivitis; its absence favors infectious causes 1, 3
• Conjunctival reaction: Follicular reaction on inferior tarsal conjunctiva indicates viral etiology, while papillary reaction suggests bacterial or allergic causes 1
• Preauricular lymphadenopathy: Present in viral conjunctivitis (especially adenoviral), less common in bacterial unless caused by hypervirulent organisms 1
• Laterality: Viral typically starts unilateral but becomes sequentially bilateral; bacterial can be either; allergic is characteristically bilateral 1
• Associated symptoms: Concurrent upper respiratory infection suggests viral; history of atopy, asthma, or seasonal pattern suggests allergic 1, 2

Treatment by Etiology

Viral Conjunctivitis

Viral conjunctivitis is self-limited (resolving in 5-14 days) and requires only supportive care—antibiotics provide no benefit and should be avoided to prevent unnecessary toxicity and resistance. 1, 4

Supportive management includes:

• Artificial tears (preferably preservative-free, refrigerated) 4 times daily to dilute viral particles and inflammatory mediators 1, 4
• Cold compresses for symptomatic relief 1, 4
• Topical antihistamines for relief of itching and discomfort 1, 4

Patient education is critical:

• Highly contagious for 10-14 days from symptom onset—minimize contact with others 1
• Strict hand hygiene with soap and water 1, 4
• Avoid sharing towels, pillows, or personal items 1
• Discard multiple-dose eyedrop containers to prevent cross-contamination 4

Special consideration for severe cases:

• Topical corticosteroids may be considered for severe viral conjunctivitis with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close ophthalmology follow-up for monitoring intraocular pressure and cataract formation 1, 4
• Never use corticosteroids in HSV conjunctivitis without antiviral coverage, as they potentiate infection 1, 4

HSV conjunctivitis requires specific treatment:

• Topical ganciclovir 0.15% gel or topical trifluridine 1% solution 4
• Oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used 4
• Avoid topical corticosteroids as they worsen HSV infection 4
• Prolonged use of topical trifluridine beyond 2 weeks can cause epithelial toxicity 4

Bacterial Conjunctivitis

For moderate to severe bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic—no specific agent is superior, so choose based on convenience, cost, and local resistance patterns. 1, 4

Mild bacterial conjunctivitis is often self-limited and may resolve without treatment, but topical antibiotics decrease duration and allow earlier return to school or work. 1, 3

First-line antibiotic options:

• Topical moxifloxacin 0.5% three times daily (superior gram-positive coverage including some MRSA strains, with 81% complete resolution at 48 hours) 4
• Polymyxin B/trimethoprim drops 1
• Erythromycin ointment 1
• Other fluoroquinolones (levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) 4

Patients should return for evaluation if no improvement after 3-4 days of treatment. 2

Critical exceptions requiring systemic antibiotics:

• Gonococcal conjunctivitis: Presents with marked eyelid edema, severe purulent discharge, and can cause corneal perforation 1

  • Adult treatment: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 4
  • Neonatal treatment: Ceftriaxone 25-50 mg/kg IV or IM single dose 4
  • Requires daily monitoring until resolution and hospitalization for severe cases 4, 2
  • Obtain conjunctival cultures and Gram staining before initiating treatment 4
  • Treat sexual contacts concurrently 2

• Chlamydial conjunctivitis: Requires systemic therapy as topical treatment alone is inadequate 1, 4

  • Adult treatment: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 4
  • Neonatal treatment: Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided in 4 doses for 14 days (more than 50% of infants have infection at other sites) 4, 2
  • Treat sexual contacts and consider sexual abuse in children 4, 2
  • In low-resource settings, povidone-iodine 1.25% ophthalmic solution can be used 2

Consider MRSA in patients from nursing homes or with community-acquired infections; fluoroquinolones remain effective, though compounded vancomycin may be needed for resistant cases. 1, 4

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) are first-line treatment for allergic conjunctivitis. 1, 4, 2

Comprehensive management approach:

• Environmental modifications: 1, 2

  • Wear sunglasses as barrier to airborne allergens
  • Apply cold compresses
  • Use refrigerated preservative-free artificial tears
  • Avoid eye rubbing
  • Identify and avoid allergen triggers

• Pharmacologic treatment: 1, 2

  • First-line: Topical antihistamines with mast cell-stabilizing properties (olopatadine, ketotifen)
  • For persistent/recurrent cases: Mast cell stabilizers
  • For severe refractory cases: Brief 1-2 week course of low side-effect profile topical corticosteroids with monitoring of intraocular pressure 1, 2

• Adjunctive measures: 1

  • Oral antihistamines (less effective than topical for ocular symptoms)
  • Allergen-specific immunotherapy (more beneficial in children than adults)
  • Multidisciplinary approach with allergists for severe cases

Giant papillary conjunctivitis in contact lens wearers:

• Discontinue contact lens use 4
• Topical anti-inflammatory agents 4
• Appropriate lens care and frequent replacement to prevent recurrence 1

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently to ophthalmology if any of the following are present: 1, 4, 2

• Visual loss or decreased vision
• Moderate or severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma)
• Severe purulent discharge (consider gonococcal infection)
• Corneal involvement (infiltrate, ulcer, opacity, or fluorescein staining showing epithelial defects)
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised state
• Neonatal conjunctivitis (requires systemic treatment coordinated with pediatrician)
• Recent ocular surgery
• Vesicular rash on eyelids or nose

Common Pitfalls to Avoid

• Never use topical antibiotics indiscriminately for viral conjunctivitis—they provide no benefit, cause unnecessary toxicity, and contribute to antibiotic resistance 1, 4, 2

• Never use topical corticosteroids without close ophthalmology follow-up—they can prolong adenoviral infections, worsen HSV infections, cause elevated intraocular pressure, and promote cataract formation 1, 4

• Never use corticosteroids in HSV conjunctivitis without concurrent antiviral coverage—they potentiate infection 1, 4

• Do not miss gonococcal or chlamydial conjunctivitis—delayed recognition leads to poor outcomes including corneal perforation and vision loss; these require systemic antibiotics, not just topical therapy 1, 4

• Always consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 4, 2

• Avoid chronic use of topical vasoconstrictors—can cause rebound hyperemia 1

• Discontinue contact lens wear during any infectious conjunctivitis 1

• Inadequate patient education about contagiousness leads to community spread—emphasize hand hygiene and isolation precautions for viral conjunctivitis 1

Follow-Up Recommendations

• Patients with severe viral conjunctivitis should be re-evaluated within 1 week 1
• Those not on corticosteroids should return if symptoms persist beyond 2-3 weeks 1
• Bacterial conjunctivitis patients should return if no improvement after 3-4 days of antibiotics 2
• Patients on topical corticosteroids require regular monitoring of intraocular pressure and periodic pupillary dilation 1, 4
• Gonococcal conjunctivitis requires daily follow-up until resolution 4, 2