What is the treatment for conjunctivitis in an otherwise healthy individual?

Treatment of Conjunctivitis

Treatment depends entirely on the etiology: use topical fluoroquinolones (moxifloxacin or levofloxacin) for bacterial conjunctivitis, topical antihistamines with mast cell-stabilizing properties for allergic conjunctivitis, and supportive care only for viral conjunctivitis. 1

Bacterial Conjunctivitis

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

First-Line Antibiotic Options

• Topical fluoroquinolones are the preferred first-line agents, including moxifloxacin 0.5%, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin, as they provide excellent coverage against Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. 1
• Moxifloxacin 0.5% three times daily offers superior gram-positive coverage, including activity against some MRSA strains, with an 81% complete resolution rate at 48 hours. 1
• No specific topical antibiotic has proven superiority over another, so choose based on dosing convenience, cost, and local resistance patterns. 1
• Alternative options include erythromycin ointment, polymyxin B/trimethoprim drops, or gentamicin if fluoroquinolones are unavailable. 1

Important Clinical Context

• Mild bacterial conjunctivitis is often self-limited and resolves spontaneously in 1-2 weeks without treatment. 1, 2
• However, topical antibiotics provide earlier clinical and microbiological remission (68.2% cure rate vs 55.5% with placebo by days 4-9), allowing faster return to work or school. 1
• Instruct patients to return if no improvement occurs after 3-4 days of treatment. 1, 3

Severe or Complicated Bacterial Conjunctivitis

For severe bacterial conjunctivitis with copious purulent discharge, pain, and marked inflammation, obtain conjunctival cultures and Gram staining before initiating treatment. 1

• Consider MRSA in patients from nursing homes or with community-acquired infections—compounded topical vancomycin may be needed for resistant cases. 1
• Gonococcal conjunctivitis requires immediate systemic antibiotics: ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose, with daily monitoring until resolution. 1, 3
• Chlamydial conjunctivitis requires systemic therapy: azithromycin 1 g oral single dose or doxycycline 100 mg oral twice daily for 7 days, as more than 50% of infants have infection at other sites. 1, 3
• Treat sexual partners concurrently and consider sexual abuse in children with gonococcal or chlamydial conjunctivitis. 1, 3

Viral Conjunctivitis

No proven effective treatment exists for adenoviral conjunctivitis—management is supportive care only. 1

Supportive Care Measures

• Prescribe refrigerated preservative-free artificial tears four times daily to dilute viral particles and inflammatory mediators. 1
• Recommend cold compresses for symptomatic relief. 1, 4
• Topical antihistamines may be used for itching and discomfort, though they do not alter disease course. 1
• Avoid topical antibiotics entirely, as they provide no benefit and may cause toxicity. 1, 3

Special Viral Etiologies

• For HSV conjunctivitis, use topical ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily, plus oral antivirals (acyclovir, valacyclovir, or famciclovir). 1
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage, as they potentiate infection. 1
• For severe adenoviral conjunctivitis with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, topical corticosteroids may be considered with close ophthalmology monitoring for elevated intraocular pressure and cataract formation. 1

Infection Control

• Emphasize strict hand hygiene with soap and water to prevent transmission. 1, 4
• Advise avoiding close contact for 7-14 days from symptom onset. 1
• Discard multiple-dose eyedrop containers to avoid cross-contamination. 1

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are first-line treatment for allergic conjunctivitis. 1, 3, 2

Treatment Algorithm

• First-line: Prescribe second-generation topical antihistamine/mast cell stabilizers (olopatadine or ketotifen). 1, 3
• Adjunctive measures: Recommend cold compresses, refrigerated preservative-free artificial tears, and sunglasses as an allergen barrier. 1, 3
• Second-line: If symptoms persist, add a brief 1-2 week course of low side-effect profile topical corticosteroids, with monitoring of intraocular pressure and for cataract. 1, 3
• Avoid chronic use of topical vasoconstrictors, as they cause rebound vasodilation. 1
• Oral antihistamines may worsen dry eye syndrome and actually exacerbate allergic conjunctivitis. 1

Identifying Allergic Conjunctivitis

• Itching is the most consistent and distinguishing feature. 1, 2, 5
• Typically bilateral with watery discharge and no preauricular lymphadenopathy. 1, 4
• Often seasonal or perennial with concurrent allergic rhinitis or asthma. 6

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present: 1, 6, 3

• Visual loss or decreased vision
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement (fluorescein staining showing epithelial defects, infiltrate, ulcer, or opacity)
• 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)

Common Pitfalls to Avoid

• Delayed referral for gonococcal conjunctivitis can lead to corneal perforation and vision loss—this requires systemic antibiotics and daily monitoring. 1
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage potentiates infection. 1
• Prolonged use of topical trifluridine (>2 weeks) causes epithelial toxicity. 1
• Indiscriminate use of topical antibiotics for viral conjunctivitis contributes to resistance and causes unnecessary adverse effects. 1, 3
• Failing to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis. 1, 3