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

Management and Treatment of Conjunctivitis

For mild bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic (moxifloxacin 0.5% three times daily is preferred), while viral conjunctivitis requires only supportive care with artificial tears and cold compresses, and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing properties. 1, 2

Initial Diagnostic Approach

Determine the etiology based on specific clinical features:

Viral Conjunctivitis:

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 1, 2
• Preauricular lymphadenopathy present 1, 3
• Often starts unilateral but becomes sequentially bilateral 3
• May have concurrent upper respiratory infection 3
• Subconjunctival hemorrhages and chemosis are distinctive findings 3

Bacterial Conjunctivitis:

• Mucopurulent discharge with matted eyelids on waking 2, 3
• Papillary (not follicular) reaction 3
• Can be unilateral or bilateral 3
• Preauricular lymphadenopathy less common unless hypervirulent organisms 3

Allergic Conjunctivitis:

• Itching is the most consistent and distinguishing feature 2, 3
• Bilateral presentation with watery discharge 3
• History of atopy, asthma, or eczema 3
• Absence of preauricular lymphadenopathy 3

Treatment by Etiology

Bacterial Conjunctivitis

Mild to Moderate Cases:

• Topical moxifloxacin 0.5% one drop three times daily for 5-7 days 2, 4
• No single antibiotic demonstrates superiority; choice based on convenience and cost 1
• Alternative options include topical fluoroquinolones (levofloxacin, gatifloxacin, ciprofloxacin, besifloxacin) 2
• Clinical cure rates of 66-69% by Day 5-6 with microbiological eradication rates of 84-94% 4

Moderate to Severe Cases:

• Obtain conjunctival cultures and Gram staining before treatment 1
• Copious purulent discharge, pain, and marked inflammation characterize severe disease 1
• Consider MRSA in nursing home residents or community-acquired infections 1
• Compounded topical vancomycin may be required for MRSA if unresponsive to fluoroquinolones 1, 2

Special Bacterial Pathogens Requiring Systemic Therapy:

Gonococcal Conjunctivitis:

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 2
• Add topical antibiotics (though not strictly necessary) 1
• Saline lavage for comfort 1
• Daily follow-up until resolution mandatory 1
• Treat sexual contacts and consider sexual abuse in children 1
• Can cause corneal perforation if untreated 2

Chlamydial Conjunctivitis:

• Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 2
• Systemic therapy mandatory because >50% of infants have infection at other sites (nasopharynx, genital tract, lungs) 1
• No evidence supports adding topical therapy to systemic treatment 1
• Treatment failure rate up to 19%; re-evaluate after treatment 1
• Treat sexual contacts simultaneously and consider sexual abuse in children 1

Pediatric Bacterial Conjunctivitis:

• Topical fluoroquinolones approved for children >12 months 2, 5
• Neonatal conjunctivitis (birth to 28 days) requires immediate evaluation and systemic treatment 5
• Gonococcal neonatal: ceftriaxone 25-50 mg/kg IV or IM single dose 2
• Chlamydial neonatal: erythromycin base or ethylsuccinate 50 mg/kg/day oral divided into 4 doses for 14 days 2
• Monitor infants on erythromycin for infantile hypertrophic pyloric stenosis 2

Viral Conjunctivitis

Adenoviral Conjunctivitis (Most Common):

• Supportive care ONLY: refrigerated preservative-free artificial tears four times daily 2
• Cold compresses for symptomatic relief 2
• Topical antihistamines may reduce itching and discomfort 2
• Avoid topical antibiotics entirely—they provide no benefit and cause unnecessary toxicity 2, 3
• Self-limited, typically resolves within 5-14 days 3

Severe Adenoviral Cases:

• Consider topical corticosteroids ONLY for marked chemosis, severe lid swelling, epithelial sloughing, or membranous conjunctivitis 1, 2
• Requires close ophthalmology monitoring for elevated intraocular pressure and cataract 1, 2
• Use minimum effective dose with slow taper 2
• Measure intraocular pressure periodically and perform pupillary dilation 2

HSV Conjunctivitis:

• Topical ganciclovir 0.15% gel three to five times daily OR trifluridine 1% solution five to eight times daily 2
• Add oral antivirals (acyclovir, valacyclovir, or famciclovir) 2
• Topical corticosteroids are absolutely contraindicated—they potentiate HSV infection 1, 2
• Avoid trifluridine use >2 weeks due to epithelial toxicity 2

Allergic Conjunctivitis

First-Line Treatment:

• Topical antihistamines with mast cell-stabilizing properties (olopatadine or ketotifen) 2, 3
• Environmental modifications: sunglasses as allergen barrier, cold compresses, refrigerated artificial tears 2, 3
• Avoid eye rubbing 3

Second-Line Treatment:

• Brief 1-2 week course of low side-effect profile topical corticosteroids if symptoms persist 2
• Monitor intraocular pressure and evaluate for cataract with periodic pupillary dilation 2

Avoid:

• Chronic use of topical vasoconstrictors (cause rebound vasodilation) 2
• Oral antihistamines may worsen dry eye and exacerbate allergic conjunctivitis 2

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if ANY of the following present:

• Visual loss or decreased vision 1
• Moderate or severe pain 1
• Severe purulent discharge 1
• Corneal involvement (infiltrate, ulcer, opacity) 1
• Conjunctival scarring 1
• Lack of response to therapy after 3-4 days 1
• Recurrent episodes 1
• History of HSV eye disease 1
• Immunocompromised state 1
• Neonatal conjunctivitis (mandatory) 1, 2

Follow-Up Recommendations

Routine Bacterial Conjunctivitis:

• Return in 3-4 days if no improvement 1

Gonococcal Conjunctivitis:

• Daily visits until complete resolution 1
• Interval history, visual acuity, and slit-lamp biomicroscopy at each visit 1

Chlamydial Conjunctivitis:

• Re-evaluate after treatment completion due to 19% failure rate 1
• Retest approximately 3 months after treatment 2

Severe Viral Conjunctivitis:

• Re-evaluate within 1 week if on corticosteroids 3
• Return if symptoms persist beyond 2-3 weeks 3

Infection Control and Prevention

Critical Measures:

• Strict hand hygiene with soap and water (most important) 1, 2
• Avoid close contact for 7-14 days from symptom onset in viral conjunctivitis 2
• Discard multiple-dose eyedrop containers to avoid cross-contamination 2
• Do NOT wear contact lenses during any infectious conjunctivitis 3, 4
• Avoid sharing towels, pillows, and personal items 3

Common Pitfalls to Avoid

Critical Errors:

• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage potentiates infection 1, 2
• Prescribing antibiotics for viral conjunctivitis contributes to resistance and causes toxicity 2, 3
• Missing gonococcal conjunctivitis leads to corneal perforation and vision loss 2
• Failing to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2
• Using oral antibiotics for routine bacterial conjunctivitis when topical therapy is appropriate 2
• Prolonged corticosteroid use (>2 weeks) without ophthalmology supervision risks glaucoma and cataracts 2

Alternative When Antibiotics Unavailable

• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics for bacterial and chlamydial conjunctivitis 1
• Particularly useful in low- to middle-income countries with limited antibiotic access 1