What is the treatment for conjunctivitis (pink eye)?

Treatment of Conjunctivitis

Treatment of conjunctivitis depends entirely on the etiology: viral conjunctivitis requires only supportive care with artificial tears and cold compresses, bacterial conjunctivitis benefits from topical moxifloxacin 0.5% three times daily for 5-7 days in moderate-to-severe cases, and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing activity such as olopatadine or ketotifen. 1, 2

Viral Conjunctivitis

Avoid antibiotics entirely—they provide no benefit and may cause unnecessary toxicity. 1, 2

• Supportive care is the cornerstone of management, including refrigerated preservative-free artificial tears four times daily to dilute viral particles and inflammatory mediators, cold compresses for comfort, and topical antihistamines for symptomatic relief of itching. 3, 1, 2

• The disease is self-limited, typically resolving within 5-14 days without specific treatment. 1

• Patient education about contagiousness is critical—advise avoiding close contact for 10-14 days from symptom onset, strict handwashing with soap and water, avoiding sharing towels or pillows, and disinfecting surfaces with EPA-registered hospital disinfectant. 1, 2

• Topical corticosteroids may be considered only in severe cases with marked chemosis, severe lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close ophthalmology follow-up for monitoring intraocular pressure and cataract formation. 1, 2

• Never use topical corticosteroids in herpes simplex virus (HSV) conjunctivitis without antiviral coverage, as they potentiate viral replication and worsen infection. 1, 2

• For HSV conjunctivitis specifically, use topical ganciclovir 0.15% gel or trifluridine 1% solution, plus oral antivirals (acyclovir, valacyclovir, or famciclovir). 2

Bacterial Conjunctivitis

For moderate-to-severe bacterial conjunctivitis, prescribe topical moxifloxacin 0.5% one drop three times daily for 5-7 days. 1, 2, 4

• Mild bacterial conjunctivitis is self-limited and may resolve without treatment in 64% of cases by days 6-10, but topical antibiotics shorten the duration of clinical disease and allow earlier return to work or school. 1, 2, 5, 6

• No single antibiotic has demonstrated superiority over others, so choice can be based on dosing convenience, cost, and local resistance patterns. 1, 2

• Moxifloxacin 0.5% achieves clinical cure rates of 66-69% by day 5-6 and microbiological eradication rates of 84-94%. 4

• Alternative options include erythromycin ointment, polymyxin B/trimethoprim drops, or other fluoroquinolones if moxifloxacin is unavailable. 1

• Obtain conjunctival cultures and Gram staining if gonococcal infection is suspected (marked eyelid edema, severe purulent discharge, preauricular lymphadenopathy). 1, 2

Special Bacterial Pathogens Requiring Systemic Treatment

Gonococcal and chlamydial conjunctivitis require systemic antibiotics in addition to topical therapy—topical treatment alone is inadequate. 1, 2

• Gonococcal conjunctivitis in adults: Ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose, with daily follow-up until resolution. 1, 2

• Chlamydial conjunctivitis in adults: Azithromycin 1 g oral single dose or doxycycline 100 mg oral twice daily for 7 days. 1, 2

• Neonatal gonococcal conjunctivitis: Ceftriaxone 25-50 mg/kg IV or IM single dose, with hospitalization for parenteral therapy. 1, 2

• Neonatal chlamydial conjunctivitis: Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided into 4 doses for 14 days (monitor for infantile hypertrophic pyloric stenosis in infants <6 weeks). 2

• Evaluate and treat sexual partners, and consider sexual abuse in preadolescent children with gonococcal or chlamydial conjunctivitis. 1, 2

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) are first-line treatment for allergic conjunctivitis. 3, 1, 2

• Environmental modifications include wearing sunglasses as a barrier to airborne allergens, using cold compresses, refrigerated artificial tears to dilute allergens, and avoiding eye rubbing. 3, 1

• Avoid chronic use of topical vasoconstrictors, as they cause rebound vasodilation. 2

• Oral antihistamines may worsen dry eye syndrome and actually exacerbate allergic conjunctivitis, though they can be used adjunctively for concurrent allergic rhinitis. 3

• For refractory cases, a brief 1-2 week course of low side-effect profile topical corticosteroids can be added, with monitoring of intraocular pressure. 3, 1, 2

• Avoid punctal plugs in allergic conjunctivitis, as they prevent flushing of allergens and inflammatory mediators from the ocular surface. 3

Severe Vernal/Atopic Conjunctivitis

• For acute exacerbations, topical corticosteroids are usually necessary to control severe symptoms. 3

• Topical cyclosporine 0.05% in frequent dosing or cyclosporine 2% has demonstrated efficacy and may allow reduced steroid use. 3

• For severe sight-threatening atopic keratoconjunctivitis unresponsive to topical therapy, consider supratarsal corticosteroid injection or systemic immunosuppression (montelukast, oral cyclosporine, tacrolimus). 3

• Topical tacrolimus 0.1% applied conjunctivally is effective in patients who failed corticosteroids, cyclosporine, and/or antiallergy medications. 3

Red Flags Requiring Urgent Ophthalmology Referral

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

• Visual loss or decreased vision
• Moderate or severe pain
• Severe purulent discharge suggesting gonococcal infection
• Corneal involvement (infiltrate, ulcer, opacity, or subepithelial infiltrates)
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of herpes simplex virus eye disease
• Immunocompromised state
• Neonatal conjunctivitis (requires systemic treatment coordinated with pediatrician)
• Recent ocular surgery

Common Pitfalls to Avoid

• Never prescribe antibiotics indiscriminately for viral conjunctivitis—this contributes to resistance, causes unnecessary toxicity, and provides no benefit. 1, 2

• Never use topical corticosteroids without close ophthalmology follow-up, as they can prolong adenoviral infections, worsen HSV infections, cause elevated intraocular pressure, and promote cataract formation. 1, 2

• Do not miss gonococcal conjunctivitis—it can cause corneal perforation and requires immediate systemic treatment with daily monitoring. 1, 2

• Advise patients not to wear contact lenses during any form of infectious conjunctivitis. 1, 4

• If corticosteroids are used chronically, perform baseline and periodic measurement of intraocular pressure and pupillary dilation to evaluate for glaucoma and cataract. 3, 1