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

Treatment of Conjunctivitis

Treatment of conjunctivitis must be directed at the specific etiology—viral conjunctivitis requires only supportive care, bacterial conjunctivitis benefits from topical antibiotics in moderate-to-severe cases, and allergic conjunctivitis responds to topical antihistamines with mast cell-stabilizing properties. 1

Initial Diagnostic Approach

Before initiating treatment, determine the etiology based on these clinical features:

Viral conjunctivitis typically presents with:

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 1
• Preauricular lymphadenopathy 1
• Often sequential bilateral involvement starting unilaterally 1
• Concurrent upper respiratory infection 1
• Subconjunctival hemorrhages and chemosis may be present 1

Bacterial conjunctivitis characteristically shows:

• Mucopurulent discharge with matted eyelids upon waking 1, 2
• Papillary rather than follicular reaction 1
• Absence of itching 2
• May be unilateral or bilateral 1

Allergic conjunctivitis is distinguished by:

• Itching as the most consistent feature 1
• Bilateral presentation 1
• Watery discharge with mild mucous component 1
• History of atopy, asthma, or eczema 1
• Absence of preauricular lymphadenopathy 1

Treatment by Etiology

Viral Conjunctivitis

Avoid antibiotics entirely for viral conjunctivitis, as they provide no benefit and may cause unnecessary toxicity. 1

Supportive care includes:

• Refrigerated preservative-free artificial tears four times daily to dilute viral particles and inflammatory mediators 3
• Cold compresses for symptomatic relief 4, 1
• Topical antihistamines for itching and discomfort (no specific standardized dose) 3
• Patient education about high contagiousness—minimize contact with others for 10-14 days from symptom onset 1

For severe adenoviral cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis, consider a brief course of topical corticosteroids with close ophthalmology monitoring for elevated intraocular pressure and cataract formation. 4, 1, 3 Use low side-effect profile steroids such as fluorometholone, rimexolone, or loteprednol 3.

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). 3 Never use topical corticosteroids in HSV without antiviral coverage, as they potentiate viral replication and worsen infection 1, 3.

Bacterial Conjunctivitis

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

For moderate-to-severe bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic. 1, 3

Topical moxifloxacin 0.5% three times daily for 5-7 days is the preferred first-line treatment, offering superior gram-positive coverage including some MRSA strains, with clinical cure rates of 66-69% by day 5-6 and microbiological eradication rates of 84-94%. 3, 5 No single antibiotic has demonstrated superiority, so choice can be based on dosing convenience, cost, and local resistance patterns 1, 3.

Alternative topical options if fluoroquinolones are unavailable:

• Erythromycin ointment 1
• Polymyxin B/trimethoprim drops 1
• Gentamicin 3
• Tetracycline 3
• Ofloxacin 0.3% four times daily 3

Gonococcal conjunctivitis requires systemic treatment: ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose, with daily follow-up until resolution. 3 This can cause corneal perforation if untreated 1.

Chlamydial conjunctivitis requires systemic treatment: azithromycin 1 g oral single dose or doxycycline 100 mg oral twice daily for 7 days, as more than 50% of infants have concurrent infection at other sites. 3, 6 Evaluate and treat sexual partners concurrently 1, 6.

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties (such as olopatadine or ketotifen) are first-line treatment for allergic conjunctivitis. 4, 1, 3

Environmental modifications:

• Wear sunglasses as barrier to airborne allergens 4, 6
• Use cold compresses and refrigerated artificial tears 4, 6
• Avoid eye rubbing 4
• Consider hypoallergenic bedding and frequent clothes washing 4

For persistent symptoms, add a brief 1-2 week course of low side-effect profile topical corticosteroids with monitoring of intraocular pressure. 4, 1, 3 Avoid chronic use of vasoconstrictor agents due to rebound vasodilation 4, 3.

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present:

• Visual loss or decreased vision 1, 3, 6
• Moderate or severe pain 1, 3, 6
• Severe purulent discharge 1, 3, 6
• Corneal involvement (infiltrate, ulcer, opacity) 1, 3, 6
• Conjunctival scarring 1, 3, 6
• Lack of response to therapy after 3-4 days 1, 6
• Recurrent episodes 1, 3, 6
• History of HSV eye disease 1, 3, 6
• Immunocompromised state 1, 3, 6
• Neonatal conjunctivitis 3, 6

Common Pitfalls to Avoid

Indiscriminate use of topical antibiotics or corticosteroids should be avoided—antibiotics can induce toxicity in viral cases, and corticosteroids can prolong adenoviral infections and worsen HSV infections. 4, 1, 6

• Do not prescribe oral antibiotics for routine bacterial conjunctivitis; they are reserved exclusively for gonococcal and chlamydial infections 3
• Do not use topical corticosteroids without confirming viral etiology and ruling out HSV 3
• Do not allow contact lens wear during any form of infectious conjunctivitis 3
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 3, 6
• Measure intraocular pressure periodically if using steroid-containing drops 3

Infection Control Measures

Strict hand hygiene with soap and water is the single most important measure to prevent transmission. 1, 3, 6

Additional measures:

• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 4, 3
• Avoid sharing towels, pillows, or cosmetics 6
• Discard multiple-dose eyedrop containers after inadvertent contact with ocular surface 4
• For tonometer disinfection, use dilute bleach soaks (1:10 sodium hypochlorite) for 5-10 minutes 4

Follow-Up Recommendations

• Patients with bacterial conjunctivitis should return if no improvement after 3-4 days 3, 6
• Severe viral conjunctivitis cases require re-evaluation within 1 week 1
• Patients on topical corticosteroids require regular monitoring of intraocular pressure and periodic pupillary dilation 1, 3
• Gonococcal conjunctivitis requires daily visits until resolution 3