What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

Treatment of conjunctivitis must be tailored to the specific etiology—viral conjunctivitis requires only supportive care, bacterial conjunctivitis may benefit from topical antibiotics in moderate-to-severe cases, and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing activity. 1

Immediate Red Flags Requiring Ophthalmology Referral

Before initiating treatment, rule out serious conditions that mandate urgent specialist evaluation:

• Visual loss or decreased vision 1
• Moderate or severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 1
• Severe purulent discharge (especially concerning for gonococcal infection) 1
• Corneal involvement (fluorescein staining showing epithelial defects) 1
• Conjunctival scarring 1
• History of herpes simplex virus eye disease 1
• Immunocompromised state 1
• Recurrent episodes or lack of response to therapy 1

Viral Conjunctivitis

Clinical Features

• Watery discharge with follicular reaction on inferior tarsal conjunctiva 1
• Preauricular lymphadenopathy 1
• Often starts unilateral but becomes sequentially bilateral 1
• May have concurrent upper respiratory infection 1

Treatment Approach

Antibiotics should NOT be prescribed for viral conjunctivitis—they provide no benefit and may cause unnecessary toxicity. 1

Supportive care measures include:

• Artificial tears for symptomatic relief and to dilute viral particles 1, 2
• Cold compresses to reduce inflammation 1, 2
• Topical antihistamines for itching and discomfort 1
• Oral analgesics for pain management 3

Patient Education and Infection Control

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 3
• Strict hand hygiene with soap and water 1
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach (adenovirus survives for weeks on surfaces) 3
• Avoid sharing towels, pillows, or cosmetics 1

Severe Cases

For severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing blurred vision or photophobia, topical corticosteroids may be considered, but ONLY with mandatory close ophthalmology follow-up due to risks of increased intraocular pressure, cataract formation, prolonged viral shedding, and worsening of HSV infections if misdiagnosed 4, 3

• Prefer corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) 3
• Monitor intraocular pressure and perform periodic pupillary dilation 4
• Taper slowly to minimum effective dose 3

Follow-Up

• Re-evaluate within 1 week for severe disease 3
• Return if symptoms persist beyond 2-3 weeks for patients not on corticosteroids 3

Bacterial Conjunctivitis

Clinical Features

• Mucopurulent discharge with matted eyelids upon waking 1, 5
• Papillary (not follicular) reaction 1
• Lack of itching 5
• May be associated with otitis media, sinusitis, or pharyngitis in children 1

Treatment Approach

Mild bacterial conjunctivitis is self-limited and may resolve without antibiotics, but topical antibiotics can shorten duration and allow earlier return to school or work. 1, 5

For moderate-to-severe cases, prescribe a 5-7 day course of broad-spectrum topical antibiotic: 1

• Erythromycin ointment (apply approximately 1 cm up to 6 times daily) 6
• Polymyxin B/trimethoprim drops 1
• Fluoroquinolones 1

No specific antibiotic has proven superiority—choose the most convenient or least expensive option. 1

Special Bacterial Pathogens

Gonococcal Conjunctivitis:

• Requires systemic antibiotics PLUS topical therapy 1
• Hospitalization may be necessary for parenteral therapy 1
• Daily follow-up until resolution 1
• Treat sexual contacts concurrently 1
• Can cause corneal perforation if untreated 1

Chlamydial Conjunctivitis:

• Requires systemic antibiotic therapy (topical alone is inadequate, as >50% of infants have infection at other sites) 1
• Treat sexual contacts concurrently 1
• In low-resource settings, povidone-iodine 1.25% ophthalmic solution can be used 1

Follow-Up

• Return for evaluation if no improvement after 3-4 days of treatment 1

Allergic Conjunctivitis

Clinical Features

• Itching is the most consistent and distinguishing feature 1, 5
• Bilateral presentation 1
• Watery discharge with mild mucous component 1
• May have concurrent allergic rhinitis or asthma 1
• Absence of preauricular lymphadenopathy and matted eyelids 1

Treatment Approach

First-line: Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1, 5, 2

Environmental modifications: 1

• Wear sunglasses as barriers to airborne allergens
• Apply cold compresses
• Use refrigerated artificial tears to dilute allergens and inflammatory mediators
• Avoid eye rubbing (can lead to keratoconus progression) 4

For persistent or recurrent cases:

• Mast cell stabilizers can be used 1
• Oral antihistamines (less effective than topical for ocular symptoms) 1

For severe cases:

• Brief course (1-2 weeks) of topical corticosteroids with low side-effect profile (such as loteprednol etabonate) 1, 7
• Monitor intraocular pressure if corticosteroids used chronically 4

Refractory cases:

• Topical cyclosporine 0.05% or tacrolimus can be considered 4
• Consultation with allergist for allergen-specific immunotherapy 4

Vernal/Atopic Conjunctivitis

For severe sight-threatening cases:

• Topical cyclosporine 0.05% has been shown effective and may reduce need for steroids 4
• Topical tacrolimus 0.1% for patients who failed other therapies 4
• Supratarsal corticosteroid injection for cases not responsive to topical therapy 4

Critical Pitfalls to Avoid

• Never use antibiotics indiscriminately for viral conjunctivitis—they cause unnecessary toxicity and contribute to resistance 1, 3
• Never use topical corticosteroids without confirming the diagnosis is NOT HSV—they can worsen HSV infections and cause corneal scarring 3
• Avoid punctal plugs in allergic conjunctivitis—they prevent flushing of allergens and inflammatory mediators 4
• Discontinue contact lens wear during any infectious conjunctivitis 1
• Consider child abuse in sexually transmitted conjunctivitis in children—mandates appropriate reporting 1
• Monitor for keratoconus in allergic/atopic patients—control allergy and eye rubbing to decrease ectasia progression 4

Neonatal Conjunctivitis

Requires immediate ophthalmology referral and may necessitate hospitalization for parenteral therapy. 1, 3

• Gonococcal prophylaxis: Erythromycin ointment approximately 1 cm into each lower conjunctival sac (do not flush) 6
• For infants born to mothers with clinically apparent gonorrhea: systemic penicillin G (50,000 units for term infants, 20,000 units for low birth weight)—topical prophylaxis alone is inadequate 6