What is the appropriate treatment plan and patient education for a patient diagnosed with conjunctivitis (pink eye)?

Treatment Plan for Pink Eye (Conjunctivitis)

Immediate Treatment Based on Etiology

For mild bacterial conjunctivitis, apply a broad-spectrum topical antibiotic (such as erythromycin ointment or fluoroquinolone drops) 1-3 times daily for 5-7 days directly into the conjunctival sac, which provides earlier clinical remission at days 2-5 compared to no treatment. 1

Bacterial Conjunctivitis Treatment

• Mild cases: Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) are effective against common pathogens including S. aureus, S. pneumoniae, and H. influenzae 1, 2
• Alternative options: Erythromycin ointment applied up to 6 times daily depending on severity, or bacitracin ointment 1-3 times daily 3, 4
• Moderate to severe cases: Obtain conjunctival cultures and Gram staining before treatment, especially if gonococcal infection or MRSA is suspected 1, 2
• Gonococcal conjunctivitis: Requires systemic antibiotics (ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose) with daily monitoring until resolution—topical treatment alone is insufficient 1, 2
• Chlamydial conjunctivitis: Systemic therapy mandatory (azithromycin 1 g oral single dose or doxycycline 100 mg oral twice daily for 7 days) because >50% have infection at other sites 1, 2

Viral Conjunctivitis Treatment

• Adenoviral conjunctivitis: No proven effective treatment for virus eradication—provide symptomatic care with refrigerated preservative-free artificial tears 4 times daily, topical antihistamines, and cold compresses 1, 2
• Avoid antibiotics as they provide no benefit and cause potential adverse effects 1, 2
• HSV conjunctivitis: Apply topical ganciclovir 0.15% gel 3-5 times daily or topical trifluridine 1% solution 5-8 times daily; oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used 1, 2
• Never use topical corticosteroids without antiviral coverage in HSV as they potentiate infection 1, 2

Allergic Conjunctivitis Treatment

• First-line: Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1, 2
• Adjunctive measures: Cold compresses, refrigerated preservative-free artificial tears, sunglasses as allergen barrier 2, 5
• Refractory cases: Brief 1-2 week course of low side-effect profile topical corticosteroids (fluorometholone, rimexolone, or loteprednol) with monitoring of intraocular pressure 2, 6

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately for: 1, 2, 5

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

Patient Education

Infection Control Measures

• Strict hand hygiene with soap and water is the most critical measure to prevent transmission 2, 5
• Avoid close contact for 7-14 days from symptom onset in viral conjunctivitis 2
• Do not share towels, pillows, or personal items 5
• Disinfect surfaces with EPA-registered hospital disinfectant 5
• Discard multiple-dose eyedrop containers after infection resolves to avoid cross-contamination 2

Medication Application

• Apply ointment directly into the conjunctival sac, not on the eyelid surface 3, 4
• For ointment: approximately 1 cm ribbon into lower conjunctival sac 4
• Avoid gross contamination of the ointment tube tip 3
• In blepharitis, remove all scales and crusts before applying ointment to lid margins 3

Expected Course and Follow-Up

• Bacterial conjunctivitis: Return in 3-4 days if no improvement; complete resolution typically occurs within 7-10 days with appropriate treatment 1
• Viral conjunctivitis: Self-limited, typically resolves within 5-14 days; return if symptoms persist beyond 2-3 weeks 5
• Gonococcal conjunctivitis: Daily visits until resolution are necessary 1

Activity Restrictions

• Avoid contact lens wear during any form of infectious conjunctivitis 5
• Children may return to school/work after starting antibiotics for bacterial conjunctivitis (earlier return than without treatment) 7
• For viral conjunctivitis, minimize contact with others for 10-14 days from symptom onset due to high contagiousness 5

Warning Signs to Return Immediately

• Worsening pain or vision changes 1, 2
• Development of severe purulent discharge 1
• No improvement after 3-4 days of antibiotic treatment 1
• Development of light sensitivity or eye pain 1

Common Pitfalls to Avoid

• Delayed referral for gonococcal conjunctivitis leads to poor outcomes including corneal perforation—systemic antibiotics and daily monitoring are mandatory 1, 2
• Failure to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage potentiates infection 1, 2
• Prescribing antibiotics for viral conjunctivitis causes unnecessary adverse effects and promotes resistance 1, 2
• Failing to treat sexual contacts in chlamydial or gonococcal cases 1, 2
• Prolonged use of topical trifluridine (>2 weeks) can cause epithelial toxicity 2