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

Management and Treatment of Conjunctivitis

The appropriate management of conjunctivitis depends entirely on the etiology: viral conjunctivitis requires only supportive care with artificial tears and cold compresses, bacterial conjunctivitis benefits from a 5-7 day course of broad-spectrum topical antibiotics (with moxifloxacin 0.5% preferred), and allergic conjunctivitis responds best to topical antihistamines with mast cell-stabilizing activity such as olopatadine or ketotifen. 1, 2

Initial Diagnostic Approach

Distinguish the etiology based on specific clinical features:

• Viral conjunctivitis presents with watery discharge, follicular reaction on inferior tarsal conjunctiva, preauricular lymphadenopathy, abrupt onset (often unilateral initially but becomes sequentially bilateral), and may have concurrent upper respiratory infection 1
• Bacterial conjunctivitis shows mucopurulent discharge with matted eyelids upon waking, papillary (not follicular) reaction, and preauricular lymphadenopathy is less common unless caused by hypervirulent organisms 1
• Allergic conjunctivitis is characterized by itching as the most consistent feature, bilateral presentation, watery discharge with mild mucous component, absence of preauricular lymphadenopathy, and may have concurrent allergic rhinitis or asthma 1, 3

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present:

• Visual loss or decreased vision 1, 2, 3
• Moderate or severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 1, 3
• Severe purulent discharge (may indicate gonococcal infection) 1, 2
• Corneal involvement (fluorescein staining showing epithelial defects, infiltrates, or ulceration) 1, 3
• Conjunctival scarring 1, 3
• History of herpes simplex virus eye disease 1, 2
• Immunocompromised state 1, 2
• Neonatal conjunctivitis (requires prompt evaluation and may need hospitalization for parenteral therapy) 1, 3

Treatment Algorithm by Etiology

Viral Conjunctivitis

Most cases are self-limited and resolve within 5-14 days without specific treatment: 1

• Supportive care only: Refrigerated preservative-free artificial tears 4 times daily, cold compresses for symptomatic relief, and topical antihistamines for itching 1, 2
• Avoid topical antibiotics entirely as they provide no benefit and may cause toxicity 1, 2
• Patient education: Highly contagious for 10-14 days from symptom onset; strict hand hygiene with soap and water, avoid sharing towels/pillows, disinfect surfaces with EPA-registered disinfectant 1
• Severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis: Consider topical corticosteroids (fluorometholone, rimexolone, or loteprednol) with extreme caution and close ophthalmology follow-up for monitoring intraocular pressure and cataract formation 1, 2
• HSV conjunctivitis: Topical ganciclovir 0.15% gel 3-5 times daily or trifluridine 1% solution 5-8 times daily, PLUS oral antivirals (acyclovir, valacyclovir, or famciclovir); never use corticosteroids without antiviral coverage as they potentiate viral replication 1, 2

Bacterial Conjunctivitis

Mild cases are often self-limited (64% resolve by days 6-10 without treatment), but topical antibiotics decrease duration and allow earlier return to work/school: 2, 4

• First-line treatment: Topical moxifloxacin 0.5% three times daily for 5-7 days (superior gram-positive coverage including some MRSA strains, 81% complete resolution at 48 hours) 2
• Alternative options if fluoroquinolones unavailable: Gentamicin, tetracycline, or ofloxacin 0.3% four times daily for 5-7 days; erythromycin ointment; polymyxin B/trimethoprim drops 1, 2
• No specific antibiotic is superior for uncomplicated cases; choose based on dosing convenience, cost, and local resistance patterns 1, 2
• Suspected MRSA (nursing home patients, community-acquired infections): May require compounded topical vancomycin if unresponsive to moxifloxacin within 48-72 hours 2
• Return for evaluation if no improvement after 3-4 days 2, 3

Special bacterial pathogens requiring systemic treatment:

• Gonococcal conjunctivitis: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose; obtain conjunctival cultures and Gram staining before treatment; requires daily follow-up until resolution; can cause corneal perforation 1, 2
• Chlamydial conjunctivitis: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days; topical therapy alone is inadequate; treat sexual partners concurrently; consider sexual abuse in children 1, 2
• Neonatal gonococcal: Ceftriaxone 25-50 mg/kg IV or IM single dose 2
• Neonatal chlamydial: 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

Allergic Conjunctivitis

First-line treatment with environmental modifications: 1, 2

• Topical antihistamines with mast cell-stabilizing activity: Olopatadine or ketotifen (most effective for ocular symptoms) 1, 2, 3
• Environmental modifications: Wear sunglasses as barrier to airborne allergens, cold compresses, refrigerated preservative-free artificial tears, avoid eye rubbing 1, 3
• Persistent/severe cases: Brief 1-2 week course of low side-effect profile topical corticosteroids (fluorometholone, rimexolone, or loteprednol) with monitoring of intraocular pressure 1, 2
• Refractory cases: Consider mast cell stabilizers for persistent symptoms; allergen-specific immunotherapy (more beneficial in children than adults) 1, 3
• Avoid chronic use of topical vasoconstrictors as they cause rebound vasodilation 2

Common Pitfalls to Avoid

• Indiscriminate use of topical antibiotics for viral conjunctivitis leads to unnecessary toxicity, adverse effects, and antibiotic resistance 1, 2
• Using topical corticosteroids without close ophthalmology follow-up risks elevated intraocular pressure, cataract formation, prolonged adenoviral infections, and worsening HSV infections 1, 2
• Never use corticosteroids in HSV conjunctivitis without antiviral coverage as they potentiate viral replication and can cause corneal perforation 1, 2
• Missing gonococcal or chlamydial conjunctivitis leads to poor outcomes including vision loss; these require systemic antibiotics and evaluation of sexual partners 1, 2
• Failing to consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 2, 3
• Prescribing oral antibiotics for routine bacterial conjunctivitis when topical drops are unavailable; instead use supportive care alone as mild cases are self-limited 2
• Contact lens wear during any form of infectious conjunctivitis should be avoided 1

Follow-Up Recommendations

• Viral conjunctivitis: Re-evaluate within 1 week if severe; return if symptoms persist beyond 2-3 weeks 1
• Bacterial conjunctivitis: Return if no improvement in 3-4 days 2, 3
• Patients on topical corticosteroids: Regular monitoring of intraocular pressure and periodic pupillary dilation 1, 2
• Gonococcal conjunctivitis: Daily visits until resolution 2
• Chlamydial/gonococcal: Retest approximately 3 months after treatment 2