What is the appropriate management of acute conjunctivitis in a young adult woman?

Management of Acute Conjunctivitis in Young Adult Women

For a young adult woman with acute conjunctivitis, determine the etiology first—most cases are viral and require only supportive care, while bacterial conjunctivitis benefits from topical antibiotics, and allergic conjunctivitis responds to topical antihistamine/mast-cell stabilizers. 1, 2

Diagnostic Approach: Distinguishing Etiology

Viral conjunctivitis is the most common cause overall and presents with: 3

• Watery discharge (not purulent)
• Follicular reaction on palpebral conjunctiva
• Preauricular lymphadenopathy
• Often bilateral with sequential involvement
• History of recent upper respiratory infection or sick contacts 1, 4

Bacterial conjunctivitis presents with: 3, 4

• Mucopurulent or purulent discharge
• Eyelids matted shut upon waking
• Absence of itching
• No history of recurrent conjunctivitis
• More commonly unilateral initially 5

Allergic conjunctivitis presents with: 2, 3

• Itching as the predominant symptom
• Watery discharge
• Bilateral presentation
• History of atopy or seasonal pattern
• Conjunctival chemosis 4

Treatment by Etiology

Viral Conjunctivitis (Most Common)

Supportive care only—no antibiotics: 1, 2

• Refrigerated preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 2
• Cold compresses for comfort 1, 4
• Topical antihistamines (second-generation) for symptomatic relief of itching 2

Critical infection control measures: 1, 2

• Strict handwashing with soap and water
• Avoid close contact for 10-14 days from symptom onset
• Use separate towels and pillowcases
• Discard multiple-dose eyedrop containers to prevent cross-contamination 2

Never use topical antibiotics in viral conjunctivitis—they provide no benefit, cause ocular toxicity, and promote antimicrobial resistance. 1, 2

Bacterial Conjunctivitis

Topical fluoroquinolones are first-line for 5-7 days: 2

• Moxifloxacin 0.5% three times daily offers superior gram-positive coverage including some MRSA strains 2
• Alternative options: levofloxacin, gatifloxacin, or besifloxacin 2
• If fluoroquinolones unavailable: gentamicin, tetracycline, or ofloxacin 0.3% four times daily 2

Expected outcomes: 2

• Topical antibiotics provide earlier clinical remission (68% cure vs 55% placebo by days 4-9)
• Allow faster return to work or school
• Natural resolution occurs in 64% of untreated cases by days 6-10 2

Important caveat: Mild bacterial conjunctivitis in immunocompetent adults is self-limited, but antibiotics shorten symptom duration and reduce transmissibility. 2, 3, 5

Allergic Conjunctivitis

Second-generation topical antihistamines with mast-cell stabilizing properties are first-line: 2

• Examples: olopatadine, ketotifen, azelastine
• Adjunctive measures: cold compresses, refrigerated preservative-free artificial tears, sunglasses as allergen barrier 2

For persistent symptoms: 2

• Add a brief 1-2 week course of low side-effect profile topical corticosteroids (fluorometholone, rimexolone, or loteprednol)
• Monitor intraocular pressure and for cataract formation 2

Avoid chronic topical vasoconstrictors—they cause rebound vasodilation. 2

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present: 1, 2, 4

• Visual loss or decreased vision
• Moderate to severe eye pain (beyond mild irritation)
• Severe purulent discharge suggesting gonococcal infection
• Corneal involvement (opacity, infiltrate, or ulcer)
• Conjunctival scarring
• History of herpes simplex virus eye disease
• Immunocompromised state
• Lack of response after 3-4 days of appropriate therapy
• Recent ocular surgery or trauma 4

Special Considerations for Young Adult Women

Sexually Transmitted Infections

Gonococcal conjunctivitis requires systemic therapy: 1, 2

• Presents with hyperacute onset, marked eyelid edema, and profuse purulent discharge
• Can cause corneal perforation within 24-48 hours if untreated
• Treatment: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose
• Obtain conjunctival cultures and Gram stain before treatment
• Daily monitoring until resolution
• Treat sexual partners and screen for concurrent genital infections 2

Chlamydial conjunctivitis requires systemic therapy: 1, 2

• Presents with follicular conjunctivitis, mucopurulent discharge, and distinctive follicles on bulbar conjunctiva
• Treatment: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days
• Topical antibiotics alone are insufficient
• Treat sexual partners and screen for cervicitis, urethritis, or pelvic inflammatory disease 2

Contact Lens Wearers

Higher risk of Pseudomonas infection: 2

• Discontinue contact lens use immediately
• Use fluoroquinolones (ofloxacin or ciprofloxacin) for better Pseudomonas coverage
• Consider corneal involvement and refer if present 3

Common Pitfalls to Avoid

Do not use combination antibiotic-steroid drops (e.g., Tobradex) without definitively excluding viral conjunctivitis—steroids potentiate HSV infection, prolong adenoviral shedding, and can cause corneal perforation. 1, 2

Do not use topical corticosteroids in HSV conjunctivitis without antiviral coverage—they exacerbate infection. 1, 2

Do not prescribe oral antibiotics for routine bacterial conjunctivitis—topical therapy achieves higher tissue concentrations and oral antibiotics are reserved exclusively for gonococcal and chlamydial infections. 2

Do not continue antibiotics beyond 7 days without ophthalmology consultation—prolonged use causes ocular toxicity. 2

Follow-Up Strategy

Return for evaluation if: 2

• No improvement after 3-4 days of appropriate treatment
• Worsening symptoms
• Development of any red flag signs

For gonococcal conjunctivitis: Daily visits until complete resolution 2

For chlamydial conjunctivitis: Re-evaluate after treatment completion; retest at 3 months 2