Management of Conjunctivitis in Adults and Children
For most cases of conjunctivitis, treatment should be tailored to the specific etiology: viral conjunctivitis requires only supportive care, bacterial conjunctivitis benefits from delayed antibiotic prescribing in uncomplicated cases, and allergic conjunctivitis responds to topical antihistamines with mast cell stabilizers. 1, 2
Initial Assessment: Differentiate by Clinical Features
Bacterial Conjunctivitis
- Purulent or mucopurulent discharge (green or yellow) that mats the eyelids, especially upon waking 2
- More common in children; typically bilateral presentation 2, 3
- Lack of itching and absence of prior conjunctivitis history favor bacterial etiology 3
Viral Conjunctivitis
- Watery to serofibrinous discharge with burning or gritty sensation 2, 4
- More common in adults; may start unilateral before becoming bilateral 2, 5
- Often accompanied by pharyngitis, fever, or upper respiratory symptoms (pharyngoconjunctival fever) 2
- Periauricular or preauricular lymphadenopathy is characteristic 2
Allergic Conjunctivitis
- Bilateral itching is the most consistent and distinguishing feature 3
- Watery discharge without mattering 5
- Seasonal pattern or environmental trigger history 6
Critical Red Flags Requiring Immediate Ophthalmology Referral
Always examine the cornea with fluorescein staining in any purulent conjunctivitis to detect early corneal involvement. 2
Emergency Situations
- Severe purulent discharge in sexually active adults or neonates—suspect gonococcal conjunctivitis, which can cause corneal perforation within 24-48 hours 2
- Dendritic lesions on fluorescein staining—indicates HSV keratitis requiring antiviral therapy 2
- Vesicular rash on eyelids—suggests HSV or varicella zoster virus requiring systemic treatment 2
- Visual loss, moderate-to-severe pain, or corneal opacity 2, 7
- Contact lens wearers with purulent discharge—risk of bacterial keratitis 3, 6
Special Populations
- Any purulent conjunctivitis in neonates is an emergency until gonococcal and chlamydial causes are excluded 2
- Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 2, 7
- Immunocompromised patients require immediate referral due to atypical presentations and severe complications 2, 7
Treatment by Etiology
Bacterial Conjunctivitis in Adults and Children >2 Months
Delayed antibiotic prescribing is preferred for uncomplicated cases—provide a prescription but advise waiting 2-3 days before filling if symptoms do not improve, as most cases resolve spontaneously within 1-2 weeks. 2, 3
When to Use Immediate Topical Antibiotics
- Purulent discharge with desire for rapid return to school/work 2
- Trimethoprim-polymyxin B: 1 drop every 3 hours (maximum 6 doses/day) for 7-10 days in adults and children >2 months 8
- Topical antibiotics increase 7-day cure rate by absolute risk difference of 0.09 and shorten symptom duration 2
Infants (Under 2 Years)
- Broad-spectrum topical antibiotic applied 4 times daily for 5-7 days 7
- Return for evaluation if no improvement after 3-4 days 7
- Nasolacrimal duct obstruction is a common predisposing factor 7
Special Bacterial Pathogens Requiring Systemic Therapy
Gonococcal Conjunctivitis:
- Obtain conjunctival cultures and Gram stain before treatment 7
- Ceftriaxone 125 mg IM (single dose for adults; 25-50 mg/kg for infants, max 125 mg) 2, 7
- Add topical antibiotics and saline lavage for comfort 7
- Daily ophthalmology follow-up until complete resolution 2, 7
- Screen and treat sexual partners 7
- Infants require hospitalization 7
Chlamydial Conjunctivitis:
- Presents with follicles on bulbar conjunctiva and semilunar fold 2
- Systemic antibiotics required—topical therapy alone is insufficient 2
- For infants: Erythromycin base or ethylsuccinate 50 mg/kg/day divided into 4 doses for 14 days (80% efficacy; second course may be needed) 7
- More than 50% of infants have infection at other sites (nasopharynx, genital tract, lungs) 7
- Screen and treat mother and sexual partners 7
Viral Conjunctivitis
Treatment is supportive only—viral conjunctivitis is self-limited, resolving within 5-14 days. 2, 3
Supportive Care
- Preservative-free artificial tears for symptom relief 7, 4
- Cold compresses to reduce discomfort 5
- Topical antihistamine eye drops for itching 5
Infection Control
- Strict hand hygiene and avoid touching eyes 4, 9
- Avoid sharing towels or close contact during period of contagion 1, 9
- Avoid group activities while discharge is present 9
- Disinfect surfaces with EPA-registered hospital disinfectant 1
- Tonometers should be disinfected with 1:10 dilute bleach solution 1
HSV Conjunctivitis
- Mild cases without corneal involvement are self-limiting within 4-7 days 2
- Corneal involvement (dendritic keratitis) requires prompt ophthalmology referral and antiviral therapy 2
- Unilateral presentation with minimal watery discharge and periauricular lymphadenopathy 2
Adenoviral Pharyngoconjunctival Fever
- Monitor for progression to epidemic keratoconjunctivitis with subepithelial infiltrates 2
- Severe cases may develop pseudomembranes associated with conjunctival scarring, symblepharon, and lacrimal stenosis 2
Allergic Conjunctivitis
Topical antihistamines with mast cell-stabilizing activity are first-line treatment. 5, 3
- Olopatadine: 1 drop in affected eye(s) twice daily, every 6-8 hours (adults and children ≥2 years) 10
- Wait at least 5 minutes between different ophthalmic products 10
- Systemic antihistamines are an alternative 6
- Preservative-free artificial tears for additional symptom relief 7
Common Pitfalls to Avoid
- Indiscriminate use of topical antibiotics or corticosteroids—viral conjunctivitis will not respond to antibacterials, and mild bacterial conjunctivitis is self-limited 1
- Topical corticosteroids can mask serious conditions and lead to complications 9
- Missing gonococcal or chlamydial infection in sexually active adults or neonates—these require systemic therapy to prevent corneal perforation and systemic complications 2, 7
- Failure to fluorescein stain the cornea in purulent conjunctivitis—early corneal involvement changes management 2
- Treating contact lens wearers as simple bacterial conjunctivitis—always refer to evaluate for corneal ulcers 3, 6
Infectious Period and Return to Activities
- Bacterial conjunctivitis: Non-infectious after 24-48 hours of appropriate antibiotic treatment 11
- Gonococcal conjunctivitis: Non-infectious after 24 hours of systemic antibiotics 11
- Chlamydial conjunctivitis: Can persist 3-12 months without treatment 11
- Infants should not attend daycare until 24 hours of antibiotic treatment completed 11