eMedicine Specialties > Emergency Medicine > Ophthalmology
Conjunctivitis: Treatment & Medication
Updated: Jun 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Prehospital transport rarely is indicated for patients with conjunctivitis. More serious concerns may warrant emergency medical services (EMS) transport. Prehospital personnel should not overlook more serious comorbidity; they should focus on preventing transmission. Thorough hand washing by EMS personnel and glove use are necessary.
Treatment often is supportive. Artificial tears help the discomfort of keratitis and photophobia. Cold compresses improve the swelling and discomfort of the lids. Antibiotic drops help prevent a secondary bacterial infection. Reserve topical corticosteroids for use by an ophthalmologist when substantial inflammation is present and herpes simplex is excluded. Broad-spectrum antibiotics, such as Ciloxan (ciprofloxacin) or Ocuflox (ofloxacin), are good choices. Sulfacetamide is also acceptable. Aminoglycoside is toxic to epithelia and retards healing. Polytrim (trimethoprim/sulfamethoxazole) is a reasonable choice particularly in children.
Emergency Department Care
Physicians and other medical personnel must be careful not to transmit this infection. Prevention of transmission includes thorough hand washing and using eye drops in individual or unit dose containers. Patients can be given moist compresses for comfort.
For treatment guidelines, see the American Academy of Ophthalmology's guidelines.1
Consultations
Consult with an ophthalmologist for all serious eye complaints. Simple conjunctivitis usually can be followed up by the patient's primary care provider. Discuss with an ophthalmologist solutions to questions or equivocal diagnosis. Neisserial conjunctivitis is an ocular emergency and should be viewed as an ocular finding of systemic disease. Ophthalmologic consultation is essential.
Medication
Treatment with antimicrobials and symptomatic therapy is recommended for all patients initially presenting to the ED with simple conjunctivitis. Numerous topical antimicrobial agents may be used, including topical sulfacetamide, erythromycin, gentamicin, ciprofloxacin, or ofloxacin. Avoid neomycin-containing solutions because 8-15% of patients have hypersensitivity reactions. Instill drops every 2 hours. An ointment can be used at night or every 4-6 hours throughout the day.
Consider gonococcal conjunctivitis part of a systemic disease, thus requiring systemic treatment. Inpatient medical regimens include cefoxitin, ceftriaxone, cefotaxime, or spectinomycin. Treat all patients who have chlamydia with tetracycline, doxycycline, azithromycin, or erythromycin. Outpatient therapy is acceptable in less serious cases in which compliance can be ensured and includes ceftriaxone (50 mg/kg, not to exceed 1 g) IV followed by doxycycline 100 mg twice a day or erythromycin 500 mg qid. Identify and treat patients' sexual partners.
Chlamydial conjunctivitis can be treated with doxycycline 100 mg twice a day for 10 days or azithromycin 1 g. Erythromycin can be used in pregnant patients and infants.
Topical therapy with erythromycin also is recommended and may speed resolution. As with gonococcal infections, identify and treat patients' sexual partners.
Antibiotics, ophthalmic
Used for infectious conjunctivitis. Therapy must cover all likely pathogens in the context of the clinical setting. However, when prescribing the antibiotic, the care provider must take into account that the incidence of MRSA has continued to increase in recent years.The FDA has approved a new drug, besifloxacin, for the treatment of bacterial conjunctivitis.2
Ciprofloxacin 3% (Ciloxan)
Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase in susceptible organisms. Broad-spectrum antibiotic with good gram-positive and gram-negative coverage.
Adult
1-2 gtt q2h in conjunctival sac(s) during waking hours for 2 d, then 1-2 gtt q4h during waking hours for the next 5 d
Pediatric
Not established
None reported
Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
A white crystalline precipitate located in superficial portion of corneal defect may occur (onset in 1-7 d); precipitate usually is cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy
Gatifloxacin ophthalmic solution 0.3% (Zymar)
Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. Elicits a dual mechanism of action by possessing an 8-methoxy group, thereby inhibiting the enzymes DNA-gyrase and topoisomerase IV. DNA gyrase is involved in bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial cell division.
Indicated for bacterial conjunctivitis due to C propinquum, S aureus, S epidermidis, S mitis, S pneumoniae, or H influenzae.
Adult
Days 1-2: Instill 1 gtt into affected eye q2h while awake; not to exceed 8 administrations per day
Days 3-7: Instill 1 gtt into affected eye up to qid while awake
Pediatric
<1 year: Not established
>1 year: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For ophthalmic use only; commonly causes conjunctival irritation, increased lacrimation, corneal inflammation, or papillary conjunctivitis; less common adverse effects include conjunctival hemorrhage, dry eye, eye discharge, eye irritation, eye pain, eyelid swelling, headache, red eye, reduced visual acuity, or taste disturbance
Norfloxacin 0.3% (Noroxin, Chibroxin)
Inhibits bacterial growth by inhibiting DNA gyrase. Has limited use and is not readily available. Ciprofloxacin and ofloxacin are superior in spectrum and effectiveness. Approved for pediatric use in children >1 y.
Adult
1-2 gtt qid to affected eye for 7 d
Pediatric
<1 year: Not established
>1 year: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in deep ocular infections likely to become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms
Besifloxacin ophthalmic (Besivance)
Quinolone antimicrobial ophthalmic susp indicated for bacterial conjunctivitis. Susceptible bacteria include CDC coryneform group G (Corynebacterium pseudodiphtheriticum, Corynebacterium stratum), Haemophilus influenza, Moraxella lacunata, Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Streptococcus mitis, Streptococcus oralis, Streptococcus pneumoniae, and Streptococcus salivarius. Available as a 0.6% ophthalmic susp.
Adult
Instill 1 gtt in affected eye(s) tid (4-12 h between doses) for 7 d
Pediatric
<1 year: Not established
>1 year: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In clinical trials, adverse effects occurred in <3% of patients and included redness of eyes, blurred vision, eye pain, eye irritation, eye itching, and headache; do not use with contact lens (remove and do not wear contacts during course of therapy and with symptoms of bacterial conjunctivitis); for topical ophthalmic use only; prolonged use may lead to bacterial resistance
Bacitracin ointment 500 U/g (AK-Tracin, Baciguent)
Prevents transfer of mucopeptides into the growing cell wall, which results in inhibition of cell wall synthesis and, as a result, bacterial growth. Gram-positive better than gram-negative coverage.
Adult
Severe infections: Apply 0.25- to 0.5-in ribbon q3-4h into conjunctival sac for 7-10 d
Mild-to-moderate infections: Apply bid/tid
Pediatric
Not established
None reported
Documented hypersensitivity; vaccinia; varicella, epithelial herpes simplex keratitis; mycobacterial infections; fungal diseases of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Ophthalmic ointments may delay healing of corneal epithelia; in deep-seated infections of the eye, supplement with systemic medications; prolonged use may result in overgrowth of nonsusceptible organisms
Erythromycin ointment (Ilosone, E-Mycin)
Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections. Good gram-positive coverage.
Adult
Apply 0.5-in (1.25-cm) ribbon to affected eye 2-8 times/d, depending on severity of infection
Pediatric
Administer as in adults
Prophylaxis of neonatal gonorrhea and chlamydia: Apply 0.5- to 1.25-cm ribbon to each conjunctival sac
None reported
Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)
Azithromycin ophthalmic (Azasite)
Ophthalmic macrolide antibiotic. Indicated for bacterial conjunctivitis caused by CDC coryneform group G bacteria, Haemophilus influenzae, Staphylococcus aureus, Streptococcus mitis group, and Streptococcus pneumoniae.
Adult
Instill 1 gtt in affected eye(s) bid (administer doses 8-12 h apart) for 2 d, then 1 gtt qd for next 5 d
Pediatric
<1 year: Not established
>1 year: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Thoroughly wash hands before using; for topical ophthalmic use only; prolonged use may result in resistant organisms; do not wear contact lenses until infection resolves; may cause eye irritation; less common adverse effects include burning, stinging, and/or irritation when instilled; other less common adverse effects include contact dermatitis, corneal erosion, dry eyes, dysgeusia, nasal congestion, ocular discharge, punctate keratitis, and sinusitis
Gentamicin (Garamycin, Genoptic)
Aminoglycoside antibiotic (ointment or solution) used for gram-negative bacterial coverage. Tends to be toxic to epithelia and retards healing.
Adult
Solution: 1-2 gtt q4h to affected eye
Ointment: Apply 0.5-in (1.25-cm) ribbon bid/tid q3-4h to affected eye
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infections
Tobramycin (Tobrex, AKTob)
Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. Available as a solution, ointment, and lotion. Superior to gentamicin in that streptococcal species are often resistant to gentamicin.
Adult
Solution: 1-2 gtt q4h to affected eye during waking hours and less frequently at night; in severe infections, instill 2 gtt q30-60 min initially, followed by less frequent intervals
Ointment: Apply 0.5-in ribbon bid/tid in conjunctival sac; in severe infections, apply q3-4h
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Effects of this drug diminish when used concurrently with gentamicin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms
Sulfacetamide 10% (Bleph-10, Sodium Sulamyd)
Inhibits folic acid synthesis, which results in inhibition of bacterial growth. Has better gram-positive than gram-negative coverage. Available as solution, ointment, and lotion.
Adult
Solution: 1-3 gtt q2-3h in affected eye while awake, with less frequent administration at night
Ointment: Apply 0.5-in (1.25-cm) ribbon 1-4 times/d into conjunctival sac
Pediatric
<2 months: Not established
>2 months: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in severely dried eye; ointment may retard corneal epithelial healing; significant percentage of staphylococcal isolates are completely resistant; may sting when applied; do not use in deep ocular infections likely to become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms
Decongestants
Generally have vasoconstricting effects with ability to control pruritus.
Naphazoline 0.1%, (Clear Eyes, AK-Con, Opcon)
OTC drug for temporary relief of pruritus and hyperemia associated with mild allergic conjunctivitis. Has alpha-adrenergic effects in the arterioles of the conjunctiva and nasal mucosa to produce vasoconstriction.
Adult
1-2 gtt q2h prn; not to exceed qid; do not administer for more than 3-5 d
Pediatric
<6 years: Not recommended
>6 years: Administer as in adults
None reported with ophthalmic use; in systemic use, risk of hypertensive reactions increases when used concurrently with tricyclic antidepressants or MAOIs; toxicity increases when used concurrently with anesthetics
Documented hypersensitivity; narrow-angle glaucoma; do not use before a peripheral iridectomy is performed
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may cause rebound congestion; caution in diabetes, hypertension, heart disease, cerebral arteriosclerosis, hyperthyroidism, and asthma
Levocabastine (Livostin)
Most potent topical antihistamine available. Has rapid onset and sustained effect. Can be used as many as 4 times daily or prn.
Adult
1 gtt qid to affected eye
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in patients wearing soft contact lenses; not for injection
Mast cell stabilizers
Inhibit degranulation of sensitized mast cells following exposure to specific antigens.
Cromolyn 4%, (Intal)
Long-term use by patients with seasonal allergies; not used for short-term treatment. Alomide is a far more potent mast cell stabilizer. Patanol is a combination antihistamine and mast cell stabilizer and is used either bid/tid.
Adult
1-2 gtt q4-6h to each eye; use at regular intervals
Pediatric
<4 years: Not established
>4 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use with soft contact lenses in place; may experience a transient stinging or burning sensation after application; caution when withdrawing drug because symptoms may recur
Nonsteroidal anti-inflammatory agents (NSAIDs)
These agents are used for the treatment of allergic conjunctivitis. Although most NSAIDs are used primarily for anti-inflammatory effects, they are effective analgesics and are useful for the relief of mild-to-moderate pruritus. Ketorolac 0.4% has also been shown as effective in treating allergic conjunctivitis.3
Ketorolac 0.5%, (Acular, Toradol)
Approved for temporary relief of pruritus associated with allergic conjunctivitis. Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Adult
1 gtt qid to affected eye
Pediatric
Not established
None reported
Documented hypersensitivity; patients wearing soft contact lenses
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision, and macula degeneration
More on Conjunctivitis |
| Overview: Conjunctivitis |
| Differential Diagnoses & Workup: Conjunctivitis |
 Treatment & Medication: Conjunctivitis |
| Follow-up: Conjunctivitis |
| References |
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References
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Further Reading
Keywords
pink eye, pinkeye, conjunctivitis, bacterial conjunctivitis, viral conjunctivitis, keratoconjunctivitis, chlamydial conjunctivitis, follicular conjunctivitis, preauricular adenopathy, superficial keratitis, allergic conjunctivitis, giant papillary conjunctivitis, inflammation of the conjunctiva, purulent bacterial conjunctivitis, hyperpurulent conjunctivitis, Neisseria gonorrhoeae, conjunctival scarring, Chlamydia trachomatis, trachoma, adenovirus, herpes simplex, viral syndrome, sexually transmitted disease, STD, ophthalmia neonatorum, hyperacute purulent conjunctivitis, photophobia, keratitis sicca, trichiasis, chronic blepharitis, epidemic keratoconjunctivitis, vernalconjunctivitis, atopic conjunctivitis, shield corneal ulcers, Horner-Trantas dots, vernal keratoconjunctivitis, giant papillary conjunctivitis, chemosis, Staphylococcus epidermidis, Streptococcus pyogenes, Streptococcus pneumoniae, Neisseria meningitidis, Moraxella lacunata, Haemophilus, Enterobacteriaceae, Loa loa, Trichinella, Onchocerca, sicca, pemphigoid, sarcoidosis, tuberculosis, Reiter syndrome, Kawasaki disease
