Conjunctivitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul, M.D., Mohamed Moubarak, M.D. [2], Sara Mehrsefat, M.D. [3]

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Overview

Allergic conjunctivitis may be treated with artificial tears and topical antihistamines, vasoconstrictive agents, mast cell stabilizers, NSAIDs, and corticosteroids. Cool compresses are recommended to reduce eyelid and periorbital edema. Topical antimicrobial therapy is only recommended for patients with either bacterial or herpetic conjunctivitis, but not allergic or adenoviral conjunctivitis. Systemic antibiotic therapy is necessary to treat conjunctivitis due to Neisseria gonorrhoeae and Chlamydia trachomatis.

Medical Therapy

Conjunctivitis sometimes requires medical attention. The appropriate treatment depends on the cause of the problem. For the allergic conjunctivitis, cool water constricts capillaries, and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, non-steroidal anti-inflammatory medications and antihistamines may be prescribed. Some patients with persistent allergic conjunctivitis may also require topical steroid drops.

Bacterial conjunctivitis is usually treated with antibiotic eye drops or ointments that cover a broad range of bacteria (Chloramphenicol or fusidic acid). However evidence suggests that this does not affect symptom severity and gains only modest reduction in duration from an average of 4.8 days (untreated controls) to 3.3 days for those given immediate antibiotics. Deferring antibiotics yields almost the same duration as those immediately starting treatment with 3.9 days duration, but with half the two-week clinic reattendance rate.[1]

Although there is no cure for viral conjunctivitis, symptomatic relief may be achieved with cool compresses and artificial tears. For the worst cases, topical corticosteroid drops may be prescribed to reduce the discomfort from inflammation. However prolonged usage of corticosteroid drops increases the risk of side effects. Antibiotic drops may also be used for treatment of complementary infections. Patients are often advised to avoid touching their eyes or sharing towels and washcloths. Viral conjunctivitis usually resolves within 3 weeks. However in worst cases it may take over a month.

Conjunctivitis due to burns, toxic and chemical require careful wash-out with saline, especially beneath the lids, and may require topical steroids. The more acute chemical injuries are medical emergencies, particularly alkali burns, which can lead to severe scarring, and intraocular damage. Fortunately, such injuries are uncommon.

Treatment for keratoconjunctivitis sicca (dry eye syndrome) is often simple and effective. However, the patient should educated that the condition is chronic, and treatment is long-term. Treatment for dry eye syndrome based on the disease severity includes:[2]

  • Mild cases
    • Environmental modifications
    • Elimination of systemic medications
    • Eyelid therapy (warm compresses and eyelid scrubs)
    • Correction of eyelid abnormalities may be used in mild cases.
  • Moderate cases
    • Lubricating eye drops
    • Lubricating ointments
  • Severe cases

Superior limbic keratoconjunctivitis (SLK) is usually treated with topical silver nitrate, topical vitamin-A, topical cyclosporine A 0.5%, ketotifen fumarate, cromolyn sodium, lodoxamide tromethamine, supratarsal triamcinolone injection, autologous serum derived drops, and botulinum injection in the muscle of Riolan.[3][4][5]

Antimicrobials

  • Mild bacterial conjunctivitis is usually self-limited, and it typically resolves spontaneously without specific treatment in immune-competent adults (except for methicillin resistant staphylococcal MRSA conjunctivitis, gonococcal conjunctivitis, and conjunctivitis due to C. trachomatis).
  • Severe bacterial conjunctivitis requires antimicrobial therapy.
  • Systemic antibiotic therapy is necessary to treat conjunctivitis due to Neisseria gonorrhoeae and Chlamydia trachomatis.
  • Methicillin-resistant Staphylococcal infections (MRSA) should be treated with topical antibiotics.
  • Topical and/or oral antiviral therapy is recommended for HSV conjunctivitis to prevent corneal infection.
  • Neither topical nor oral antiviral treatment is recommended to treat either adenoviral or VZV conjunctivitis. Empiric topical antibiotics may be administered to prevent secondary bacterial infection.

Antimicrobial Regimens

  • Infectious conjunctivitis[6][7]
  • 1. Causative pathogens
  • 2. Conjunctivitis, neonatal prophylaxis
  • Preferred regimen (1): 0.5% Erythromycin ophthalmic ointment, single dose
  • Alternative regimen: 2.5% Providone-iodine solution ophthalmic ointment, single dose
  • 3. Empiric antimicrobial therapy
  • Preferred regimen (1): Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week
  • Preferred regimen (2): Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week
  • Preferred regimen (3): Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week
  • Preferred regimen (4): Erythromycin 0.5% ophthalmic ointment qhs to qid for 1 week OR Azithromycin 1% ophthalmic ointment bid for 2 days then qd for 5 days
  • Preferred regimen (5): Ciprofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Ofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Levofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Moxifloxacin 0.5% ophthalmic ointment bid to tid for 1 week OR Besifloxacin 0.6% ophthalmic suspension tid for 1 week OR Gatifloxacin 0.5% ophthalmic solution tid for 1 week
  • Preferred regimen (6): Polymyxin B/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week
  • Preferred regimen (7): Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week
  • Preferred regimen (8): Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week
  • Preferred regimen (9): Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week
  • Preferred regimen (10): Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week
  • Note (1): All regimens have similar efficacy.
  • Note (2): When empiric antimicrobial therapy is administered, the patient's age, environment, and related ocular findings may guide the treatment of choice.
  • Note (3): Some regimens are associated with transient blurring of vision.
  • Note (4): Topical steroids are not recommended for bacterial conjunctivitis.
  • 4. Pathogen-directed antimicrobial therapy
  • 4.1 Chlamydia trachomatis
  • Preferred regimen (1): Azithromycin 1 g PO, single dose
  • Preferred regimen (2): Doxycycline 100 mg PO bid for 7 days
  • Pediatric regimen (1): Children who weigh < 45 kg: Erythromycin solution 50 mg/kg/day PO qid for 2 weeks OR Ethylsuccinate 50 mg/kg/day PO qid for 2 weeks
  • Pediatric regimen (2): Chidren who weigh ≥ 45 kg but are aged < 8 years: Azithromycin 1 g PO, single dose
  • Pediatric regimen (3): Children ≥ 8 years: Azithromycin solution 1 g PO, single dose OR Doxycycline 100 mg PO bid for 1 week
  • Neonatal regimen: Erythromycin 50 mg/kg/day PO qid for 2 weeks OR Ethylsuccinate 50 mg/kg/day PO qid for 2 weeks
  • Note (1): Neonates administered Erythromycin should be followed for signs and symptoms of infantile hypertrophic pyloric stenosis
  • Note (2): Sexual contacts of patients with C. trachomatis conjunctivitis should be treated at the same time
  • 4.2 Neisseria gonorrhoeae
  • Hyperacute bacterial conjunctivitis, adult
  • Preferred regimen: Ceftriaxone 25 mg IM, single-dose AND (Azithromycin 1 g PO, single dose OR Doxycycline 100 mg PO bid for 1 week)
  • Alternative regimen, cephalosporin-allergic: Azithromycin 2 g PO, single dose
  • Pediatric dose: Children who weigh < 45 kg: Ceftriaxone 125 mg IM, single dose OR Spectinomycin 40 mg/kg (maximum dose 2 g) IM, single dose
  • Neonatal dose: Ceftriaxone 25-50 mg/kg (maximum dose 125 mg) IV or IM, single dose
  • Note (1): The regimen provides adequate coverage for both N. gonorrhea and C. trachomatis
  • Note (2): Children who weigh > 45 kg are administered adult doses for the management of N. gonorrhoeae conjunctivitis
  • Note (3): Neisseria meningitidis must be ruled out as a causative organism before concluding that Neisseria gonorroeae is responsible
  • Note (4): Patients diagnosed with gonococcal conjunctivitis should be seen daily until resolution of conjunctivitis. Interval history, visual acuity measurement, and slit-lamp biomicroscopy should be performed daily.
  • 4.3 Staphylococcus aureus
  • 4.3.1 Methicillin-sensitive Staphylococcus aureus (MSSA)
  • 4.3.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 1% ophthalmic ointment qid for 2 weeks
  • 4.3.3 Methicillin-sensitive Staphylococcus epidermidis (MSSE)
  • 4.3.4 Methicillin-resistant Staphylococcus aureus (MRSE)
  • Preferred regimen: Vancomycin 1% ophthalmic ointment qid for 2 weeks
  • 4.4 Streptococcus species
  • 4.4.1 Streptococcus pnuemoniae
  • 4.4.2 Streptococcus haemolyticus
  • 4.5 Haemophilus influenzae
  • 4.6 Moraxella spp.
  • 4.7 Proteus mirabilis
  • 4.8 Escherichia coli
  • 4.9 Pseudomonas aeruginosa
  • Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Ciprofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Ofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Levofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Moxifloxacin 0.5% ophthalmic ointment bid to tid for 1 week OR Besifloxacin 0.6% ophthalmic suspension tid for 1 week OR Gatifloxacin 0.5% ophthalmic solution tid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week
  • 4.10 Herpes Simplex Virus
  • Preferred regimen: Ganciclovir 0.15% ophthlamic gel qid for 1 week
  • Alternative regimen (1): Trifluridine 1% solution q4h for 1 week
  • Alternative regimen (2): Acyclovir 200 mg to 400 mg PO q5h per day for 1 week
  • Alternative regimen (3): Valacyclovir 500 mg PO tid for 1 week
  • Alternative regimen (4): Famciclovir 250 mg PO bid for 1 week
  • Note: Corticosteroids should be avoided.
  • 4.11 Varicella Zoster Virus
  • Preferred regimen: Acyclovir 800 mg PO q5hr for 1 week
  • Alternative regimen (1): Valacyclovir 1000 mg PO q8h for 1 week
  • Alternative regimen (2): Famciclovir 500 mg PO tid for 1 week

References

  1. Hazel A Everitt, Paul S Little, Peter W F Smith (2006). "A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice". BMJ.Error: Bad DOI specified!. Unknown parameter |month= ignored (help)
  2. Messmer EM (2015). "The pathophysiology, diagnosis, and treatment of dry eye disease". Dtsch Arztebl Int. 112 (5): 71–81, quiz 82. doi:10.3238/arztebl.2015.0071. PMC 4335585. PMID 25686388.
  3. Nelson JD (1989). "Superior limbic keratoconjunctivitis (SLK)". Eye (Lond). 3 ( Pt 2): 180–9. doi:10.1038/eye.1989.26. PMID 2695351.
  4. American Academy of Ophthalmology (2015) http://eyewiki.aao.org/Superior_limbic_keratoconjunctivitis Accessed on June 27, 2016
  5. Quinto GG, Campos M, Behrens A (2008). "Autologous serum for ocular surface diseases". Arq Bras Oftalmol. 71 (6 Suppl): 47–54. PMID 19274411.
  6. Quinn, Christopher J.; Mathews, Dennis E. (Nov 8 2002). "Optometric clinical practice guideline care of the patient with conjunctivitis". Check date values in: |date= (help)
  7. McLeod, Stephen D.; Feder, Robert S. (2013). "Conjunctivitis: Preferred Practice Pattern - American Academy of Ophthalmology".


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