Conjunctivitis medical therapy

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]

Conjunctivitis Microchapters
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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

Acute Pharmacotherapies

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 used in UK). 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.

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. This involves keeping the eye moist and preserving the tears that are made naturally. Patient education is important and includes the facts that dry eye is a chronic disease, and treatment is long-term. Treatment for dry eye disease involves a step ladder approach corresponding to disease severity. Treatment methods used include:

• In mild cases, environmental modifications, elimination of systemic medications, eyelid therapy (warm compresses and eyelid scrubs), and correction of eyelid abnormalities may be used.
• As the severity of the dry eye increases, lubricating eye drops and lubricating ointments may be prescribed. Lubricating eye drops or artificial tears, mimic the eyes natural tears. These eye drops are available over-the-counter. They provide relief from the discomfort caused by keratoconjunctivitis sicca and help maintain the natural moistness of the eye. Lubricating ointments, they are similar to artificial tears, except they have a much thicker consistency and last longer than eye drops. They are used to provide moisture for more severe cases of keratoconjunctivitis sicca. However, because of the thick texture, the drops may cause vision to be blurry. For this reason, they are usually used at night, before bedtime.
• In more severe cases, anti-inflammatory medications (topical cyclosporin and corticosteroids), systemic omega-3 fatty acids supplements, systemic cholinergic agents, systemic anti-inflammatory agents, and mucolytic agents may be prescribed.

Superior limbic keratoconjunctivitis 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.

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

• 1. Causative pathogens

• Neisseria gonorrhoeae
• Neisseria meningitidis
• Chlamydia trachomatis
• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus pneumoniae
• Streptococcus haemolyticus
• Haemophilus influenzae
• Moraxella spp
• Proteus mirabilis
• Escherichia coli
• Pseudomonas aeruginosa
• Adenovirus
• Herpes simplex virus
• Herpes zoster virus

• 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)

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week OR 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 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 OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week

• 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)

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week OR 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 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 OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week

• 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

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR 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 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/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.4.2 Streptococcus haemolyticus

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR 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 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/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.5 Haemophilus influenzae

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week OR 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 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 OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.6 Moraxella spp.

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.7 Proteus mirabilis

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week

• 4.8 Escherichia coli

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week

• 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