Counsel the patient that viral conjunctivitis is a self-limited condition that typically gets worse for the first 4 to 7 days after onset and may not resolve for 2 to 3 weeks (potentially longer with corneal involvement).

Viral conjunctivitis is highly contagious (usually for 10 to 12 days from onset) as long as the eyes are red (when not on steroids) or have active discharge/tearing. Patients should avoid touching their eyes, shaking hands, sharing towels or pillows, etc. Restrict work and school for patients with significant exposure to others while the eyes are red and weeping.

Frequent handwashing.

Preservative-free artificial tears or tear ointment four to eight times per day for 1 to 3 weeks. Advise single-use vials to limit tip contamination and spread of the condition.

Cool compresses several times per day.

Antihistamine drops (e.g., epinastine 0.05% b.i.d.) if itching is severe.

If a membrane/pseudomembrane is present, it should be gently peeled with a cotton-tip
applicator or smooth forceps to enhance comfort, minimize corneal defects, and help prevent symblepharon formation.

If a membrane/pseudomembrane is present or if SEIs reduce vision and/or cause significant photophobia, topical steroids should be initiated. For membranes/pseudomembranes, use a more frequent steroid dose or stronger steroid (e.g., loteprednol 0.5% or prednisolone acetate 1% q.i.d.). Consider a steroid ointment (e.g., fluorometholone 0.1% ointment q.i.d. or dexamethasone/tobramycin 0.1%/0.3% ointment q.i.d.) in the presence of significant tearing to maintain longer medication exposure. For SEIs alone, a weaker steroid with less frequent dosing is usually sufficient (e.g., loteprednol 0.2% or 0.5% b.i.d.). Given the possible side effects, prescription of topical steroids is cautionary in the emergency room setting or in patients with questionable follow-up. Steroids may hasten the resolution of the symptoms but prolong the infectious period. Additionally, steroids often necessitate a long-term taper and delayed SEIs can recur during or after such a taper.

Eliminate the inciting agent. Frequent washing of hair and clothes may be helpful.

Cool compresses several times per day.

Topical drops, depending on the severity.

Severe: Mild topical steroid (e.g., loteprednol 0.2% or fluorometholone 0.1% q.i.d. for 1 to 2 weeks) in addition to the preceding medications.

Oral antihistamine (e.g., diphenhydramine 25 mg p.o. t.i.d. to q.i.d. or loratadine 10 mg p.o. daily) in moderate-to-severe cases can be very helpful.

Treat as for allergic conjunctivitis except ensure prophylactic use of a mast-cell stabilizer or combination antihistamine/mast-cell stabilizer (e.g., olopatadine 0.2% or 0.7% daily, alcaftadine 0.25% daily, olopatadine 0.1% b.i.d., ketotifen 0.1% b.i.d., lodoxamide 0.1% q.i.d., pemirolast 0.1% q.i.d.) for 2 to 3 weeks before the allergy season starts.

If a shield ulcer is present, add:

Cool compresses q.i.d.

Consider cyclosporine 0.05% to 2% b.i.d. to q.i.d. if not responding to the preceding treatment. Inform the patient that maximal effect of this drop is not seen for several weeks.

If associated with atopic dermatitis of eyelids, consider tacrolimus 0.03% to 0.1% ointment q.h.s. or b.i.d. (preferred), pimecrolimus 1% cream b.i.d., or topical steroid ophthalmic ointment (e.g., fluorometholone 0.1% q.i.d.) to the affected skin for 1 to 2 weeks.

Use topical antibiotic therapy (e.g., trimethoprim/polymyxin B or fluoroquinolone drops or ointment q.i.d.) for 5 to 7 days.

H. influenzae conjunctivitis should be treated with oral amoxicillin/clavulanate (20 to 40 mg/kg/day in three divided doses) because of occasional extraocular involvement (e.g., otitis media, pneumonia, and meningitis).

If associated with dacryocystitis, systemic antibiotics are necessary. SEE 6.9, DACRYOCYSTITIS/INFLAMMATION OF THE LACRIMAL SAC.

A dual treatment regimen of ceftriaxone 1 g intramuscularly (i.m.) PLUS azithromycin 1 g p.o. both in a single dose is recommended. If corneal involvement exists, or cannot be excluded because of chemosis and eyelid swelling, hospitalize the patient and treat with
ceftriaxone 1 g intravenously (i.v.) every 12 to 24 hours in place of i.m. ceftriaxone. The duration of treatment may depend on the clinical response. Consider an infectious disease consultation in all cases of gonococcal conjunctivitis.

If ceftriaxone is not available or unable to be tolerated (e.g., cephalosporin-allergic patients), consider the following treatment regimens:

Topical fluoroquinolone ointment q.i.d. or fluoroquinolone drop q2h. If the cornea is involved, use a fluoroquinolone drop q1h (e.g., gatifloxacin, moxifloxacin, besifloxacin, levofloxacin, or ciprofloxacin).

Saline irrigation q.i.d. until the discharge resolves.

Treat for possible chlamydial coinfection (e.g., azithromycin 1 g p.o. single dose or doxycycline 100 mg p.o. b.i.d. for 7 days).

Treat sexual partners with oral antibiotics for both gonorrhea and chlamydia as described.

Mechanical removal of lice and eggs with jeweler’s forceps.

Any bland ophthalmic ointment (e.g., erythromycin) to the eyelids t.i.d. for 10 days to smother the lice and nits.

Anti-lice lotion and shampoo as directed to nonocular areas for patient and close contacts.

Thoroughly wash and dry all clothes, towels, and linens.

Azithromycin 1 g p.o. single dose, doxycycline 100 mg p.o. b.i.d., or erythromycin 500 mg p.o. q.i.d. for 7 days is given to the patient and his or her sexual partners.

Topical erythromycin or tetracycline ointment b.i.d. to t.i.d. for 2 to 3 weeks.

Azithromycin 20 mg/kg p.o. single dose, doxycycline 100 mg p.o. b.i.d., or erythromycin 500 mg p.o. q.i.d. for 2 weeks.

Tetracycline, erythromycin, or sulfacetamide ointment b.i.d. to q.i.d. for 3 to 4 weeks.