- Allergic Conjunctivitis
Treatment of allergic conjunctivitis is based upon identification and elimination of specific antigens, when practical, and upon the use of medications that decrease or mediate the immune response. The use of supportive treatment, including nonpreserved lubricants and cold compresses, may provide symptomatic relief. A variety of pharmacologic agents, listed below and described in greater detail in the guideline document, may be useful in treating allergic conjunctivitis:
- Topical steroids
- Topical vasoconstrictor/antihistamines
- Topical antihistamine
- Topical nonsteroidal anti-inflammatory drugs
- Topical mast-cell stabilizers
- Agents with multiple mechanisms of action
- Immunosuppressants
- Systemic antihistamines
- Bacterial Conjunctivitis
The ideal method of treating bacterial conjunctivitis is to identify the causative organism and initiate the specific antimicrobial treatment known to be effective against the offending organism. Table 7 in the original guideline document lists the commonly available topical antimicrobial drugs, their spectrum of activity, and drug dosage recommendations. In the absence of a culture or smear, the etiologic agent should be considered with respect to the patient's age, environment, and related ocular findings. In most cases, broad-spectrum topical antibiotics are the treatment of choice. Although most cases of bacterial conjunctivitis are self-limiting, treatment with antibiotics can lessen the patient's symptoms and the duration and chances of recurrence of the disease.
Hyperacute conjunctivitis requires special consideration because of potential blinding from inadequately treated gonococcal infections. Conjunctival smears and cultures should be obtained before beginning treatment. The administration of systemic antibiotics that are effective against the identified organisms should be started immediately. Saline lavage may be beneficial in removing purulent discharge. In the case of gonococcal infection, the Centers for Disease Control and Prevention (CDC) recommends the administration of a single dose of intramuscular ceftriaxone. Although the CDC does not recommend topical treatment, practitioners may wish to consider the addition of a topical fluoroquinolone as adjunctive therapy. Patients should also be evaluated for co-infection with other sexually transmitted diseases. Care of the patient with sexually transmitted disease should be coordinated with the patient's primary care physician.
- Viral Conjunctivitis
Supportive therapy for adenoviral infection includes the time-honored treatment options: cold compresses, lubricants, and ocular decongestants.
Topical antibiotics are not routinely used to treat viral conjunctivitis unless there is evidence of secondary bacterial infection. The risk of toxic and allergic reactions may outweigh the potential benefit of antibiotic use. The use of steroids in the management of adenoviral conjunctivitis remains controversial. Because of the potential side effects of topical ophthalmic corticosteroids, practitioners may wish to limit the use of these agents to patients who are significantly symptomatic or who develop visual loss from inflammatory keratitis.
The treatment of herpes simplex conjunctivitis may include the use of antiviral agents such as trifluridine, although there is no evidence that this therapy results in a lower incidence of recurrent disease or keratitis. Supportive therapy, including lubricants and cold compresses, which may be as effective as antiviral drugs, eliminates the potential for toxic side effects. Topical steroids are specifically contraindicated for treating herpes simplex conjunctivitis.
Herpes zoster conjunctivitis treatment includes the use of topical antibiotic/steroid combinations to reduce the risk of secondary bacterial infection and decrease the inflammatory response. In contrast to their effect on herpes simplex infections, topical steroids do not exacerbate herpes zoster infections. In addition to topical therapy, systemic antiviral treatment reduces the duration of both viral shedding and post-herpetic neuralgia. To be most effective in reducing the duration of post-herpetic neuralgia, systemic antiviral therapy should be started within 72 hours of the first signs of herpes zoster infection.
- Chlamydial Conjunctivitis
The primary treatment for adult inclusion conjunctivitis is systemic antibiotics; topical therapy alone is inadequate. The recommended systemic treatment, based on the patient's age, weight, and medical history, is either of two equally efficacious options: a single dose of azithromycin 1 g or doxycycline 100 mg twice daily for 7 days. Azithromycin is the preferred treatment, especially when patient compliance is a potential problem. Patients' sexual partners should also be evaluated for the presence of the infection, and treatment should be initiated as indicated. In cases of chlamydial infection affecting preadolescent children, the clinician should consider the possibility that sexual abuse has occurred.
- Contact Lens-Related Conjunctivitis
The primary treatment of contact lens-related conjunctivitis involves discontinuing contact lens wear and determining the underlying etiologic mechanism for the conjunctivitis. Solution allergies, hypoxic conditions, giant papillary conjunctivitis (GPC), bacterial infections, or contact lens-related trauma should be identified and corrected prior to resuming contact lens wear.
- Mechanical Conjunctivitis
Removal of the offending trauma-inducing agent (e.g., misdirected lash, exposed suture) and subsequent lubrication usually constitute adequate treatment of mechanical conjunctivitis. In addition to lubricants, prophylactic broad-spectrum antibiotic ophthalmic drops should be considered in cases of significant epithelial disruption (staining) until the epithelial defects have resolved.
- Traumatic Conjunctivitis
The treatment of traumatic conjunctivitis depends upon the nature of the trauma. Conjunctival abrasions may be treated with topical antibiotics, cycloplegia, and pressure patching. Topical antibiotics may be used in cases of epithelial disruption, and oral analgesics should be prescribed for pain as needed. The initial treatment of chemical injuries should include copious irrigation with normal saline or balanced salt solution until the pH of the conjunctival cul-de-sac has returned to normal. Chemical injuries, particularly alkali burns, have the potential for significant ocular morbidity and require aggressive management.
- Toxic Conjunctivitis
Most cases of toxic conjunctivitis result from overuse of topical medications and/or cosmetics, or both. Occasionally, environmental exposure to noxious agents results in toxic conjunctivitis. Treatment involves identifying and removing the offending agent. Molluscum lesions on the lids should be excised. Symptomatic patients may benefit from using cold compresses or topical ophthalmic antibiotic/corticosteroid combinations, or both. The treatment of toxic conjunctivitis from overuse of topical preparations should be to stop all topical medications initially, when possible, and use preservative-free topical lubricants 4 to 8 times a day for 3 to 5 days. Patients who show no sign of clinical improvement after this treatment should be reevaluated for another underlying cause.
- Neonatal Conjunctivitis
The optometrist should consider comanaging neonatal conjunctivitis with a pediatrician, neonatologist, or pediatric infectious disease specialist. Treatment should begin immediately upon diagnosis. Initially, antimicrobial therapy should be directed at the organism identified in conjunctival smears. The guideline document summarizes the current therapeutic approaches to the most common causes of neonatal conjunctivitis.
- Parinaud's Oculoglandular Syndrome
Because the vast majority of cases are self-limiting, the aim of therapy for Parinaud's oculoglandular syndrome is symptomatic relief of preauricular lymphadenopathy. The application of a mild topical vasoconstrictor/lubricant and warm soaks of the inflamed preauricular area are generally sufficient. Biopsy of conjunctival granuloma not only provides diagnostic information regarding the etiologic agent but may have therapeutic benefits; however, this procedure is indicated only in severe cases.
- Phlyctenular Conjunctivitis
The treatment of phlyctenular conjunctivitis is directed at the underlying mechanism, to eradicate the sensitizing agent when possible. This generally means eliminating chronic lid disease, which serves as a reservoir for Staphylococcus aureus. The conjunctivitis itself responds favorably to the topical use of an antibiotic/corticosteroid combination applied 4 times a day for several days and then tapered. When there is associated blepharitis or other dermatologic disorder (e.g., acne rosacea), oral doxycycline can be helpful. In children younger than 8 years of age or in pregnant women, erythromycin should be used rather than doxycycline. When the patient's history is significant for potential mycobacterium tuberculosis exposure, the practitioner should consider and rule out tuberculosis as the etiologic agent.
- Secondary Conjunctivitis
The management of secondary conjunctivitis requires identification and treatment of the underlying ocular or systemic conditions. Patients who develop conjunctivitis as a manifestation of systemic disease should be evaluated and comanaged with an appropriate medical specialist.
