Conservative and natural treatments for pink eye are the most sensible approaches.

Conjunctivitis, also known as pink eye, is the inflammation of the eye’s transparent covering caused by viruses, bacteria, pollen, dust, pet dander, smoke and pollutants. Viruses and bacteria are the most frequent suspects in infective conjunctivitis. Viral conjunctivitis is more common than bacterial conjunctivitis. Common symptoms include red eye, itching sensation, watery eyes, green to yellow discharge, blurred vision and light sensitivity. These symptoms make the diagnosis straightforward, however it is difficult to distinguish between viral and bacterial conjunctivitis.

Only 50% of bacterial pink eye cases are correctly diagnosed . Bacteria normally found in our eyes can also be misinterpreted and mistaken as a positive test for bacterial conjunctivitis. For bacterial pink eye, antibiotic eye drops are typically prescribed. Due to the difficulty in distinguishing between viral and bacterial pink eye, sometimes antibiotics are also prescribed when the cause of the pink eye is a virus. Antibiotics are not designed to kill viruses, and their inappropriate use can lead to bacterial antibiotic resistance. Antibiotic treatment for all cases of pink eye can also  interfere with the diagnosis of other conditions, such as glaucoma, dry eye, or a stye.

A 2009 review looked through four studies to determine whether antibiotics were in fact necessary for resolving bacterial conjunctivitis, and to find the best alternative treatment for pink eye. There was minimal evidence supporting treatment with ophthalmic antibiotics. In fact, the evidence suggested to delay antibiotic use.

The recommended natural treatment for pink eye was supportive care through repeated eye cleansing with sterile water, warm water compresses, thorough hand and eyelid hygiene, and artificial tears for comfort. However, a 2013 review suggested that more studies are needed to determine the effectiveness of these natural or alternative treatments for pink eye.

One study evaluated delayed antibiotic use in 307 adults and children diagnosed with bacterial conjunctivitis. The study compared the results of three patient groups: 1) immediate ophthalmic antibiotic prescription, 2) delayed antibiotic prescription, and 3) no antibiotic prescription. Patients in the delayed antibiotic prescription group were prescribed two to three days after diagnosis, if symptoms persisted or worsened. The delayed treatment strategy reduced antibiotic use and medical consultations for future bacterial conjunctivitis incidents. However, more time was needed to educate and ensure patients that bacterial conjunctivitis is self-limiting – that is, can resolve itself without treatment.

The review highlighted three studies that reinforced the importance of patient compliance and education. One study investigated an annual report where 80% of Dutch patients with infective conjunctivitis were prescribed ophthalmic antibiotics. The overuse of ophthalmic antibiotics was widespread in Netherlands despite their guidelines advocating for conservative management. Another study discovered the following factors contribute to prescribing antibiotics: 1) parents’ belief in the early use and benefits of antibiotic treatment, and 2) physician uncertainty reinforcing parents’ beliefs. Finally, a study identified that most patients did not realize that conjunctivitis is self-limiting. This knowledge gap can be filled with well-designed pamphlets to reinforce physician consultation. Inappropriate prescribing of ophthalmic antibiotics can be prevented through patient and physician education to manage parents’ expectations and to prevent antibiotic overuse.

Overall, the following strategies are recommended for the treatment of infective conjunctivitis:

1. Physicians must have a complete patient history and physical examination to rule out other conditions similar to conjunctivitis.
2. Parents and patients should be given a simple, informative pamphlet to reinforce their physician consultation on infective conjunctivitis, especially when to make a follow-up appointment and when to fill antibiotic prescription.
3. If the symptoms worsen over three days, then a prescription for an ophthalmic antibiotic would be appropriate to fill.

Infective conjunctivitis is either viral or bacterial making it difficult for physicians to differentiate from their similar signs and symptoms. Conservative treatment is achieved through patient education and compliance with delayed antibiotic use.

Patients should rely on natural treatments for pink eye, involving repeated eye cleansing with sterile water, warm water compresses, thorough hand and eyelid washing, and artificial tears for comfort. Physicians and patients should resort to ophthalmic antibiotics for pink eye if symptoms worsen over three days. Conservative treatment for pink eye is the most sensible approach to prevent antibiotic resistance and overuse.

Written by, Manuel Bangsil, PharmD, MBA, BCMAS

References:

1. Visscher KL, Hutnik CM, Thomas M. Evidence-based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing. Can Fam Physician. 2009;55(11):1071-1075.
2. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment [published correction appears in JAMA. 2014 Jan 1;311(1):95. Dosage error in article text]. JAMA. 2013;310(16):1721-1729. doi:10.1001/jama.2013.280318