Medical therapy for conjunctivitis. Literature review

Conjunctivitis, according to various studies, is the most common reason for going to the initial outpatient appointment and can be caused by several factors at the same time. Treatment is carried out comprehensively, depending on the clinical picture, somatic status and anamnesis data. In accordance with the clinical guidelines developed by the Russian Association of Ophthalmologists, the following groups of drugs are recommended for use: antibacterial, antiseptic, antihistamine, nonsteroidal anti-inflammatory drugs.

Purpose: to analyze the use of the above groups of drugs in the treatment of conjunctivitis in order to recommend a reasonable prescription of the necessary therapy.

Materials and methods. The literature data on the study of the features of the action of the above pharmacological groups in the treatment of conjunctivitis, obtained on the resources of PubMed, eLibrary, Crossref Metadata, mainly over the past 20 years, are presented.

Results. The presence of signs of an allergic reaction involves the appointment of antiallergic drugs with multiple pharmacological effects – blockade of histamine receptors, stabilization of mast cell membranes and suppression of eosinophil filtration. Given the different mechanisms of action within this group of drugs, it is necessary to select them individually. When prescribing tablet forms of antihistamines, it must be remembered that with prolonged use, they can cause patients to feel dry in their eyes. In cases where the above antiallergic drugs do not adequately control the allergic inflammatory process, anti-inflammatory drugs are used. Nonsteroidal and steroid anti-inflammatory drugs are used as anti-inflammatory drugs. Usually nonsteroidal anti-inflammatory drugs are recommended for use in chronic conjunctivitis and patients with a history of systemic diseases. Steroid drugs are indicated for severe forms of manifestation of the allergic process on the eyes, as well as the appointment of steroid anti-inflammatory drugs is recommended for use in short courses (up to 2 weeks), and with their longer use, control of intraocular pressure is necessary. Literature data indicate the lack of efficacy of antiviral drugs such as acyclovir and others from this group in the treatment of conjunctivitis of adenoviral etiology. Drugs with an immunomodulatory effect based on interferon or inducers of interferon synthesis are widely used. The prescription of antibiotics should be justified, since in recent years the level of resistance to them has significantly increased. Antiseptics that have a wide spectrum of action (bacteria, viruses, fungi and protozoa) are an alternative to antibiotics, but it must be remembered that this group of drugs often causes allergic reactions.

Conclusion. The treatment of conjunctivitis must be approached carefully, taking into account not only the etiology of the disease, but also the somatic and immune status of the patient. To avoid the negative effects of the use of antibiotics, replace them with alternative drugs and do not use them in the treatment of conjunctivitis of a non-bacterial nature.

1. Granet D. Allergic rhinoconjunctivitis and differential diagnosis of the red eye. Allergy Asthma Proc. 2008;29(6):565–574. https://doi.org/10.2500/aap.2008.29.3170

2. Yu K., Bunya V., Maguire M., Asbell P., Ying G.S. Dry Eye Assessment and Management Study Research Group. Systemic Conditions Associated with Severity of Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management Study. Ophthalmology. 2021;128(10):1384–1392. https://doi.org/10.1016/j.ophtha.2021.03.030

3. Zhemchugova A.V., Kurenkov V.V., Polunin G.S., Polunina E.G., Alieva A., Martirosova N.I. The therapeutic eyelids hygiene for prophylaxis and treatment complications caused by change of microflora and tear production after refractive surgery. Ophthalmology in Russia. 2012;9(1):18–22. (In Russ.) https://doi.org/10.18008/1816-5095-2012-1-18-22

4. Trubilin V.N., Polunina E.G., Kozhukhov A.A., Kurenkov V., Moreva N.V., Trubilin A.V., Chinenova K.V. Differential Diagnostic Indicators for the Appointment of NonSteroidal Anti-Inflammatory Therapy in the Treatment of Red Eye Syndrome at the Stage of Primary Outpatient Admission. Ophthalmology in Russia. 2023;20(2):332–340. https://doi.org/10.18008/1816-5095-2023-2-332-340

5. Clinical recommendations “Conjunctivitis” approved by the Ministry of Health of Russia. (In Russ.) URL: https://legalacts.ru/doc/klinicheskie-rekomendatsii-koniunktivitutv-minzdravom-rossii/ (accessed: 18.12.2022).

6. Azari A.A., Barney N.P. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310(16):1721–1729. https://10.1001/jama.2013.280318

7. Rigoli L., Briuglia S., Caimmi S., Ferraú V., Gallizzi R., Leonardi S. et al. Gene-environment interaction in childhood asthma. Int J Immunopathol Pharmacol. 2011;24(4 Suppl):41–47. https://10.1177/03946320110240S409

8. Leonardi S., Miraglia del Giudice M., La Rosa M., Bellanti J.A. Atopic disease, immune system, and the environment. Allergy Asthma Proc. 2007;28(4):410–417. https://doi.org//10.2500/aap.2007.28.2954

9. Trubilin V.N., Poluninа E.G., Andzhelova D.V., Kapkova S.G., Kurenkov V.V., Chinenova K.V. Diseases of the Ocular Surface Associated with Eyelid Makeup and Eyelash Extensions. Clinical Examples. Ophthalmology in Russia. 2019;16(3):386– 392. (In Russ.) https://doi.org/10.18008/1816-5095-2019-3-386-392

10. Del Cuvillo A., Sastre J., Montoro J., Jáuregui I., Dávila I., Ferrer M. et al. Allergic conjunctivitis and H1 antihistamines. J Investig Allergol Clin Immunol. 2009;19 Suppl 1:11–18.

11. Stokes T.C., Feinberg G. Rapid onset of action of levocabastine eye-drops in histamine-induced conjunctivitis. Clin Exp Allergy. 1993;23(9):791–794. https://doi.org/10.1111/j.1365-2222.1993.tb00368.x

12. Leonardi S., Marchese G., Marseglia G.L., La Rosa M. Montelukast in allergic diseases beyond asthma. Allergy Asthma Proc. 2007;28(3):287–291. https://doi.org/10.2500/aap.2007.28.2955

13. Bielory L., Lien K.W., Bigelsen S. Efficacy and tolerability of newer antihistamines in the treatment of allergic conjunctivitis. Drugs. 2005;65(2):215–228. https://doi.org/10.2165/00003495-200565020-00004

14. Maziak W., Behrens T., Brasky T.M., Duhme H., Rzehak P., Weiland S.K., Keil U. Are asthma and allergies in children and ado lescents increasing? Results from ISAAC phase I and phase III surveys in Münster, Germany. Allergy. 2003;58(7):572–579. https://doi.org/10.1034/j.1398-9995.2003.00161.x

15. Welch D., Ousler G.W. 3rd, Nally L.A., Abelson M.B., Wilcox K.A. Ocular drying associated with oral antihistamines (loratadine) in the normal population-an evaluation of exaggerated dose effect. Adv Exp Med Biol. 2002;506(Pt B):1051–1055. https://doi.org//10.1007/978-1-4615-0717-8_149

16. Matyukhina E.N. The Use of Bromfenac Ophthalmic Solution in Clinical Practice (Literature Review). Ophthalmology in Russia. 2021;18(4):784–790. (In Russ.) https://doi.org/10.18008/1816-5095-2021-4-784-790

17. Bielory L., Meltzer E.O., Nichols K.K., Melton R., Thomas R.K., Bartlett J.D. An algorithm for the management of allergic conjunctivitis. Allergy Asthma Proc. 2013;34(5):408–420. https://doi.org/10.2500/aap.2013.34.3695

18. Zhu L., Zhang C., Chuck R.S. Topical steroid and non-steroidal anti-inflammatory drugs inhibit inflammatory cytokine expression on the ocular surface in the botulinum toxin Binduced murine dry eye model. Mol Vis. 2012;18:1803–1812.

19. Lekhanont K., Park C.Y., Smith J.A., Combs J.C., Preechawat P., Suwan-Apichon O. et al. Effects of topical antiinflammatory agents in a botulinum toxin B-induced mouse model of keratoconjunctivitis sicca. J Ocul Pharmacol Ther. 2007;23(1):27–34. https://doi.org/10.1089/jop.2006.0071

20. Comstock T.L., DeCory H.H. Advances in corticosteroid therapy for ocular inflammation: loteprednol etabonate. Int J Inflam. 2012;2012:789623. https://doi.org/10.1155/2012/789623

21. Holland E.J., Fingeret M., Mah F.S. Use of Topical Steroids in Conjunctivitis: A Review of the Evidence. Cornea. 2019;38(8):1062–1067. https://doi.org/10.1097/ICO.0000000000001982

22. Varu D.M., Rhee M.K., Akpek E.K., Amescua G., Farid M., Garcia-Ferrer F.J. et al. American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Conjunctivitis Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P94–P169. https://doi.org/10.1016/j.ophtha.2018.10.020

23. Skevaki C.L., Galani I.E., Pararas M.V., Giannopoulou K.P., Tsakris A. Treatment of viral conjunctivitis with antiviral drugs. Drugs. 2011;71(3):331–347. https://doi.org/10.2165/11585330-000000000-00000

24. Drozdova E.A., Golubev S.Yu., Brzheskiy V.V., Romanova E.A., Kireeva V.A., Berdnikova E.V. Keratopathy in Patients with Adenoviral Keratoconjunctivitis: Evaluation of the Effectiveness of Modern Interferon Preparations. Ophthalmology in Russia. 2023;20(1):165–171. (In Russ.) https://doi.org/10.18008/1816-5095-2023-1-165-171

25. Chernakova G.M., Maychuk D.Yu., Klescheva E.A., Mezentseva M.V., Russu L.I., Suetina I.A., Isaeva E.I. In Vitro Study of Picloxidine 0.05 % Antiviral Activity (on the Example of Adenovirus). Ophthalmology in Russia. 2020;17(3s):634– 639. (In Russ.) https://doi.org/10.18008/1816-5095-2020-3S-634-639

26. Grzybowski A., Kuklo P., Pieczynski J., Beiko G. A review of preoperative manoeuvres for prophylaxis of endophthalmitis in intraocular surgery: topical application of antibiotics, disinfectants, or both? Curr Opin Ophthalmol. 2016;27(1):9– 23. https://doi.org/10.1097/ICU.0000000000000216

27. Kim S.J., Toma H.S. Antimicrobial resistance and ophthalmic antibiotics: 1-year results of a longitudinal controlled study of patients undergoing intravitreal injections. Arch Ophthalmol. 2011;129(9):1180–1188. https://doi.org/10.1001/archophthalmol.2011.213

28. Dave S.B., Toma H.S., Kim S.J. Changes in ocular flora in eyes exposed to ophthalmic antibiotics. Ophthalmology. 2013;120(5):937–941. https://doi.org/10.1016/j.ophtha.2012.11.005

29. Pollack L.A., Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis. 2014;59 Suppl 3(Suppl 3):S97– 100. https://doi.org/10.1093/cid/ciu542.

30. Parke D.W. 2nd, Coleman A.L., Rich W.L. 3rd, Lum F. Choosing Wisely: five ideas that physicians and patients can discuss. Ophthalmology. 2013;120(3):443–444. https://doi.org/10.1016/j.ophtha.2013.01.017

31. Lestner J.M., Versporten A., Doerholt K., Warris A., Roilides E., Sharland M. et al.; ARPEC Project Group. Systemic antifungal prescribing in neonates and children: outcomes from the Antibiotic Resistance and Prescribing in European Children (ARPEC) Study. Antimicrob Agents Chemother. 2015;59(2):782– 789. https://doi.org/10.1016/10.1128/AAC.04109-14

32. Armstrong R.A. The microbiology of the eye. Ophthalmic Physiol Opt. 2000;20(6):429–441.

33. Trubilin V.N., Poluninа E.G., Andzhelova D.V., Kurenkov V.V., Evstigneeva Yu.V., Chinenova K.V. The Antibacterial Eye Ointments in the Treatment of Eyelids and Conjunctiva Acute and Chronic Diseases. Ophthalmology in Russia. 2019;16(1):31–37. (In Russ.) https://doi.org/10.18008/1816-5095-2019-1-31-37

34. Lachapelle J.M. A comparison of the irritant and allergenic properties of antiseptics. Eur J Dermatol. 2014;24(1):3–9. https://doi.org/10.1684/ejd.2013.2198