First line:

Recommend bathing eyes regularly with tepid water, wiping away from the bridge of the nose to the side. The patient should not wear contact lenses until symptoms have cleared. Advise strict hand hygiene; towels and pillows should not be shared. 

Both bacterial and viral conjunctivitis are self-limiting and a delayed prescribing approach is appropriate. Consider starting treatment after 3 days if there is no improvement, unless the patient considers the symptoms to be distressing or signs on examination are severe.

Second line:

Chloramphenicol 0.5% eye drops, apply 1 drop 2 hourly initially. Reduce frequency to 3-4 times a day once symptoms improve and continue for 48 hours after healing

and/or

Chloramphenicol 1% eye ointment, apply at night if eye drops used during the day (or apply 3-4 times a day if ointment used alone)

Third line:

Fusidic acid 1% eye drops, apply twice daily

Acute infective conjunctivitis presents with red, irritated eyes, foreign body sensation accompanied by excessive tear production or discharge, and eyelids that stick together upon waking. Bacterial conjunctivitis is usually unilateral with thick purulent discharge. Viral conjunctivitis is generally bilateral and preceded by a typical viral prodromal illness; the eye is profusely watery. The pre-auricular lymph nodes may be palpable and tender.

If any of the following are present, refer the patient for specialist same-day assessment - significant photophobia, reduced visual acuity, pain deep in the eye, history of recent eye surgery, abnormal pupil response, irregular pupils, corneal damage or opacity on fluorescein staining, restricted or painful eye movements, history of head/eye trauma.

Ask patients to return for review if there is visual disturbance, significant eyelid swelling, photophobia or pain in the eye, or if symptoms do not settle within 7 days.

Swab the affected eye(s) to identify a possible bacterial cause when conjunctivitis is severe or persistent.