DESCRIPTION

Inflammation of the bulbar and/or palpebral conjunctiva of <4 weeks’ durationGeriatric Considerations

• Suspect bacterial, autoimmune, or irritative process.
• If purulent, risk of bacterial cause increases with age and long-term care facility residence, with age >65 years and bilateral eyelid adherence. Risk for bacterial infection is >70%.

Pediatric Considerations
Neonatal conjunctivitis may be gonococcal, chlamydial, irritative, or related to dacryocystitis. Children <5 years of age are more likely to have bacterial involvement than adults, but most are self-resolve in 2 to 5 days.

EPIDEMIOLOGY

• Bacterial conjunctivitis is more common in children and viral conjunctivitis is more common in adults.
• Infectious conjunctivitis occurs equally in females and males.

ETIOLOGY AND PATHOPHYSIOLOGY

• Viral
  • Adenovirus (common cold), coxsackievirus; enterovirus (acute hemorrhagic conjunctivitis); herpes simplex; herpes zoster or varicella; measles, mumps, or influenza; SARS-CoV-2
• Bacterial
  • Staphylococcus aureus, MRSA, or Staphylococcus epidermidis; Streptococcus pneumoniae; Haemophilus influenzae (children); Moraxella catarrhalis
  • Pseudomonas spp. or anaerobes (contact lenses users); Acanthamoeba-contaminated contact lenses solution (rare; ~30 cases/yr in United States); Neisseria gonorrhoeae; Chlamydia trachomatis: gradual onset 1 to 4 weeks
• Allergic
  • Hay fever, seasonal allergies, atopy
• Nonspecific
  • Irritative: topical medications, wind, dry eye, UV light exposure, smoke, chlorine
  • Autoimmune: Sjögren syndrome, etc.

RISK FACTORS

• History of contact with infected persons; sexually transmitted disease (STD) contact: gonococcal, chlamydial, syphilis, or herpes; contact lenses: pseudomonal or acanthamoeba keratitis
• Epidemic bacterial (streptococcal) conjunctivitis reported in school settings, epidemic adenoviral transmission in crowded settings, MRSA in long term care facilities

GENERAL PREVENTION

• Wash hands frequently.
• Eyedropper technique: while eye is closed and head back, several drops over nasal canthus and then open eyes to allow liquid to enter; never touch the tip of the dropper to skin or eye.

COMMONLY ASSOCIATED CONDITIONS

Viral infection (e.g., common cold); possible sexually transmitted infection

HISTORY

• Viral: contact or travel; may start with one eye and then both; if herpetic, recurrences or vesicles on skin
• Bacterial: difficult to distinguish from viral; assume bacterial in contact lenses wearer, unless cultures are negative. If recent STD or concurrent urethritis, suspect chlamydia/gonococcus. Gonococcal conjunctivitis is sight threatening and requires immediate ophthalmologic referral. Nursing home residents may have MRSA conjunctivitis—obtain culture.
• Allergic: itching, atopy, seasonal, dander
• Irritative: feels dry; exposure to wind; tear-film deficit may persist 30 days after acute conjunctivitis; chlorine from pools; medications: atropine, aminoglycosides, iodide, phenylephrine, antivirals among others
• Foreign body: Redness may persist 24 hours after removal.

PHYSICAL EXAM

• Must document normal visual acuity
• General: common to all types of conjunctivitis
  • Conjunctival injection; foreign-body sensation
  • Eyelid sticking or crusting, discharge; normal visual acuity and pupillary reactivity
• Viral
  • Pharyngitis, preauricular lymphadenopathy and/or recent infectious contact make viral diagnosis much more likely
  • Hemorrhagic coxsackievirus, adenoviral epidemics seen in health care facilities and community
  • Severe viral: herpes simplex or zoster: burning sensation, rarely itching; unilateral, dermatomal distribution herpetic skin vesicles in zoster; palpable preauricular node
• Bacterial (non-STD): may be epidemic
  • Mucopurulent discharge, or concomitant otitis media make bacterial diagnosis twice as likely (1)[A].
  • Conjunctival chemosis/edema
  • If contact lenses user, must rule out pseudomonal (or other bacterial) keratitis. If long-term care resident, culture to rule out MRSA.
• Bacterial: gonococcal (or meningococcal) hyperacute infection
  • Rapid onset 12 to 24 hours; severe purulent discharge; chemosis/conjunctival/eyelid edema
  • Rapid growth of superior corneal ulceration; preauricular adenopathy; signs of STDs (chlamydia, GC, HIV, etc.)
• Allergic
  • Itching predominant, chemosis, edema; seasonal or animal dander allergies
• Nonspecific irritative
  • Dry eyes, intermittent redness, chemical/drug exposure
  • Foreign body: may have redness and discharge 24 hours after removal
• Cornea should be clear and without fluorescein uptake. Cloudy or ulcerated cornea signifies keratitis; consult ophthalmologist. Evert eyelid to inspect for foreign bodies.
• Skin: Look for herpetic vesicles, nits on lashes (lice), scaliness (seborrhea), and eyelid inflammation (blepharitis, rosacea, or styes).
• Limbal flush at corneal margin if uveitis; if pupil is irregular (i.e., penetrating foreign body), emergent referral is warranted.
• Discharge on eyelid margin but no conjunctival injection: blepharitis

DIFFERENTIAL DIAGNOSIS

• Punctate keratitis due to prolonged contact lenses wear
• Uveitis (iritis, iridocyclitis, choroiditis): limbal flush, hazy anterior chamber, and decreased visual acuity
• Acute glaucoma (emergency): headache, corneal clouding, poor visual acuity; corneal ulcer, keratitis, or foreign body: lesions or tear-film deficits on fluorescein exam; dacryocystitis: tenderness and swelling over tear sac (below medial canthus)
• Scleritis and episcleritis: red injected vessels radially oriented; pingueculitis: inflammation of a yellow nodular or wedge-like area of chronic conjunctival degeneration (pinguecula)
• Ophthalmia neonatorum: neonates in the first 2 days of life (gonococcal; 5 to 12 days of life): chlamydial, herpes simplex virus (HSV); blepharitis: Eyelid margins are inflamed producing itching, scale, or discharge but no conjunctival injection.
• Giant fornix syndrome: an elderly patient with recurrent or chronic conjunctivitis due to accumulation of infected material in enlarged fornices

DIAGNOSTIC TESTS & INTERPRETATION

Usually not needed initially for most common causes; culture swab if STD is suspected, severe symptoms, contact lenses user, or failed prior treatment

GENERAL MEASURES

Viral conjunctivitis does not require antibiotics, most resolve spontaneously. Clean external eyelid with wet cloth up to 4 times per day. Stop use of contact lenses as long as eye is red. Eye patching is not beneficial.

MEDICATION

ISSUES FOR REFERRAL

Refer to ophthalmology for decreased visual acuity, suspected herpetic keratitis/contact lenses–related conjunctivitis or immunocompromised (HIV), symptoms of acute angle closure glaucoma (fixed pupil, severe headache with nausea, ciliary flush). Suspicion for hyperacute bacterial conjunctivitis (gonococcal); refer for prolonged symptoms or worsening over 7 days (concern for severe adenoviral keratitis).

COMPLEMENTARY & ALTERNATIVE MEDICINE

Usually benign and self-limited; saline flushes, cool compresses, and similar treatments help.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Acute gonococcal conjunctivitis (or very rare case of meningococcal conjunctivitis) requires inpatient treatment with ceftriaxone 50 mg/kg IV every day (pediatric), 1 g IM for one (adult) along with ophthalmologic consultation.

FOLLOW-UP RECOMMENDATIONS

• If not resolved within 5 to 7 days, reconsider diagnosis or consult specialist
• Allergic conjunctivitis (noncontagious) should return to school with doctor’s note.

PATIENT EDUCATION

• No contact lenses until eyes are fully healed (~1 week). Discard current contact lenses.
• Adenovirus may persist on surfaces up to 28 days; practice soap hand washing and hypochlorite surface wipe use.
• Discard old eye makeup, especially mascara. Cool and moist compresses can ease irritation and itch.

PROGNOSIS

• Viral: 5 to 10 days of symptoms for pharyngitis with conjunctivitis, 2 weeks with adenovirus
• Herpes simplex: 2 to 3 weeks of symptoms
• Most common bacterial—H. influenzae, Staphylococcus, Streptococcus: self-limited; 74–80% resolution within 7 days, whether treated or not

COMPLICATIONS

• Corneal scars
• Corneal ulcers or perforation

SEE ALSO

• Rhinitis, Allergic
• Algorithm: Eye Pain

ICD10

• H10.30 Unspecified acute conjunctivitis, unspecified eye
• H10.33 Unspecified acute conjunctivitis, bilateral
• H10.32 Unspecified acute conjunctivitis, left eye
• H10.31 Unspecified acute conjunctivitis, right eye
• H10.021 Other mucopurulent conjunctivitis, right eye
• H10.022 Other mucopurulent conjunctivitis, left eye
• H10.023 Other mucopurulent conjunctivitis, bilateral
• H10.029 Other mucopurulent conjunctivitis, unspecified eye
• B30.9 Viral conjunctivitis, unspecified
• P39.1 Neonatal conjunctivitis and dacryocystitis

SNOMED

• 53726008 Acute conjunctivitis (disorder)
• 241759005 Pink eye disease (disorder)
• 34298002 Neonatal conjunctivitis (disorder)
• 128350005 Bacterial conjunctivitis (disorder)
• 45261009 Viral conjunctivitis (disorder)