AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Conjunctivitis is one of the most common nontraumatic eye complaints resulting in presentation to the ED. The term describes any inflammatory process that involves the conjunctiva; however, to most patients, conjunctivitis (often called pink eye) is a diagnosis in its own right. Most causes of conjunctivitis are benign, and the role of the emergency physician is to separate those few conditions requiring more vigorous treatment from the majority that can be handled satisfactorily in the ED.

Cellular infiltration and exudation characterize conjunctivitis on a cellular level. Classification usually is based on cause, including viral, bacterial, fungal, parasitic, toxic, chlamydial, chemical, and allergic agents. It also can be based on age of occurrence or course of disease. Etiology often can be distinguished on clinical grounds. In keratoconjunctivitis, an associated corneal involvement is present.

Pathophysiology

The conjunctiva is a loose connective tissue that covers the surface of the eyeball (bulbar conjunctiva) and reflects back upon itself to form the inner layer of the eyelid (palpebral conjunctiva). The conjunctiva firmly adheres to the sclera at the limbus, where it meets the cornea. The accessory lacrimal glands (Krause and Wolfring), along with goblet cells, are contained within the conjunctiva and are responsible for keeping the eye lubricated. As with any mucous membrane, infectious agents may adhere to the conjunctiva, thus overwhelming normal defense mechanisms and producing clinical symptoms of redness, discharge, irritation, and possibly photophobia. Viral etiologies are more common than bacterial, and incidence of viral conjunctivitis increases in the late fall and early spring.

Frequency

United States

Conjunctivitis is considered extremely common in the United States. Three percent of all ED visits are ocular related, and conjunctivitis is responsible for approximately 30% of all eye complaints. Approximately 15% of the population will have an allergic conjunctivitis episode at some time.

International

Conjunctivitis is extremely common.

Mortality/Morbidity

Conjunctivitis typically is a self-limited process; however, depending on the immune status of the patient and the etiology, conjunctivitis can progress to increasingly severe and sight-threatening infections.

• Purulent bacterial conjunctivitis in the neonate usually is caused by Neisseria gonorrhoeae. This type of conjunctivitis can be invasive and can lead to rapid corneal perforation.
• Chlamydial conjunctivitis can lead to conjunctival scarring (cicatrix) that can be severe enough to cause lid derangement and ingrown eyelashes.
• Trachoma is a more chronic, insidious form of Chlamydia trachomatis infection. The condition affects 500 million people worldwide and is considered the leading cause of blindness in the world, blinding approximately 10% of those affected.
• Chlamydial pneumonia can occur in infants up to 6 months after their conjunctivitis.
• Three major agents associated with follicular conjunctivitis, preauricular adenopathy, and superficial keratitis are adenovirus, chlamydia, and herpes simplex. Neisserial species can be associated with adenopathy, but the keratitis is ulcerative and not superficial. Frequently, a history of viral syndrome, sexually transmitted disease (STD), or fever blister can be elicited, which can aid in diagnosing the condition. Adenovirus is extremely contagious. Advise individuals to be diligent with hand washing and to avoid contact with their tears. Sharing pillows, towels, computer keyboards, and anything in contact with infected secretion helps spread the infection, a major cause of missed work hours.

Race

No racial predilection exists.

Sex

No sex predilection exists, although 90% of women with chlamydial eye infections have associated genital infections, and as many as 60% of men have associated genitourinary symptoms.

Age

Conjunctivitis occurs in all ages.

• Conjunctivitis of the newborn is the term used by the World Health Organization (WHO) for any conjunctivitis with discharge occurring during the first 28 days of life. Ophthalmia neonatorum was the term used to describe a hyperacute purulent conjunctivitis, usually caused by gonococci, in the first 10 days of life. In this instance, transmission is vertical.
• Any individual with follicular conjunctivitis or preauricular adenopathy with or without keratitis should be questioned about the possibility of STD; high-risk individuals should be treated empirically for chlamydia.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

In classic presentations, patients complain of eyelids sticking together on waking. They may describe itching and burning or a gritty foreign-body sensation. Pus sliding across the eye may distort vision, though visual acuity is normal. Photophobia is minimal. Family members with similar complaints typically present with conjunctivitis from an infectious cause. A history of a recent upper respiratory infection (URI) typically is associated with a viral cause.

• Bacterial conjunctivitis is characterized by acute onset, minimal pain, occasional pruritus, and, sometimes, exposure history.
• • Ocular surface disease (eg, keratitis sicca, trichiasis, chronic blepharitis) predisposes the patient to bacterial conjunctivitis.
  • Staphylococcal and streptococcal species are the most common pathogens.
• Viral conjunctivitis is characterized by acute or subacute onset, minimal pain level, and, often, exposure history.
• • Pruritus is common. A clear, watery discharge is typical.
  • Occasionally, severe photophobia and foreign-body sensation occurs, usually caused by adenovirus (epidemic keratoconjunctivitis [EKC]), when associated with keratitis.
  • Check for preauricular adenopathy and a follicular conjunctival change, particularly on the palpebral conjunctiva. If present, the likely diagnosis is EKC.
  • Be aware that herpes simplex and chlamydia also cause follicular conjunctivitis and preauricular adenopathy.
• Chlamydial conjunctivitis is characterized by chronic onset, minimal pain level, occasional pruritus, and STD history.
• Allergic conjunctivitis is characterized by acute or subacute onset, no pain, and no exposure history.
• • Pruritus is extremely common. Clear, watery discharge is typical with or without a moderate amount of mucous production.
  • An aggressive form of allergic conjunctivitis is vernal conjunctivitis in children and atopic conjunctivitis in adults. Vernal disease often is associated with shield corneal ulcers. Perilimbal accumulation of eosinophils (Horner-Trantas dots) typifies vernal disease. Vernal keratoconjunctivitis (VKC), usually affecting young boys, tends to be bilateral and occurs in warm weather. VKC is presumed to be a hypersensitivity to exogenous antigens and may be associated with or accompanied by keratoconus.
• Giant papillary conjunctivitis resembles vernal disease.
• • This condition occurs mainly in contact lens wearers who develop a syndrome of excessive pruritus, mucous production, and increasing intolerance to contact use.
  • The giant papillae are predominantly on the upper palpebral conjunctiva and can be seen only on lid eversion.

Physical

On any patient with ocular complaints, perform a complete physical examination of the eye, including visual acuity, fluorescein staining, slit-lamp examination, and tonometry. Specific helpful clues in differentiating the causes of conjunctivitis are listed below.
 
For a CME/CE activity, see The Diagnosis and Treatment of Bacterial Conjunctivitis in Pediatric Patients.

• Bacterial conjunctivitis
• • Preauricular adenopathy sometimes occurs; chemosis (thickened, boggy conjunctiva) is common.
  • Discharge is copious; discharge quality is thick and purulent. Conjunctival injection is moderate or marked.
• Viral conjunctivitis
• • Preauricular adenopathy is common in EKC and herpes; chemosis is variable.
  • Discharge amount is moderate, stringy, or sparse; discharge quality is thin and seropurulent. Conjunctival injection is moderate or marked.
• Chlamydial conjunctivitis tends to be chronic with exacerbation and remission.
• • Preauricular adenopathy is occasional; chemosis is rare.
  • Discharge amount is minimal; discharge quality is seropurulent. Conjunctival injection is moderate.
• Allergic conjunctivitis occurs with pruritus as the hallmark symptom.
• • Preauricular adenopathy is absent; chemosis is common.
  • Discharge amount is moderate, stringy, or sparse; discharge quality is clear. Conjunctival injection is moderate.
• Marginal ulcers (small white ulcers that appear on the cornea at the limbus) may indicate an allergic reaction to staphylococcal antigen.
• • This is a toxin-related complication of staphylococcal species that frequently cause blepharitis.
  • Pain, photophobia, and a foreign-body sensation are common. The ulcers are sterile and respond to topical steroids.
• Bilateral disease typically is infectious or allergic.
• Unilateral disease suggests toxic, chemical, mechanical, or lacrimal origin.
• • Intraocular pressure, pupil size, and light response are all normal.
  • Ciliary flush, corneal staining, and anterior chamber reaction is absent unless a significant amount of keratitis is associated (as seen in EKC).

Causes

Several studies demonstrate that acute conjunctivitis occurs with almost equal frequency between bacterial and viral causes. Fitch et al noted that viral conjunctivitis occurs more frequently in the summer, and bacterial conjunctivitis occurs more often in the winter and spring.

• Mucopurulent conjunctivitis is caused by bacterial organisms.
• • Gram-positive for the following cocci - Staphylococcus epidermidis, Streptococcus pyogenes, and Streptococcus pneumoniae
  • Gram-negative for the following cocci - Neisseria meningitidis and Moraxella lacunata
  • Gram-negative for the following rods - genus Haemophilus and family Enterobacteriaceae
• Approximately one-third of children had an anaerobic bacterial etiology in studies that used adequate recovery methods. Predominant anaerobic organisms include Clostridium species, gram-negative anaerobic bacilli, and Peptostreptococcus species. 
• Hyperpurulent conjunctivitis usually is caused by N gonorrhoeae.
• N gonorrhoeae, C trachomatis, and other bacteria (mainly staphylococcal species and S pneumoniae) cause conjunctivitis of the newborn. (Approximately 90% of infants receiving Credé prophylaxis [ie, silver nitrate application] for gonorrheal ophthalmologic problems experience a mild, transient conjunctival injection and tearing with variable purulence that typically resolves in 24-48 hours.)
• Many types of viruses, most commonly adenovirus, cause viral conjunctivitis.
• Atopic conjunctivitis typically occurs in male teenagers who have a history of childhood atopic dermatitis. The condition resembles vernal conjunctivitis but is not seasonal.
• Vernal conjunctivitis is a bilateral recurrent hypersensitivity that occurs during the warm months of the year, particularly in hot climates.
• Giant papillary conjunctivitis predominantly is associated with contact lens wear.
• Toxic conjunctivitis occurs with airborne irritants or a direct splash of liquid or powder to the eye.
• Unusual causes may be considered in patients with atypical presentations, including parasitic (eg, Loa loa, Trichinella, Onchocerca), autoimmune (eg, sicca, pemphigoid), and systemic diseases (eg, sarcoidosis, tuberculosis, Reiter syndrome, Kawasaki disease).

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Episcleritis, an inflammatory condition of the episclera, usually is sectorial and self-limiting. The eye is often tender and mildly photophobic. Topical phenylephrine (Neo-Synephrine [2.5%]) can be used diagnostically; the conjunctival vessels blanch, but the episcleral vessels remain engorged in episcleritis as opposed to conjunctivitis, in which most vessels blanch.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Conjunctivitis usually is diagnosed by history and physical examination. Lab tests typically are reserved for patients that do not improve in 48-72 hours despite treatment. Lab studies include the following:
• • Gram stain is considered the criterion standard for determining the bacterial cause of conjunctivitis. Simple conjunctivitis does not require a Gram stain. Eosinophils seen on Gram stain are indicative of allergic conjunctivitis but can be seen in parasitic causes.
  • Culture and sensitivity of conjunctival scrapings typically are not performed for simple conjunctivitis. Obtain cultures in all newborns, neonates, persons who are immunosuppressed, or when N gonorrhoeae is under consideration as the etiology. When performed, collect exudate from the lower conjunctival fornix with a calcium alginate swab moistened with saline. Sheep blood and mannitol agar plates routinely are used. Expect viral and chlamydial causes in culture-negative conjunctivitis.
  • Giemsa staining is performed to look for the inclusion bodies of Chlamydia versus a viral etiology in culture-negative conjunctivitis. This technique has a low yield, except in neonatal inclusion conjunctivitis. The presence of eosinophils is diagnostic of allergic conjunctivitis.
  • Immunofluorescent antibody testing of the conjunctival discharge can be performed to detect the immunoglobulin G (IgG) or immunoglobulin M (IgM) antibodies to Chlamydia. Consider chlamydial etiology when conjunctivitis persists beyond 14 days and in all sexually active individuals. A high index of suspicion is necessary in patients aged 15-50 years.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Prehospital transport rarely is indicated for patients with conjunctivitis. More serious concerns may warrant emergency medical services (EMS) transport. Prehospital personnel should not overlook more serious comorbidity; they should focus on preventing transmission. Thorough hand washing by EMS personnel and glove use are necessary.

Treatment often is supportive. Artificial tears help the discomfort of keratitis and photophobia. Cold compresses improve the swelling and discomfort of the lids. Antibiotic drops help prevent a secondary bacterial infection. Reserve topical corticosteroids for use by an ophthalmologist when substantial inflammation is present and herpes simplex is excluded. Broad-spectrum antibiotics, such as Ciloxan (ciprofloxacin) or Ocuflox (ofloxacin), are good choices. Sulfacetamide is also acceptable. Aminoglycoside is toxic to epithelia and retards healing. Polytrim (trimethoprim/sulfamethoxazole) is a reasonable choice particularly in children.

Emergency Department Care

Physicians and other medical personnel must be careful not to transmit this infection. Prevention of transmission includes thorough hand washing and using eye drops in individual or unit dose containers. Patients can be given moist compresses for comfort.

Consultations

Consult with an ophthalmologist for all serious eye complaints. Simple conjunctivitis usually can be followed up by the patient's primary care provider. Discuss with an ophthalmologist solutions to questions or equivocal diagnosis. Neisserial conjunctivitis is an ocular emergency and should be viewed as an ocular finding of systemic disease. Ophthalmologic consultation is essential.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Treatment with antimicrobials and symptomatic therapy is recommended for all patients initially presenting to the ED with simple conjunctivitis. Numerous topical antimicrobial agents may be used, including topical sulfacetamide, erythromycin, gentamicin, ciprofloxacin, or ofloxacin. Avoid neomycin-containing solutions because 8-15% of patients have hypersensitivity reactions. Instill drops every 2 hours. An ointment can be used at night or every 4-6 hours throughout the day.

Consider gonococcal conjunctivitis part of a systemic disease, thus requiring systemic treatment. Inpatient medical regimens include cefoxitin, ceftriaxone, cefotaxime, or spectinomycin. Treat all patients who have chlamydia with tetracycline, doxycycline, azithromycin, or erythromycin. Outpatient therapy is acceptable in less serious cases in which compliance can be ensured and includes ceftriaxone (50 mg/kg, not to exceed 1 g) IV followed by doxycycline 100 mg twice a day or erythromycin 500 mg qid. Identify and treat patients' sexual partners.

Chlamydial conjunctivitis can be treated with doxycycline 100 mg twice a day for 10 days or azithromycin 1 g. Erythromycin can be used in pregnant patients and infants.

Topical therapy with erythromycin also is recommended and may speed resolution. As with gonococcal infections, identify and treat patients' sexual partners.

Drug Category: Antibiotics, ophthalmic

Used for infectious conjunctivitis. Therapy must cover all likely pathogens in the context of the clinical setting. However, when prescribing the antibiotic, the care provider must take into account that the incidence of MRSA has continued to increase in recent years.

Drug Category: Decongestants

Generally have vasoconstricting effects with ability to control pruritus.

Drug Category: Mast cell stabilizers

Inhibit degranulation of sensitized mast cells following exposure to specific antigens.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents are used for the treatment of allergic conjunctivitis. Although most NSAIDs are used primarily for anti-inflammatory effects, they are effective analgesics and are useful for the relief of mild-to-moderate pruritus. Ketorolac 0.4% has also been shown as effective in treating allergic conjunctivitis.¹

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients with gonorrheal infections, neonates with infections, and patients who are immunocompromised should be admitted for administration of IV antibiotics.

Further Outpatient Care

• Refer patients to their primary care provider for follow-up in 2-3 days to ensure they are responding to treatment. Viral conjunctivitis usually is self-limited to 10-14 days, but symptoms may persist for as many as 6 weeks.

In/Out Patient Meds

• Prescribe one of the previously mentioned antibiotics for discharged patients. For copious ocular secretions, patients may use frequent saline irrigation or artificial tears. Avoid eye patching.

Transfer

• Manage simple conjunctivitis in the ED. Transfer may be appropriate for patients with complications from chronic or gonococcal conjunctivitis when an ophthalmologist is unavailable.

Deterrence/Prevention

• Careful and frequent hand washing is necessary to reduce transmission from one eye to the other in the patient and from contacts.

Complications

• Pneumonia can occur in 10-20% of infants with chlamydial conjunctivitis as many as 6 months later. Untreated chlamydial conjunctivitis in adults can lead to conjunctival scarring.
• Penetration of the cornea can occur within 2 days in patients with untreated N gonorrhoeae.
• Infections with N meningitidis may require systemic antibiotics to prevent meningitis.

Prognosis

• Prognosis is good. Conjunctivitis typically is self-limited and without long-term complications.

Patient Education

• Warm compresses and washing eyelids with diluted baby shampoo may speed resolution when blepharitis is an associated factor. Patients should not use eye makeup. Frequent hand washing is essential to prevent further transmission.
• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Pinkeye.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to recognize a gonococcal infection in someone with ocular and GU symptoms
• Failure to recognize herpes simplex conjunctivitis and keratitis and prescribing corticosteroids
• Failure to consider other causes in a patient with an acutely red eye (eg, iritis, uveitis, angle-closure glaucoma, ocular ischemic syndrome, penetrating or perforating ocular injury)

Special Concerns

• During birth, risk of transmission of Gonococcus, Streptococcus, or Chlamydia to the fetus exists. Obtain cervical cultures if indicated.
• Risk of chlamydial pneumonia exists. Any of the bacterial organisms that cause conjunctivitis, particularly in a premature infant, can lead to sepsis and death. Neonates are at risk for secondary meningitis, cellulitis, and septicemia, particularly if the conjunctivitis is caused by Escherichia coli, Staphylococcus aureus, or Haemophilus influenzae.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Sep 11, 2008