Conjunctivitis

Aka: Conjunctivitis

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II. Definitions

  1. Conjunctiva
    1. Clear, vascular membrane that lines the non-Corneal surface of the eye and the inner Eyelid
  2. Conjunctivitis
    1. Inflammation of the Conjunctiva

III. Symptoms

  1. Eye Discharge
    1. Bacterial Conjunctivitis: Mucoid, purulent discharge
    2. Viral Conjunctivitis: Watery discharge
    3. Allergic Conjunctivitis: Watery discharge
  2. Eye Pain minimal
    1. Scratchy foreign body Sensation
    2. Pruritus in Allergic Conjunctivitis
    3. Worse pain in Corneal Injury, Iritis, Keratitis and Acute Angle-Closure Glaucoma
  3. Photophobia minimal
    1. Worse in acute Iritis or Keratitis

IV. Signs

  1. Conjunctiva erythema
    1. Palpebral Conjunctiva injection
    2. Diffuse erythema over bulbar Conjunctiva
  2. Cornea normal
    1. Epithelial defect in Corneal Injury or diffuse uptake in Keratitis
      1. Fluorescein stain
    2. Diffusely cloudy in acute Glaucoma
  3. Visual Acuity normal
    1. Vision blurred in acute Iritis and Corneal Injury
    2. Vision markedly reduced (<20/200) in acute Glaucoma
  4. Pupil size and reactivity normal
    1. Small pupil in Corneal Injury or Iritis
    2. Dilated non-reactive pupil in Glaucoma
  5. Intraocular Pressure normal
    1. Elevated in acute Glaucoma
  6. No Ciliary Flush
    1. Contrast with Iritis and Glaucoma
  7. Preauricular Lymphadenopathy
    1. Seen in Viral Conjunctivitis (not in Bacterial)

V. Exam

  1. See Eye Exam
  2. Visual Acuity
  3. Evaluate periorbital region (e.g. Vesicles, Preseptal Cellulitis)
  4. Consider Fluorescein stain for Corneal disruption
  5. Consider everting Eyelids for foreign body

VI. Differential Diagnosis: Red Eye

  1. See Acute Red Eye
  2. Keratitis
  3. Episcleritis
  4. Uveitis
  5. Acute Iritis
  6. Scleritis
  7. Endophthalmiitis (globe infection)
  8. Blepharitis (Eyelid Inflammation)
  9. Narrow Angle Glaucoma
  10. Subconjunctival Hemorrhage
  11. Mucous membrane Pemphigoid
  12. Sjogren Syndrome
  13. Kawasaki Disease
  14. Stevens-Johnson Syndrome
  15. Carotid Cavernous Fistula

VII. Causes: Common

  1. Infectious
    1. Viral Conjunctivitis (esp. Adenovirus)
      1. Accounts for 55 to 80% of cases in adults
    2. Bacterial Conjunctivitis (esp. Haemophilus Influenzae in children, Staphylococcus Aureus in adults)
      1. Accounts for 71% of cases in children
  2. Non-Infectious
    1. Allergic Conjunctivitis
      1. Pruritic, bilateral, recurrent or persistent Conjunctivitis
      2. Typically associated with a history of allergy or atopy
    2. Dry Eye (Keratoconjunctivitis Sicca)
    3. Chemical Conjunctivitis (toxin or chemical exposure)
    4. Contact Lens use
    5. Occult Conjunctival neoplasm
    6. Corneal Foreign Body
    7. Idiopathic

VIII. Causes: Serious Conditions to Exclude

  1. Herpes Simplex Conjunctivitis
    1. Unilateral Conjunctival/Corneal Inflammation with severe pain
    2. Concurrent Cold Sores may be present
    3. Dendritic Ulcers on Fluorescein staining of Cornea
  2. Herpes Zoster
    1. See Herpes Ophthalmicus
    2. Observe for Herpes Zoster lesions in the V1 or V2 distribution
    3. Hutchinson sign (Vesicles on the tip of the nose)
  3. Chlamydial Conjunctivitis
    1. Unilateral Conjunctivitis with hyperemia and mucopurulent discharge
    2. May present as subacute case (>4 weeks)
    3. Lymphoid follicle formation (also seen in some Viral Conjunctivitis)
      1. Tiny, rice grain size, gelatinous pale bumps on the Conjunctiva
  4. Gonococcal Conjunctivitis (Hyperacute Bacterial Conjunctivitis)
    1. Severe purulent Eye Discharge, Eye Pain and decreased Vision
    2. Risk of Corneal involvement including Corneal Ulceration
    3. Obtain cultures and treat systemically for both Gonorrhea and Chlamydia
  5. Bacterial Conjunctivitis in a Contact Lens Wearer
    1. Higher risk for Keratitis (esp. Pseudomonas Aeruginosa)

IX. Labs

  1. Eye Gram Stain and culture indications
    1. Corneal Ulceration
    2. Orbital Cellulitis
    3. Severe recurrent or refractory eye infection
  2. Other testing to consider
    1. Chlamydia PCR
    2. Giemsa Stain and viral culture for herpes

X. Management

  1. See Specific management protocols
  2. See Viral Conjunctivitis
  3. See Epidemic Keratoconjunctivitis
  4. See Bacterial Conjunctivitis
  5. See Allergic Conjunctivitis
  6. See Gonococcal Conjunctivitis
  7. See Herpes Simplex Keratitis
  8. See Vernal Conjunctivitis
  9. General Measures
    1. Warm soaks to keep lids and lashes free of debris
    2. Cool compresses may be soothing
    3. Practice good hygiene to prevent contagious spread
    4. Topical lubricant eye drops (Methylcellulose, Refresh Tears) or artificial tears

XI. Management: Ophthalmology Referral Indications (typically at 3 to 5 days - up to 1 week)

  1. Contact Lens users
  2. Recent eye surgery
  3. Topical Corticosteroids required (e.g. Iritis)
  4. No improvement after 7 days
  5. Red Flag Symptoms (urgent Consultation)
    1. Severe Eye Pain
    2. Sudden Vision changes
    3. Severe photophobia esp. with Pupil Constriction (Iritis)
    4. Anisocoria with smaller pupil at the affected eye
    5. Suspected Herpes Ophthalmicus
  6. Significant comorbidity
    1. Immunocompromised State
    2. Rheumatologic Disease

XII. Prevention

  1. Frequent Hand Washing
  2. Do not share towels
  3. Throw away used Contact Lenses and their case
  4. Throw away used eye makeup
  5. Wipe contaminated surfaces with bleach
    1. Adenovirus survives on surfaces for 72 hours

XIII. Resources (Include Patient Education)

  1. See Conjunctivitis Resources

XIV. References

  1. Azari (2013) JAMA 310:1721-9 [PubMed]
  2. Cronau (2010) Am Fam Physician 81(2): 137-44 [PubMed]
  3. Mahoney (2023) Children 10(5):808 +PMID: 37238356 [PubMed]
  4. Winters (2024) Am Fam Physician 110(2):134-44 [PubMed]

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