eMedicine Specialties > Emergency Medicine > Ophthalmology

Conjunctivitis

Michael A Silverman, MD, Instructor of Emergency Medicine, The Johns Hopkins University School of Medicine; Chairman, Department of Emergency Medicine, Harbor Hospital
Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University

Updated: Jun 1, 2009

Introduction

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

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.

• 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).

Differential Diagnoses

Corneal Abrasion
Glaucoma, Acute Angle-Closure
Herpes Zoster
Herpes Zoster Ophthalmicus
Iritis and Uveitis
Scleritis

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

Laboratory 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

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.

For treatment guidelines, see the American Academy of Ophthalmology's guidelines.¹

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

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.

Antibiotics, ophthalmic

Ciprofloxacin 3% (Ciloxan)

Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase in susceptible organisms. Broad-spectrum antibiotic with good gram-positive and gram-negative coverage.

Dosing

Adult

1-2 gtt q2h in conjunctival sac(s) during waking hours for 2 d, then 1-2 gtt q4h during waking hours for the next 5 d

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

A white crystalline precipitate located in superficial portion of corneal defect may occur (onset in 1-7 d); precipitate usually is cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy

Gatifloxacin ophthalmic solution 0.3% (Zymar)

Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. Elicits a dual mechanism of action by possessing an 8-methoxy group, thereby inhibiting the enzymes DNA-gyrase and topoisomerase IV. DNA gyrase is involved in bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial cell division.
Indicated for bacterial conjunctivitis due to C propinquum, S aureus, S epidermidis, S mitis, S pneumoniae, or H influenzae.

Dosing

Adult

Days 1-2: Instill 1 gtt into affected eye q2h while awake; not to exceed 8 administrations per day
Days 3-7: Instill 1 gtt into affected eye up to qid while awake

Pediatric

<1 year: Not established
>1 year: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For ophthalmic use only; commonly causes conjunctival irritation, increased lacrimation, corneal inflammation, or papillary conjunctivitis; less common adverse effects include conjunctival hemorrhage, dry eye, eye discharge, eye irritation, eye pain, eyelid swelling, headache, red eye, reduced visual acuity, or taste disturbance

Norfloxacin 0.3% (Noroxin, Chibroxin)

Inhibits bacterial growth by inhibiting DNA gyrase. Has limited use and is not readily available. Ciprofloxacin and ofloxacin are superior in spectrum and effectiveness. Approved for pediatric use in children >1 y.

Dosing

Adult

1-2 gtt qid to affected eye for 7 d

Pediatric

<1 year: Not established
>1 year: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in deep ocular infections likely to become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms

Besifloxacin ophthalmic (Besivance)

Quinolone antimicrobial ophthalmic susp indicated for bacterial conjunctivitis. Susceptible bacteria include CDC coryneform group G (Corynebacterium pseudodiphtheriticum, Corynebacterium stratum), Haemophilus influenza, Moraxella lacunata, Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Streptococcus mitis, Streptococcus oralis, Streptococcus pneumoniae, and Streptococcus salivarius. Available as a 0.6% ophthalmic susp.

Dosing

Adult

Instill 1 gtt in affected eye(s) tid (4-12 h between doses) for 7 d

Pediatric

<1 year: Not established
>1 year: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In clinical trials, adverse effects occurred in <3% of patients and included redness of eyes, blurred vision, eye pain, eye irritation, eye itching, and headache; do not use with contact lens (remove and do not wear contacts during course of therapy and with symptoms of bacterial conjunctivitis); for topical ophthalmic use only; prolonged use may lead to bacterial resistance

Bacitracin ointment 500 U/g (AK-Tracin, Baciguent)

Prevents transfer of mucopeptides into the growing cell wall, which results in inhibition of cell wall synthesis and, as a result, bacterial growth. Gram-positive better than gram-negative coverage.

Dosing

Adult

Severe infections: Apply 0.25- to 0.5-in ribbon q3-4h into conjunctival sac for 7-10 d
Mild-to-moderate infections: Apply bid/tid

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; vaccinia; varicella, epithelial herpes simplex keratitis; mycobacterial infections; fungal diseases of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Ophthalmic ointments may delay healing of corneal epithelia; in deep-seated infections of the eye, supplement with systemic medications; prolonged use may result in overgrowth of nonsusceptible organisms

Erythromycin ointment (Ilosone, E-Mycin)

Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections. Good gram-positive coverage.

Dosing

Adult

Apply 0.5-in (1.25-cm) ribbon to affected eye 2-8 times/d, depending on severity of infection

Pediatric

Administer as in adults
Prophylaxis of neonatal gonorrhea and chlamydia: Apply 0.5- to 1.25-cm ribbon to each conjunctival sac

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)

Azithromycin ophthalmic (Azasite)

Ophthalmic macrolide antibiotic. Indicated for bacterial conjunctivitis caused by CDC coryneform group G bacteria, Haemophilus influenzae, Staphylococcus aureus, Streptococcus mitis group, and Streptococcus pneumoniae.

Dosing

Adult

Instill 1 gtt in affected eye(s) bid (administer doses 8-12 h apart) for 2 d, then 1 gtt qd for next 5 d

Pediatric

<1 year: Not established
>1 year: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Thoroughly wash hands before using; for topical ophthalmic use only; prolonged use may result in resistant organisms; do not wear contact lenses until infection resolves; may cause eye irritation; less common adverse effects include burning, stinging, and/or irritation when instilled; other less common adverse effects include contact dermatitis, corneal erosion, dry eyes, dysgeusia, nasal congestion, ocular discharge, punctate keratitis, and sinusitis

Gentamicin (Garamycin, Genoptic)

Aminoglycoside antibiotic (ointment or solution) used for gram-negative bacterial coverage. Tends to be toxic to epithelia and retards healing.

Dosing

Adult

Solution: 1-2 gtt q4h to affected eye
Ointment: Apply 0.5-in (1.25-cm) ribbon bid/tid q3-4h to affected eye

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infections

Tobramycin (Tobrex, AKTob)

Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. Available as a solution, ointment, and lotion. Superior to gentamicin in that streptococcal species are often resistant to gentamicin.

Dosing

Adult

Solution: 1-2 gtt q4h to affected eye during waking hours and less frequently at night; in severe infections, instill 2 gtt q30-60 min initially, followed by less frequent intervals
Ointment: Apply 0.5-in ribbon bid/tid in conjunctival sac; in severe infections, apply q3-4h

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Interactions

Effects of this drug diminish when used concurrently with gentamicin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms

Sulfacetamide 10% (Bleph-10, Sodium Sulamyd)

Inhibits folic acid synthesis, which results in inhibition of bacterial growth. Has better gram-positive than gram-negative coverage. Available as solution, ointment, and lotion.

Dosing

Adult

Solution: 1-3 gtt q2-3h in affected eye while awake, with less frequent administration at night
Ointment: Apply 0.5-in (1.25-cm) ribbon 1-4 times/d into conjunctival sac

Pediatric

<2 months: Not established
>2 months: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in severely dried eye; ointment may retard corneal epithelial healing; significant percentage of staphylococcal isolates are completely resistant; may sting when applied; do not use in deep ocular infections likely to become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms

Decongestants

Generally have vasoconstricting effects with ability to control pruritus.

Naphazoline 0.1%, (Clear Eyes, AK-Con, Opcon)

OTC drug for temporary relief of pruritus and hyperemia associated with mild allergic conjunctivitis. Has alpha-adrenergic effects in the arterioles of the conjunctiva and nasal mucosa to produce vasoconstriction.

Dosing

Adult

1-2 gtt q2h prn; not to exceed qid; do not administer for more than 3-5 d

Pediatric

<6 years: Not recommended
>6 years: Administer as in adults

Interactions

None reported with ophthalmic use; in systemic use, risk of hypertensive reactions increases when used concurrently with tricyclic antidepressants or MAOIs; toxicity increases when used concurrently with anesthetics

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; do not use before a peripheral iridectomy is performed

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use may cause rebound congestion; caution in diabetes, hypertension, heart disease, cerebral arteriosclerosis, hyperthyroidism, and asthma

Levocabastine (Livostin)

Most potent topical antihistamine available. Has rapid onset and sustained effect. Can be used as many as 4 times daily or prn.

Dosing

Adult

1 gtt qid to affected eye

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in patients wearing soft contact lenses; not for injection

Mast cell stabilizers

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

Cromolyn 4%, (Intal)

Long-term use by patients with seasonal allergies; not used for short-term treatment. Alomide is a far more potent mast cell stabilizer. Patanol is a combination antihistamine and mast cell stabilizer and is used either bid/tid.

Dosing

Adult

1-2 gtt q4-6h to each eye; use at regular intervals

Pediatric

<4 years: Not established
>4 years: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use with soft contact lenses in place; may experience a transient stinging or burning sensation after application; caution when withdrawing drug because symptoms may recur

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.³

Ketorolac 0.5%, (Acular, Toradol)

Approved for temporary relief of pruritus associated with allergic conjunctivitis. Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.

Dosing

Adult

1 gtt qid to affected eye

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; patients wearing soft contact lenses

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision, and macula degeneration

Follow-up

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.

Inpatient & Outpatient Medications

• 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

Medicolegal 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

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Keywords

pink eye, pinkeye, conjunctivitis, bacterial conjunctivitis, viral conjunctivitis, keratoconjunctivitis, chlamydial conjunctivitis, follicular conjunctivitis, preauricular adenopathy, superficial keratitis, allergic conjunctivitis, giant papillary conjunctivitis, inflammation of the conjunctiva, purulent bacterial conjunctivitis, hyperpurulent conjunctivitis, Neisseria gonorrhoeae, conjunctival scarring, Chlamydia trachomatis, trachoma, adenovirus, herpes simplex, viral syndrome, sexually transmitted disease, STD, ophthalmia neonatorum, hyperacute purulent conjunctivitis, photophobia, keratitis sicca, trichiasis, chronic blepharitis, epidemic keratoconjunctivitis, vernalconjunctivitis, atopic conjunctivitis, shield corneal ulcers, Horner-Trantas dots, vernal keratoconjunctivitis, giant papillary conjunctivitis, chemosis, Staphylococcus epidermidis, Streptococcus pyogenes, Streptococcus pneumoniae, Neisseria meningitidis, Moraxella lacunata, Haemophilus, Enterobacteriaceae, Loa loa, Trichinella, Onchocerca, sicca, pemphigoid, sarcoidosis, tuberculosis, Reiter syndrome, Kawasaki disease

Contributor Information and Disclosures

Author

Michael A Silverman, MD, Instructor of Emergency Medicine, The Johns Hopkins University School of Medicine; Chairman, Department of Emergency Medicine, Harbor Hospital
Michael A Silverman, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
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Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
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Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery
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CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
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Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
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