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Acute Conjunctivitis

Basics

  • Description:
    Inflammation of bulbar and/or palpebral conjunctiva lasting <4 weeks.

  • Geriatric considerations:
    Higher risk of bacterial, autoimmune, or irritative causes, especially with purulent discharge, age >65, or long-term care residence.

  • Pediatric considerations:
    Neonatal conjunctivitis can be gonococcal, chlamydial, irritative, or due to dacryocystitis. Children <5 more often bacterial; most self-resolve in 2-5 days.

Epidemiology

  • Incidence: 1-2% of ambulatory visits; up to 3% of ER visits.
  • Viral, bacterial, allergic, and irritative causes predominate depending on age group.

Etiology and Pathophysiology

  • Viral: Adenovirus, coxsackievirus, enterovirus, HSV, herpes zoster, measles, mumps, influenza, SARS-CoV-2.
  • Bacterial: Staphylococcus aureus (including MRSA), Streptococcus pneumoniae, Haemophilus influenzae (children), Pseudomonas spp. (contact lens users), Neisseria gonorrhoeae, Chlamydia trachomatis.
  • Allergic: Hay fever, atopy, seasonal allergies.
  • Irritative: Topical medications, wind, dry eye, UV exposure, smoke, chlorine.
  • Autoimmune: Sjögren syndrome, pemphigoid, Wegener granulomatosis, Reiter syndrome, sarcoid.

Risk Factors

  • Contact with infected persons.
  • Sexual transmission (gonorrhea, chlamydia, syphilis, herpes).
  • Contact lens use.
  • Long-term care facility residence.
  • Epidemic settings (schools, healthcare).

Diagnosis

  • History:
    Red eye, discharge, contact/travel history, STD risk, contact lens use, medication exposure.

  • Physical exam:
    Red eye, conjunctival injection, discharge (mucopurulent or watery), lid crusting, normal visual acuity (key to rule out other serious eye conditions), preauricular lymphadenopathy (viral), chemosis (allergic/bacterial).

  • Differential diagnosis:
    Uveitis, keratitis, acute glaucoma, dacryocystitis, scleritis, episcleritis, pingueculitis, ophthalmia neonatorum.

  • Diagnostic tests:
    Usually clinical diagnosis.
    Culture in contact lens wearers, suspected STDs, severe cases.
    Fluorescein staining to rule out corneal ulcer or foreign body.
    Viral PCR during epidemics.

Treatment

  • General measures:
    Most viral conjunctivitis is self-limited.
    Clean eyelids with wet cloth.
    Avoid contact lens use during active infection.

  • Medications:

  • Viral (nonherpetic): artificial tears, vasoconstrictor/antihistamine drops (e.g., naphazoline/pheniramine), consider single-dose povidone-iodine 5%.
  • Viral (herpetic): ganciclovir gel, oral acyclovir (ophthalmology consult).
  • Bacterial (non-STD): antibiotics after 3 days of cool compresses or immediate topical antibiotics for daycare return. Common agents include bacitracin ointment, polymyxin B-trimethoprim, erythromycin ointment, sulfacetamide, tobramycin/gentamicin drops.
  • Bacterial (gonococcal): hospitalization and IV/IM ceftriaxone, topical bacitracin.

  • Allergic: topical antihistamines/mast cell stabilizers (ketotifen, olopatadine, azelastine), oral antihistamines for nasal symptoms.

  • Precautions:
    Avoid steroids unless under ophthalmologist supervision.
    Dropper tip should not touch eye.
    Beware rebound vasodilation with prolonged vasoconstrictor use.

Issues for Referral

  • Decreased visual acuity or photophobia.
  • Suspected herpetic keratitis.
  • Contact lens wearers with infection.
  • Immunocompromised patients.
  • Symptoms >7 days or worsening condition.

Complementary & Alternative Medicine

  • Supportive care with saline flushes, cool compresses.

Admission & Nursing Considerations

  • Gonococcal or meningococcal conjunctivitis requires inpatient treatment and ophthalmology consultation.

Ongoing Care

  • Follow up if symptoms worsen or do not resolve in 5-7 days.
  • School exclusion policies vary; allergic conjunctivitis is noncontagious.

Patient Education

  • Discard contaminated contact lenses and makeup.
  • Practice frequent handwashing and surface disinfection (e.g., hypochlorite wipes).
  • Avoid eye rubbing.

Prognosis

  • Viral conjunctivitis symptoms last 5-10 days (2 weeks for adenovirus).
  • Bacterial conjunctivitis often resolves within 7 days.
  • Herpetic conjunctivitis lasts 2-3 weeks.

Complications

  • Corneal scars, ulceration (herpes simplex).
  • Lid/conjunctival scarring, symblepharon (varicella zoster, chlamydia).
  • Neonatal conjunctivitis complications: pneumonia, otitis media.

Clinical Pearls:
- Decreased visual acuity or pain with eye movement is NOT typical of conjunctivitis and requires urgent evaluation.
- Culture all contact lens wearers and nursing home residents with conjunctivitis.
- Antibiotics generally unnecessary for viral conjunctivitis.
- Cool compresses for 3 days before antibiotics may reduce unnecessary antibiotic use.