Conjunctivitis

Paul G. Auwaerter, M.D.

PATHOGENS

Infectious causes:

CLINICAL

Inflammation of eyelid and eyeball lining: Causes include infectious and non-infectious etiologies: see Table Table 1Clinical Presentations That May Distinguish in Acute Conjunctivitis for distinguishing features.

  • Non-infectious:
    • Allergic, usually IgE-mediated responses to environmental allergens.
      • Hx: bilateral redness, watery d/c, itching (hallmark), worse with rubbing.
      • PE: diffuse injection, watery/mucoserous discharge, indistinguishable from viral.
    • Vernal conjunctivitis
      • Seasonal occurrence
    • Mechanical irritation
    • Immunologic
      • Consider Kawasaki’s disease in the pediatric population.
    • Medication-related
      • Dupilumab (mab inhibiting IL-4 and Il-13, FDA-approved for atopic dermatitis): increased incidence of conjunctivitis as a side effect.
        • Usually bilateral.
  • Infectious: acute >> chronic except in low-resource settings (trachoma)
    • If chronic, be wary of the need for ophthalmological consultation and concern for either squamous cell or sebaceous carcinoma.
    • Viral: usually highly contagious
      • Adenovirus is the most common, then enteroviruses.
        • These two usually cause isolated ocular disease without fever or other systemic symptoms.
      • Some childhood viral illnesses typically cause conjunctivitis: measles, chickenpox, mumps and rubella.
        • These usually occur with systemic symptoms.
      • Common cold viruses may also be a cause.
      • Hx: thin, watery/mucoserous rather than purulent discharge. +/- viral URI. Burning, sandy or gritty feeling common, (+) photophobia.
      • PE: diffuse conjunctival injection and profuse tearing +/- preauricular LN.
      • Pathogens:
        • Adenovirus.
          • Epidemic keratoconjunctivitis (EKC): highly contagious, fulminant-type, viral conjunctivitis. Presents w/ severe foreign-body sensation and decreased visual acuity.
            • Due to specific adenovirus serotypes (5, 8, 11, 13, 19 & 37).
          • Pharyngoconjunctival fever:
            • Usually due to adenovirus 3, 4 or 7.
        • Enterovirus:
          • Acute hemorrhagic conjunctivitis (AHC): an epidemic form of highly contagious conjunctivitis characterized by the sudden onset of painful, swollen, red eyes, with conjunctival hemorrhaging and excessive tearing. Caused by a picornavirus, enterovirus 70
            • Most commonly seen in Asia and Africa.
            • It almost always resolves without sequelae.
        • HSV: red, irritated, watery eye often accompanied by multiple vesicles on the eyelid, but may also involve the face. Eyelid edema and ulcers may be present. It may involve the cornea.
        • VZV (herpes zoster ophthalmicus): severe pain and skin lesions in a dermatomal pattern involving the ophthalmic division of the trigeminal nerve. Conjunctival injection, redness and serous or purulent discharge. Preauricular adenopathy is common. Constitutional sx include fever, malaise, nausea and vomiting.
    • Bacterial
      • Staphylococcus aureus is more common in adults; S. pneumoniae, H. influenzae, and Moraxella catarrhalis are more common in children)
      • Hx/PE:
      • Typically unilateral at the beginning, but may spread to another eye.
        • Conjunctival erythema, edema, petechiae, chemosis.
        • Thick, globular, purulent white, yellow or green d/c at lid margin/eye corners. This distinguishes from viral conjunctivitis.
        • Eye stuck shut often upon awakening.
        • Preauricular LN: usually absent.
      • If tender preauricular LN, especially think of GC/chlamydia.
        • GC: Onset, often 12-48H after exposure. Rapidly progressive redness, hyperpurulence, tenderness, lid edema & tender preauricular LN suggest gonococcal hyperacute bacterial conjunctivitis.
        • Adult inclusion conjunctivitis due to chlamydia, consider if prominent tarsal follicular changes [Fig], > 3 wks of symptoms, and failure to respond to topical antibiotic therapy.
      • Dx: usually clinical.
        • Bacterial:
          • Consider Gram stain and bacterial culture if severe symptoms, recurrent, the patient is immunocompromised, or there is an insufficient response to treatment.
          • Giemsa stain: helpful to identify epithelial cell basophilic cytoplasmic inclusion bodies of chlamydial conjunctivitis (adult inclusion conjunctivitis, usually chronic unilateral, hyperemia and mucopurulent discharge).
          • Perform cultures if GC or CT is suspected.
            • PCR is preferred if available.
            • DFA or EIA also available.
            • Cytology with Gram or Giemsa stains is recommended for neonatal conjunctivitis and chronic or recurrent conjunctivitis.
              • Note: scraping if yielding eosinophils may suggest vernal conjunctivitis.
        • Viral:
          • Cultures not routinely used.
          • Antigen detection available for adenovirus (point of care)
            • The sensitivity is 88% to 89%, and the specificity is 91% to 94%.
          • Immunoassays for adenovirus
            • Sensitivity 40-93%, but specific.
          • PCR: if available (HSV, VZV, adenovirus)
        • Biopsy:
          • By ophthalmology to consider if there is a lack of response to therapy.
    • Ophthalmia neonatorum (neonatal conjunctivitis): acquired from maternal GC or Chlamydial trachomatis (CT) infections.
      • Attack rate: 20-40% of vaginal deliveries in mothers with GU infection, 2-14d after birth.
      • GC: usually bilateral, severe conjunctivitis, chemosis and mucopurulent discharge
      • Test also for chlamydia if GC is diagnosed; also test the mother and sex partners.
      • Molecular techniques are preferred but not FDA-approved, so need CLIA certified lab to perform PCR for GC or CT, which is superior to culture-based techniques.
      • DFA for CT is an FDA-approved method.
Table 1

Etiology

Discharge/Cells Seen on Scraping

Lid Edema

Pre-auricular Lymph Node

Itchiness

Clinical Presentations That May Distinguish in Acute Conjunctivitis

Viral

Clear/mononuclear

Minimal

Frequently present

None

Bacterial

Purulent /PMNs

Moderate

Usually absent

None

Allergic

Clear to mucoid, eosinophils

Moderate to severe

None

Mild to severe

DIAGNOSIS

  • Conjunctival scrapings or cultures (bacterial/viral) are generally not needed except in resistant cases as cases diagnosed clinically, also obtain in hyperpurulent, severe, visually impairing or recurrent disease.
    • Photophobia or visual impairment should prompt a slit lamp exam and fluorescein testing (refer to ophthalmology).
  • Specific testing:
    • Bacterial:
      • Swabs for Gram stain and aerobic culture will capture most standard, non-fastidious bacteria.
        • Gram stain and culture
          • Gonococcal disease is most commonly diagnosed by Gram stain, which shows characteristic Gram-negative intracellular diplococci.
          • Chlamydia is most commonly diagnosed by DFA (Direct Fluorescent Antibody) staining of conjunctival smears or Giemsa stain looking for epithelial cell basophilic cytoplasmic inclusion bodies.
        • Molecular: no tests are FDA-approved for GC or CT. Labs may have LDTs available and are preferred by the American Academy of Ophthalmology as preferred due to improved sensitivity compared to culture or microscopic techniques.
    • Viral: not frequently needed but may help distinguish from other causes.
      • Viral culture
      • Viral PCR
      • Adenovirus conjunctivitis can be diagnosed by a rapid, 10-min office test (AdenpPlus); immunohistochemical stains are available at some centers.
  • DDx for non-conjunctivitis causes include subconjunctival hemorrhage, blepharitis, eyelid disorders, scleritis, episcleritis, keratitis, pterygium, acute anterior uveitis, acute angle closure glaucoma.

TREATMENT

Topical Antibiotics

  • General comments regarding conjunctivitis:
    • Most important for early diagnosis and treatment in the adult: requires systemic therapies rather than topicals.
      • GC
      • CT
      • Graft-versus-host disease (GVHD)
      • Ocular mucous membrane pemphigoid (OMMP)
      • Superior limbic keratoconjunctivitis
        • It may reflect thyroid disorder.
    • Must use systemic abx for gonorrheal or chlamydial disease.
    • If there is a poor response after using topicals for 2-3 days, consider resistant bacterial infection or non-infectious cause (viral, allergy).
    • Indiscriminate use of either corticosteroids or topical antibiotics should be avoided.
      • Viral conjunctivitis will not respond to anti-bacterial therapies.
      • Mild bacterial conjunctivitis is usually self-limiting.
  • Routine, relatively inexpensive choices:
    • Trimethoprim/polymyxin B (Polytrim) sol 1gtt q3h x 7-10d.
    • Bacitracin/polymyxin B (Polysporin) ophthalmic 1gtt q3-4h x 7-10d.
    • Sulfacetamide (Bleph-10) 10% sol 1-2gtt q2-3h x 7-10d, taper to twice daily with improvement. Some staphylococcal strains may be resistant.
    • Erythromycin ophthalmic ointment 1/2-in four times a day inside lower lid x 5-7d. Some staph strains may be resistant.
      • The only ointment approved for use in neonates.
    • More expensive choices:
      • Azithromycin (AzaSite) 1% sol 1 gtt q12h x 2 d followed by 1 gtt daily x 5d. Offers a reasonably broad spectrum w/ high tissue penetration and a long half-life. Not effective against Pseudomonas aeruginosa.
      • Fluoroquinolones: used for more serious cases, mainly if suspected pseudomonal infection (contact lens wearers) or corneal ulcers exist.
        • Moxifloxacin 0.5% sol 1-2 gtt three times daily
        • Levofloxacin (Quixin) 0.5% sol 1-2gtt q2h x 2d then 1-2gtt four times a day.
        • Ofloxacin (Ocuflox) 0.3% sol 1-2 gtt q2-4h x 2d then 1-2gtt four times a day
        • Ciprofloxacin (Ciloxan) 0.3% sol 1-2gtt q2h x 2d then 1-2gtt q4h
        • Duration: 7-10 d
      • Bacitracin/neomycin/polymyxin B (Neosporin Ophthalmic) sol 1-2gtt q4h x 7-10d. Up to 10% pts allergic to bacitracin or neomycin.
      • Tobramycin (Tobrex) 0.3% sol 1-2gtt q4h x 7d
      • Gentamicin (Garamycin, Genoptic) 0.3% sol 1-2gtt q4h x 7d.
  • AVOID: chloramphenicol (Chloroptic) 0.5% sol 1-2gtt 4-6x/d x 3d, use only if no other options avail. Bone marrow aplasia with prolonged/frequent use has resulted in death.

Systemic Antibiotics

  • Use required for patients with gonococcal disease, treat sexual partners and consider/treat chlamydial co-infection. Vice versa for patients w/ chlamydial conjunctivitis. Also, consider screening for other STDs, and HIV.
    • Hyperacute bacterial conjunctivitis (Neisseria gonorrhoeae): severe cases should receive injectable medication if feasible.
      • Preferred:
        • Ceftriaxone 1g IM x 1 dose effective PLUS azithromycin 1 g PO x 1 dose OR doxycycline 100 mg PO twice daily x 7d
        • .Consider one-time lavage of the infected eye with saline solution.
      • Alternative (beta-lactam allergic patients): spectinomycin 2g IM x 1 dose (currently unavailable in the US) or see N. gonorrhoeae module for alternatives.
        • Cefpodoxime or cefixime is not primarily recommended but may be an alternative oral treatment instead of ceftriaxone for uncomplicated GC infection, but no clinical data supporting effectiveness for conjunctival disease.
        • Fluoroquinolones are no longer recommended for GC secondary to the development of widespread resistance.
    • Saline lavage clears mucopurulent debris and dilutes the effects of released toxins on ocular tissues.
    • Monitor closely for possible keratitis and perforation.
  • Adult inclusion conjunctivitis (Chlamydia trachomatis): Also treat sexual partners.
  • Ophthalmia neonatorum: second treatments may be required as only about 80% respond to the first course.
    • C. trachomatis:
      • Preferred: erythromycin base or ethyl succinate 50 mg/kg/d divided in four doses x 14d
      • Alternative: azithromycin suspension 20 mg/kg/d daily x 3d
    • N. gonorrhoeae:
      • Ceftriaxone 25-50 mg/kg IV or IM x single dose (125 mg max)

Topical Antivirals

  • Most cases of viral conjunctivitis are self-limiting and do not require medical care.
  • Adenovirus: some very severe cases have used cidofovir in immunocompromised patients.
  • HSV: refer all suspected cases to ophthalmology.

Systemic Antivirals

  • VZV: refer to an ophthalmologist to r/o keratitis.

Miscellaneous

  • Secondary cases of bacterial conjunctivitis following viral conjunctivitis are very rare; hence no reason to prescribe antibacterial drops or ointment for viral conjunctivitis.
  • Steroids: there is no role in using steroid eye drops or antibiotic/steroid drop combinations to treat conjunctivitis in the primary care setting.
    • Refer to ophthalmology if contemplating use.
    • Steroids may worsen some underlying infections, e.g., HSV.
  • Contact lens: all patients with red eyes should discontinue contact lenses and resume only when the eye is white and without discharge after treatment. Discard the lens case and disinfect or replace the lens.
  • Comfort measures: include cold compresses and artificial tears as needed.
  • Allergic conjunctivitis:
    • Pheniramine/naphazoline (Naphcon-A) 1-2gtt four times a day prn.
    • Loratadine (Patanol) 0.1% sol 1 gtt twice daily.
    • Ketorolac tromethamine (Acular) 0.5% sol 1gtt four times a day if above is not effective.
  • Patients with adenoviral conjunctivitis need to dispose of unclean contact lenses as adenovirus survives chemical and hydrogen peroxide disinfection.

Prevention

  • Viral conjunctivitis is highly contagious.
    • Healthcare workers: need to follow strict infection control practices.
      • See CDC Prevention of Outbreaks.
      • Use hand sanitizers or wash with soap/water > 30 seconds.
      • Disinfect all equipment used in an examination.
      • Contact and droplet precautions
    • Patients: avoid contact with others x 14d, stay home from work until improved.
      • Do not share towels or bedding at home until resolution.
      • Avoid touching the non-infected eye.
      • Don’t swim in pools or share baths/whirlpools.
    • Adenovirus vaccine: available to military personnel in the U.S. (covers types 4 & 7).
  • GC or CT neonatal infection:
    • Screen pregnant women:
      • Women at risk (e.g., women aged < 25 years and those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, a sex partner who has an STI, or live in a community with high rates of gonorrhea) at first prenatal visit.
      • Retesting women in their third trimester who are at increased risk.
      • Screening at delivery if not previously tested and at risk.
    • Ophthalmia neonatorum
      • Testing for CT and GC in infants if at risk (hx GC, high-risk mothers, lack of prenatal screening).
      • Treatment
        • Ceftriaxone 25-50 mg/kg IV or IM as since dose (max 250 mg)
      • Prophylaxis:

Selected Drug Comments

Drug

Recommendation

Chloramphenicol

Still used in some countries as systemic therapy. Cases of bone marrow aplasia and death have been reported with prolonged/frequent use.

Doxycycline

Twice-daily dosing. Preferred for chlamydial conjunctivitis over oral erythromycin. May cause fetal harm. Short courses do not appear to stain teeth in pts < 8 years old. Photosensitivity in 10-15%

Gentamicin

It treats many bacterial eye infections but may damage corneal epithelium with prolonged use. Use in treating specific gram negatives and S. aureus.

Levofloxacin

Eye drops are a big gun. Expensive. Alternative to ciprofloxacin. It would not use as the first line unless Pseudomonas is suspected, as in contact lens wearers. May achieve superior microbial eradication rates vs. ofloxacin. No crystalline precipitate.

Norfloxacin

Not as well absorbed as other fluoroquinolones. Risk of crystalluria. Patients receiving norfloxacin should be well-hydrated and instructed to drink fluids liberally. Otherwise similar to other quinolones.

Tetracycline

Inconvenient four times a day alternative to doxycycline. May cause fetal harm. Stains teeth in pts < 8 years old. Photosensitivity.

Tobramycin

May damage corneal epithelium. Alternative to gentamicin. Use in treating specific gram negatives and S. aureus.

OTHER INFORMATION

  • Cultures are unnecessary for routine diagnosis and treatment unless there are recurrent, severe symptoms, visual disturbance or suspected hyper-acute conjunctivitis.
    • Consider GC/Chlamydia in sexually active pts. Refer immediately.
  • Advise immediate contact lens discontinuation in any patient with a red eye. Refer to Ophthalmology urgently if keratitis, iritis/uveitis, scleritis or angle closure glaucoma is suspected by hx or PE.
  • Think of secondary bacterial conjunctivitis or pseudomonal infection, ulcerative keratitis and a low threshold for referral in contact lens wearers. Foreign body sensation and corneal opacity on penlight exam.
  • Red flags:
    • Severe pain/photophobia/decreased acuity.
      • Refer ASAP if any of the above present, worse after 1-2d of treatment or no better after 7d.
    • Exception: viral conjunctivitis symptoms may worsen first 3-5d, reassure if there are no red flags.

Basis for recommendation

  1. Khan A, Anders A, Cardonell M. Neonatal Conjunctivitis. Neoreviews. 2022;23(9):e603-e612.  [PMID:36047752]

    Comment: AAP publication that includes a helpful chart with the ddx of neonatal conjunctivitis, testing recommendations and prophylaxis guidance.

  2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.  [PMID:34292926]

    Comment: This guideline from the CDC handles conjunctivitis GC, CT infection, including in neonatal populations. Recommendations include screening pregnant women at risk (e.g., women aged
    < 25 years and those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, a sex partner who has an STI, or live in a community with high rates of gonorrhea) at first prenatal visit; retesting women in their third trimester at increased risk; and screening at delivery if not previously tested and at risk. Erythromycin is the only ophthalmic ointment recommended for use among neonates. Silver nitrate and tetracycline ophthalmic ointments are no longer manufactured in the United States. Testing for CT should be performed simultaneously along with GC in infants if at risk (hx GC, high risk mothers, lack of prenatal screening).

  3. Varu DM, Rhee MK, Akpek EK, et al. Conjunctivitis Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P94-P169.  [PMID:30366797]

    Comment: Highly detailed practice guideline directed toward ophthalmologists recommending molecular assays for CT and GC, if available. The document also includes descriptions of multiple subtypes of conjunctivitis of non-infectious nature with differential diagnoses and management.

References

  1. Honkila M, Koskela U, Kontiokari T, et al. Effect of Topical Antibiotics on Duration of Acute Infective Conjunctivitis in Children: A Randomized Clinical Trial and a Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(10):e2234459.  [PMID:36194412]

    Comment: This trial found that children with moxifloxacin drops had a shorter duration of symptoms. This also was similar to topical abx in general in the larger meta-analysis.

  2. Agnihotri G, Shi K, Lio PA. A Clinician's Guide to the Recognition and Management of Dupilumab-Associated Conjunctivitis. Drugs R D. 2019;19(4):311-318.  [PMID:31728936]

    Comment: This monoclonal may cause bilateral conjunctivitis. Recommendations for management are included but are not solidly evidence-based.

  3. Alfonso SA, Fawley JD, Alexa Lu X. Conjunctivitis. Prim Care. 2015;42(3):325-45.  [PMID:26319341]

    Comment: The authors address the red-eye and provide helpful clinical distinguishing features to direct treatment. Of note, even bacterial conjunctivitis is usually self-limiting. Clinical data, though, is thin on most recommendations.

  4. Sambursky R, Trattler W, Tauber S, et al. Sensitivity and specificity of the AdenoPlus test for diagnosing adenoviral conjunctivitis. JAMA Ophthalmol. 2013;131(1):17-22.  [PMID:23307204]

    Comment: A prospective, multicenter clinical trial demonstrated that AdenoPlus is a rapid, sensitive and specific in-office test for detecting adenoviral conjunctivitis when compared to traditional tests (PCR and CC-IFA).

  5. Sheikh A, Hurwitz B, van Schayck CP, et al. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012.  [PMID:22972049]

    Comment: Though usually self-limiting, a review of 11 RCTs with 3673 patients finds some faster clinical improvement with topical antibacterials.

  6. Utine CA. Update and critical appraisal of the use of topical azithromycin ophthalmic 1% (AzaSite) solution in the treatment of ocular infections. Clin Ophthalmol. 2011;5:801-9.  [PMID:21750614]

    Comment: A review of topical azithromycin’s use in treating ocular infections, including conjunctivitis. Summarizes the available RCTs.

  7. Centers for Disease Control and Prevention (CDC). Acute hemorrhagic conjunctivitis outbreak caused by Coxsackievirus A24--Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep. 2004;53(28):632-4.  [PMID:15269699]

    Comment: Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of highly contagious conjunctivitis characterized by sudden onset of painful, swollen, red eyes, w/ conjunctival hemorrhage and excessive tearing. The report summarizes the outbreak in Puerto Rico; 490K persons were affected; school-aged children and those living in crowded urban areas were at the highest risk. Prevention methods (e.g., frequent hand washing and avoidance of sharing towels and bedding) should be targeted at groups at the highest risk to control outbreaks.
    Rating: Important

  8. Schwab IR, Friedlaender M, McCulley J, et al. A phase III clinical trial of 0.5% levofloxacin ophthalmic solution versus 0.3% ofloxacin ophthalmic solution for the treatment of bacterial conjunctivitis. Ophthalmology. 2003;110(3):457-65.  [PMID:12623805]

    Comment: A prospective, randomized-controlled, double-masked, multicenter study comparing the efficacy and safety of 0.5% levofloxacin ophthalmic solution with 0.3% ofloxacin ophthalmic solution for the treatment of bacterial conjunctivitis. Although clinical cure rates in the 0.5% levofloxacin and 0.3% ofloxacin treatment groups were similar, a 5-day treatment regimen with 0.5% levofloxacin achieved microbial eradication rates that were statistically superior to those attained with 0.3% ofloxacin. There was no difference in the incidence of treatment-related adverse events.

  9. Kowalski RP, Sundar-Raj CV, Romanowski EG, et al. The disinfection of contact lenses contaminated with adenovirus. Am J Ophthalmol. 2001;132(5):777-9.  [PMID:11704040]

    Comment: Patients with adenoviral conjunctivitis need to dispose of unclean contact lenses as adenovirus survives chemical and hydrogen peroxide disinfection.

  10. Graves A, Henry M, O'Brien TP, et al. In vitro susceptibilities of bacterial ocular isolates to fluoroquinolones. Cornea. 2001;20(3):301-5.  [PMID:11322420]

    Comment: The in vitro antimicrobial susceptibilities of ocular isolates to levofloxacin, ofloxacin, and ciprofloxacin were determined. Levofloxacin demonstrated superior in vitro activity against human bacterial conjunctival isolates compared with either ofloxacin or ciprofloxacin (levofloxacin > ofloxacin > ciprofloxacin).

  11. Tabbara KF, El-Sheikh HF, Aabed B. Extended wear contact lens related bacterial keratitis. Br J Ophthalmol. 2000;84(3):327-8.  [PMID:10684847]

    Comment: The predominant organism from the corneal scrapings of 11 contact lens wearers with bacterial keratitis was Pseudomonas aeruginosa.
    Rating: Important

  12. Raizman MB, Rothman JS, Maroun F, et al. Effect of eye rubbing on signs and symptoms of allergic conjunctivitis in cat-sensitive individuals. Ophthalmology. 2000;107(12):2158-61.  [PMID:11097588]

    Comment: In patients with allergic conjunctivitis, eye rubbing causes increased ocular itching, chemosis, and hyperemia.

  13. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet. 1999;354(9174):181-5.  [PMID:10421298]

    Comment: Contact lens wearers are at risk for the development of bacterial keratitis. The bacteria most commonly isolated in this study were Serratia spp and Pseudomonas aeruginosa.

  14. Azar MJ, Dhaliwal DK, Bower KS, et al. Possible consequences of shaking hands with your patients with epidemic keratoconjunctivitis. Am J Ophthalmol. 1996;121(6):711-2.  [PMID:8644817]

    Comment: 12/26 patients with epidemic keratoconjunctivitis had positive adenovirus hand cultures.

  15. Gwon A. Ofloxacin vs tobramycin for the treatment of external ocular infection. Ofloxacin Study Group II. Arch Ophthalmol. 1992;110(9):1234-7.  [PMID:1520109]

    Comment: A multicenter, double-masked, randomized trial was conducted, comparing 0.3% ofloxacin and 0.3% tobramycin for topical treatment of external ocular infection. Ofloxacin was found as effective, safe, and comfortable as tobramycin.

  16. Gwon A. Topical ofloxacin compared with gentamicin in the treatment of external ocular infection. Ofloxacin Study Group. Br J Ophthalmol. 1992;76(12):714-8.  [PMID:1486071]

    Comment: In a double-masked, randomized-controlled study, the effectiveness and safety of 0.3% ofloxacin solution were compared with those of 0.3% gentamicin ophthalmic solution in treating external bacterial ocular infections. The two treatments were found to be equally effective.

  17. Leibowitz HM. Antibacterial effectiveness of ciprofloxacin 0.3% ophthalmic solution in the treatment of bacterial conjunctivitis. Am J Ophthalmol. 1991;112(4 Suppl):29S-33S.  [PMID:1928271]

    Comment: In two multicentered, randomized, prospective clinical studies, ciprofloxacin 0.3% ophthalmic solution was compared to a placebo and tobramycin 0.3%, respectively. In both trials, cipro was approximately 94% effective. Although cipro was significantly more effective than placebo, there was no difference in efficacy between ciprofloxacin and tobramycin.

  18. Haimovici R, Roussel TJ. Treatment of gonococcal conjunctivitis with single-dose intramuscular ceftriaxone. Am J Ophthalmol. 1989;107(5):511-4.  [PMID:2496606]

    Comment: This small study of 12 patients examined conjunctival GC. A single 1g IM injection of ceftriaxone in these 12 patients responded.

  19. Fitch CP, Rapoza PA, Owens S, et al. Epidemiology and diagnosis of acute conjunctivitis at an inner-city hospital. Ophthalmology. 1989;96(8):1215-20.  [PMID:2797725]

    Comment: Johns Hopkins study examined the epidemiology of acute conjunctivitis in an inner city population. Out of 45 patients, viral conjunctivitis was diagnosed in 36%, bacterial in 40%, while 24% of cases remained undiagnosed.

  20. Lohr JA, Austin RD, Grossman M, et al. Comparison of three topical antimicrobials for acute bacterial conjunctivitis. Pediatr Infect Dis J. 1988;7(9):626-9.  [PMID:2845348]

    Comment: 158 patients, 21 years of age or less, presenting with culture-positive (Haemophilus influenzae or Streptococcus pneumoniae) conjunctivitis were treated with trimethoprim-polymyxin B, gentamicin sulfate or sodium sulfacetamide ophthalmic solution for 10 days. Clinical response at 3 to 6 days after the start of therapy was similar for all test agents. Clinical response at 2 to 7 days after completion of therapy was also similar, as was the bacteriologic response.

  21. Wan WL, Farkas GC, May WN, et al. The clinical characteristics and course of adult gonococcal conjunctivitis. Am J Ophthalmol. 1986;102(5):575-83.  [PMID:3777076]

    Comment: Review of 21 cases of gonococcal conjunctivitis between 1972 and 1986. Keratitis, anterior chamber inflammation, periocular edema and tenderness, gaze restriction and preauricular adenopathy were common findings. All patients were hospitalized and received parenteral antibiotics. Only 2/21 patients had a poor outcome.

  22. Leibowitz HM, Hyndiuk RA, Smolin GR, et al. Tobramycin in external eye disease: a double-masked study vs. gentamicin. Curr Eye Res. 1981;1(5):259-66.  [PMID:7030632]

    Comment: A double-masked randomized study was conducted at four centers to compare the efficacy and safety of tobramycin and gentamicin ophthalmic ointment in treating superficial external eye disease. The results indicate that tobramycin is safe, effective and comparable to gentamicin. There was a trend towards better efficacy, safety and fewer adverse reactions in the tobramycin-treated group, but the differences were not statistically significant.

  23. Raizman MB. Results of a survey of patients with ocular allergy treated with topical ketorolac tromethamine. Clin Ther. 1995;17(5):882-90.  [PMID:8595640]

    Comment: 84% of responders rated ketorolac as good to excellent in relieving their overall symptoms of ocular allergy and 86% felt that the drug produced good to excellent relief of their ocular itching within minutes to 1 hour of administration.

  24. Wagner RS. Results of a survey of children with acute bacterial conjunctivitis treated with trimethoprim-polymyxin B ophthalmic solution. Clin Ther. 1995;17(5):875-81.  [PMID:8595639]

    Comment: Trimethoprim-Polymyxin B is safe and well-tolerated for treating bacterial conjunctivitis in children. It is effective against both gram-positive and gram-negative organisms, including S pneumoniae and H influenzae, the most prevalent pathogens in pediatric patients.

Media

C. trachomatis inclusion conjunctivitis

Descriptive text is not available for this image

Retracted lid shows inflammation of conjunctival lining causing inclusion bodies.

Source: CDC/S Lindsley

Last updated: December 11, 2022