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- Causes include viral (adenovirus most common), bacterial (staphylococcal more common in adults; S. pneumoniae, H. influenzae, Moraxella cattarhalis more common in children), and allergic/inflammatory.
- Allergic: IgE response to environment allergens.
- Hx: bilateral redness, watery d/c, itching (hallmark), worse with rubbing.
- PE: diffuse injection, watery/mucoserous discharge, indistinguishable from viral.
- Hx/PE: uni/bilateral redness. Thick, globular, purulent white, yellow or green d/c at lid margin/eye corners. Eye stuck shut in AM.
- If tender preauricular LN, think GC/chlamydia.
- Rapidly progressive redness, hyperpurulence, tenderness, lid edema & tender preauricular LN suggest gonococcal hyperacute bacterial conjunctivitis. Lab: pus w/ gram negative diplococci.
- Hx: thin, watery/mucoserous rather than purulent discharge. +/- viral URI. Burning, sandy or gritty feeling common.
- PE: diffuse conjunctival injection & profuse tearing +/- preauricular LN.
- Most commonly caused by adenovirus.
- HSV : red, irritated, watery eye often accompanied by multiple vesicles on eyelid, but may also involve face. Eyelid edema and ulcers may be present. May involve cornea.
- VZV (herpes zoster ophthalmicus): severe pain and skin lesions in dermatomal pattern involving the ophthalmic division of the trigeminal nerve. Conjunctival injection, redness and serous or purulent discharge. Preauricular adenopathy common. Constitutional sx include fever, malaise, nausea and vomiting.
- Epidemic keratoconjunctivitis (EKC): highly contagious, fulminant-type, viral conjunctivitis. Presents w/ severe foreign-body sensation & decreased visual acuity.
- Acute hemorrhagic conjunctivitis (AHC) : epidemic form of highly contagious conjunctivitis characterized by sudden onset of painful, swollen, red eyes, with conjunctival hemorrhaging and excessive tearing. Caused by picornavirus. Rx symptomatic. Disease course 5-7d. Almost always resolves without sequelae.
- Conjunctival scrapings or cultures (bacterial/viral) are generally not needed except in resistant cases, hyperpurulent or fulminant cases or recurrent disease.
- Specific testing: bacterial swabs for Gram stain & aerobic culture will capture most standard, non-fastidious bacteria.
- 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.
- Adenovirus conjunctivitis diagnosed by rapid, 10-min office test (AdenpPlus)
- DDx subconjunctival hemorrhage, blepharitis , eyelid disorders, scleritis, episcleritis, keratitis, pterygium, acute anterior uveitis, acute angle closure glaucoma.
- General comments: useful for bacterial conjunctivitis.
- 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 oint 1/2-in four times a day inside lower lid x 5-7d. Some staph strains may be resistant.
- More expensive choices:
- Azithromycin (AzaSite) 1% sol 1 gtt q12h x 2 d followed by 1 gtt daily x 5d. Offers fairly broad spectrum w/ high tissue penetration, and long half life. Not effective against Pseudomonas aeruginosa.
- Fluoroquinolones: use for more serious cases, especially if suspected pseudomonal infection (contact lens wearers) or corneal ulcers exist.
- 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.
- Use required for patients with gonococcal disease, treat sexual partners & consider/treat chlamydial co-infection. Vice versa for patients w/ chlamydial conjunctivitis. Also consider/screen for other STDs.
- Hyperacute bacterial conjunctivitis (Neisseria gonorrhoeae): severe cases should receive injectable medication if feasible.
- Preferred: ceftriaxone 1g IM x 1 dose effective. Some reports advocate longer treatment daily x 7d.
- Alternative (penicillin/cephalosporin allergic patients): spectinomycin 2g IM x 1 dose (currently unavailable in US) or see N. gonorrhoeae module for alternatives.
- Saline lavage to clear mucopurulent debris and dilute effects of released toxins on ocular tissues. Monitor closely for possible keratitis and perforation.
- Hyperacute bacterial conjunctivitis (Neisseria gonorrhoeae): severe cases should receive injectable medication if feasible.
- Adult inclusion conjunctivitis (Chlamydia trachomatis):
- Steroids: there is no role for the use of 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 eye should discontinue contact lenses and resume only when eye is white and without discharge after treatment completed. Discard lens case and disinfect or replace lens.
- Comfort measures: include cold compresses and artificial tears as needed.
- Allergic conjunctivitis:
- Pheniramine/naphazoline (Naphcon-A) 1-2gtt four times a day prn.
- Lopatadine (Patanol) 0.1% sol 1 gtt twice-daily.
- Ketorolac tromethamine (Acular) 0.5% sol 1gtt four times a day if above not effective.
- Viral conjunctivitis: instruct patient to avoid sharing personal items (towels, sheets, pillows etc.), use meticulous hand washing and avoid close personal contact for approximately 2 weeks.
- Patients with adenoviral conjunctivitis need to dispose of unclean contact lenses as adenovirus survives chemical and hydrogen peroxide disinfection.
- Epidemic keratoconjunctivitis (EKC): refer to ophthalmology. Highly contagious disease requiring implementation of isolation and infection control procedures.
Selected Drug Comments
More commonly used in Europe. Avoid. Cases of bone marrow aplasia and death have been reported with prolonged/frequent use.
Twice-daily dosing. Preferred for chlamydial conjunctivitis over oral erythromycin. May cause fetal harm. Stains teeth in pts < 8 years old. Photosensitivity.
Treats wide range of bacterial eye infections, but may damage corneal epithelium with prolonged use. Use in treating specific gram negatives and S. aureus.
Eye drops: Big gun. Expensive. Alternative to ciprofloxacin. Would not use as first line unless Pseudomonas suspected, as in contact lens wearers. May achieve superior microbial eradication rates vs. ofloxacin. No crystalline precipitate.
Not as well absorbed as other fluoroquinolones. Risk of crystalluria. Patients receiving norfloxacin should be well hydrated and should be instructed to drink fluids liberally. Otherwise similar to other quinolones.
Inconvenient four times a day alternative to doxycycline. May cause fetal harm. Stains teeth in pts < 8 years old. Photosensitivity.
- Cultures not necessary for routine dx & rx unless recurrent, severe sx or suspected hyper-acute conjunctivitis.
- Consider GC/Chlamydia in sexually active pts. Refer immediately.
- Advise immediate contact lens discontinuation in any patient with red eye. Refer to Ophthalmology urgently if keratitis, iritis/uveitis, scleritis or angle closure glaucoma suspected by hx or PE.
- Think of secondary bacterial conjunctivitis or pseudomonal infection, ulcerative keratitis & have low threshold for referral in contact lens wearers. Foreign body sensation & corneal opacity on penlight exam.
- Red flags: severe pain/photophobia/decreased acuity. Refer ASAP if any of above present, worse after 1-2d of rx or no better after 7d. Exception: viral conjunctivitis sx may worsen first 3-5d, reassure if no red flags.
Basis for recommendation
- Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2006. [PMID:16625540]
Comment: Review of 5 randomized controlled trials with 1034 participants found that the use of antibiotics in acute bacterial conjunctivitis is associated with significantly improved rates of clinical and microbiological remission.
- Leibowitz HM. The red eye. N Engl J Med. 2000;343(5):345-51. [PMID:10922425]
Comment: An excellent review of the common conditions manifesting as "the red eye" aimed at the primary care physician.
- 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).
- 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 the use of topical azithromycin in the treatment of ocular infections including conjunctivitis. Summarizes the available RCTs.
- Tarabishy AB, Jeng BH. Bacterial conjunctivitis: a review for internists. Cleve Clin J Med. 2008;75(7):507-12. [PMID:18646586]
Comment: A comprehensive review of bacterial conjunctivitis.
- Annan NT, Boag FC. Outpatient management of severe gonococcal ophthalmia without genital infection. Int J STD AIDS. 2008;19(8):573-4. [PMID:18663052]
Comment: A case report of HIV-positive patient treated for severe gonococcal conjunctivitis w/ daily ceftriaxone 1 g IM for 10 days.
- 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. Report summarizes outbreak in Puerto Rico; 490K persons were affected; school-aged children and those living in crowded urban areas were at highest risk. To control outbreaks, prevention methods (e.g., frequent hand washing and avoidance of sharing towels and bedding) should be targeted to groups at highest risk.
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- Buckley RJ. Allergic eye disease--a clinical challenge. Clin Exp Allergy. 1998;28 Suppl 6:39-43. [PMID:9988434]
Comment: Six basic allergic eye diseases are recognized. Of those, acute allergic conjunctivitis, seasonal allergic conjunctivitis and perennial allergic conjunctivitis can be safely treated with antihistamines, mast cell stabilizers and ocular NSAIDs in the primary care setting. The remainder are serious and require steroids and possibly eye surgery.
- 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.
- Weiss A, Brinser JH, Nazar-Stewart V. Acute conjunctivitis in childhood. J Pediatr. 1993;122(1):10-4. [PMID:8419593]
Comment: In this study, cultures from the lid and conjunctiva were obtained, together with Giemsa stains of conjunctival scrapings. 80% of patients had bacterial conjunctivitis. Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis were the major bacterial pathogens in this pediatric population. Giemsa stains showed neutrophilia in bacterial infections, lymphocytosis in viral infections and eosinophilia in allergic disease.
- 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.
- 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.
- 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 placebo and to 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.
- Haimovici R, Roussel TJ. Treatment of gonococcal conjunctivitis with single-dose intramuscular ceftriaxone. Am J Ophthalmol. 1989;107(5):511-4. [PMID:2496606]
Comment: 13 consecutive patients with culture proven Neisseria gonorrhoeae conjunctivitis were treated with single-dose intramuscular injections of ceftriaxone. The patients were admitted for antibiotic administration, a single conjunctival saline lavage, and follow-up conjunctival cultures 6 and 12 hours after treatment. All patients responded to treatment, and all 6- and 12-hour posttreatment cultures were negative for N. gonorrhoeae. These results indicate that a single intramuscular dose of ceftriaxone is curative treatment for non-neonatal gonococcal conjunctivitis.
- 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 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.
- 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 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 bacteriologic response.
- 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.
- 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 the treatment of 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.
- Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clin Ther. 1995;17(5):800-10; discussion 779. [PMID:8595633]
Comment: A current review of conjunctivitis including etiologies and current therapy. Although not the case in children, Staphylococcus species is the predominant bacterial pathogen in adults with conjunctivitis.
- 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 the treatment of 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.
- 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.
- Abelson MB, Schaefer K. Conjunctivitis of allergic origin: immunologic mechanisms and current approaches to therapy. Surv Ophthalmol. 1993;38 Suppl:115-32. [PMID:7901917]
Comment: Ocular allergy occurs through mast cell degranulation and the release of chemical mediators. Therapy targets elimination of the offending allergen, modulation of the immune system and pharmacologic inhibition of the chemical mediators involved. This article reviews the pathogenesis and therapy of ocular allergic disorders.
- Ullman S, Roussel TJ, Forster RK. Gonococcal keratoconjunctivitis. Surv Ophthalmol. 1987;32(3):199-208. [PMID:2965423]
Comment: Review of 47 patients with N. gonorrhoea conjunctivitis. 34% exhibited corneal involvement. Six of these had ulcerative keratitis resulting in permanent visual loss. Five required surgery for corneal perforation. An outpatient regimen of intramuscular antibiotics proved effective for infections limited to the conjunctiva in adults. Because of resistance patterns, a beta-lactamase resistant cephalosporin was recommended for treatment.
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