DESCRIPTION 
Inflammation of the conjunctiva arising from a broad group of etiologies. Commonly referred to as "pink eye."
ETIOLOGY
- Bacterial:
- Viral:
- Adenovirus most common
- Epidemic keratoconjunctivitis (EKC) is caused by adenovirus subtypes.
- Frequently associated with upper respiratory infections or exposure to someone with a red eye
- Most commonly referred to as "pink eye"
- Herpes simplex virus (HSV)
- Recurrent ocular infection occurs in 25% patients within 2 yr.
- Use of steroids is contraindicated:
- Frequent history of allergy, atopy, nasal symptoms
- Contact related
- May be due to chemical irritation, hypersensitivity from preservatives, medications, shampoo, chlorine, dust, smoke
- Pseudomonas commonly implicated organism:
- May be found in patients using saliva to clean contact lenses
[Outline]
SIGNS AND SYMPTOMS
- General:
- Red eye (conjunctival irritation)
- Gritty, foreign body sensation
- Sensation of eyes burning
- Discharge
- Eyelid sticking (worse upon awakening)
- Conjunctival edema (chemosis) and eyelid edema
- Itchy eyes
- Increased tearing
- Bacterial:
- Mucopurulent or purulent discharge
- Gonococcal:
- Hyperacute, copious purulent discharge:
- Discharge starts 12 hr after inoculation.
- Severe chemosis
- Eyelid swelling
- Preauricular lymphadenopathy typically absent
- Invades intact conjunctiva and cornea within 24 hr and causes ulcerations, scarring, and perforations leading to blindness
- Chlamydia:
- Lacrimation
- Mucopurulent discharge
- With or without photophobia
- Concomitant genital infection (> 50%)
- Transmission occurs via autoinoculation from genital secretions
- Viral—general:
- Viral syndrome:
- Watery, mucous discharge, lacrimation
- Gritty feeling or foreign body sensation in eye
- Spreads to other eye in 24–48 hr
- Pinpoint subconjunctival hemorrhages:
- Tarsal conjunctiva may have a bumpy appearance.
- EKC:
- Conjunctival hyperemia
- Chemosis
- Corneal infiltrates
- Decreased vision
- HSV:
- Acute follicular conjunctival reaction
- Skin lesions or vesicles along eyelid margin or periocular skin
- Corneal involvement—dendritic lesion
- Herpes zoster virus (HZV):
- Associated with pain or paresthesia of the skin
- Rash or vesicles involving the distribution of cranial nerve V1
- Dendritic characters on cornea
- Rarely vesicles or ulcers form on the conjunctiva.
- Allergic:
- Hallmark: Itching
- Red conjunctiva
- Watery discharge
- Papillary hypertrophy
- Frequent history of allergy, atopy, nasal symptoms
- Contact related:
ESSENTIAL WORKUP
- History for:
- Onset of inflammation
- Environmental or work-related exposure
- Ill contacts
- Sexual activity, discharge, rash
- Use of over-the-counter medicines or cosmetics
- Systemic diseases
- Careful physical exam including slit-lamp exam including fluorescein staining
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Bacteriologic studies:
- Not indicated in routine cases
- Indications:
- Ophthalmia neonatorum (except chemical)
- Suspected gonococcal ophthalmia
- Compromised host
- Signs and symptoms of systemic disease
- Refractory to treatment within 48–72 hr (with good compliance)
- Positive Gram stain for gram-negative intracellular diplococci:
- Rapid plasma reagent (RPR):
- For suspected cases of sexually transmitted disease
DIFFERENTIAL DIAGNOSIS
[Outline]
INITIAL STABILIZATION/THERAPY
- Initiate empiric antibiotic therapy with broad-spectrum topical agent.
- Systemic therapy for gonococcal, chlamydial, and meningococcal conjunctivitis, ophthalmia neonatorum, and all severe infections regardless of cause
- Manage herpetic eye infections in consultation with an ophthalmologist.
ED TREATMENT/PROCEDURES
- Remove discharge from the eye(s):
- Contact lens wearers should discontinue use and throw away affected contact lenses.
- Contact lens wearers should discontinue use until:
- Eye is white.
- Antibiotic therapy is completed.
- No discharge for 24 hr
- Frequent handwashing
- No sharing of towels, tissues, cosmetics, linens
- Frequent warm soaks until lashes and eyes free of debris
- Bacterial conjunctivitis:
- Antibiotics—topical:
- Can use ointment or drops
- Continue therapy for 48 hr after clearing of symptoms.
- Discontinue therapy and obtain cultures if no improvement in 48–72 hr (with good compliance).
- Antibiotics—systemic:
- Parenteral therapy mandatory for gonococcal infection
- Chlamydia requires systemic treatment of sexual partners and parents of neonates.
- Viral conjunctivitis:
- No specific antiviral therapy
- Limited use of topical antihistamine or decongestant
- EKC may require steroids and should be prescribed in consult with ophthalmology.
- Allergic conjunctivitis (there may be a lag time of up to 2 wk for improvement with these agents):
- Antihistamine or decongestant drops (naphazoline [Naphcon-A])
- Mast cell stabilizer/antihistamine or NSAID ophthalmic drops as 2nd line
- Artificial tears
- Noninfectious:
- Eye lubricant drops or ointment
- Empiric treatment:
- Topical antibiotic ointment or drops
MEDICATION
- General:
- All contact lens wearers require pseudomonal coverage.
- Bacterial:
- Bacitracin ophthalmologic ointment (no pseudomonal coverage)
- Ciprofloxacin: 0.35% 1 drop q1–6h (has antipseudomonal properties; may be used in children)
- Erythromycin: 0.5% ointment
- Gentamicin: 0.3% ointment q3–4h or drops q1–4h (has antipseudomonal coverage)
- Sulfacetamide: 10% 1 drop q1–6h (lacks pseudomonal coverage)
- Tobramycin ointment
- Chlamydia:
- Doxycycline: 100 mg PO BID for 3 wk
- Erythromycin: 250–500 mg PO QID for 3 wk (peds: 50 mg/kg/d PO in 4 div. doses for 14 days)
- Sulfisoxazole 500–1,000 mg QID for 3 wk
- Gonococcal:
- Adults:
- Ceftriaxone: 1 g IV or IM daily for 3–5 days or PRN
- Erythromycin: 500 mg PO QID for 2–3 wk or doxycycline 100 mg PO BID for 2–3 wk
- + topical antibiotics as above
- Neonates:
- Penicillin G 100,000 U/kg/d in 4 div. doses for 7 days or ceftriaxone 25–50 mg/kg/d IV for 7 days
- Viral:
- Artificial tears
- Naphcon-A or Visine AC 1 or 2 drops QID PRN for no more than 1 wk
- HSV or HZV:
- Trifluorothymidine: 1% 5 times per day
- Vidarabine: 3% ointment 5 times per day
- Allergic:
- Naphazoline (Naphcon-A): 1 drop BID–QID or Visine AC
- Acular: 1 or 2 drops BID
- Cromolyn sodium 4% (Crolom): 1 drop QID
- Noninfectious and nonallergic:
- Eye lubricant drops or ointment: Artificial tears or Lacri-Lube
- Empiric treatment:
- Erythromycin ointment 0.5% (half in QID)
- Sulfacetamide 10% ophthalmic drops (1 or 2 drops QID) for 5–7 days
Pediatric Considerations
- Often a manifestation of systemic disease in infants
- Conjunctivitis in the 1st 36 hr of life usually chemically induced caused by silver nitrate applied at birth.
- Neonates become infected during passage through the birth canal.
- Gonococcal, herpetic, chlamydial organisms most common
- Ophthalmia neonatorum is conjunctivitis within the 1st 4 wk of life.
- Chlamydia trachomatis is not eradicated by silver nitrate.
- Some newborns treated with erythromycin still develop conjunctivitis.
- Ointment is preferred over drops because of difficulty with administration of drops.
[Outline]
DISPOSITION
Admission Criteria
Known or suspected gonococcal infection (any age group)
Discharge Criteria
Close follow-up for all cases
Issues for Referral
Diagnosis of EKC and bacterial conjunctivitis requires ophthalmology referral.
FOLLOW-UP RECOMMENDATIONS
All patients with bacterial conjunctivitis require ophthalmology follow-up.
[Outline]
- Alteveer JG, McCans KM. The red eye, the swollen eye, and acute vision loss. Emerg Med Pract. 2002;4(6):27.
- Bertolini J, Pelucio M. The red eye. Emerg Med Clin North Am. 1995;13(3):561–579.
- Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
- Leibowitz HM. The red eye. New Engl J Med. 2000;343:345.
- Mueller JB, McStay C. Ocular infection and inflammation. Emerg Med Clin North Am. 2008;26(1).
- Sethuraman U, Kamat D. The red eye: Evaluation and management. Clin Pediat. 2009;48(6):588–600.
See Also (Topic, Algorithm, Electronic Media Element)
Red eye