Author:
KendraAmico
YasuharuOkuda
Description
Infectious and noninfectious inflammation of the conjunctiva; majority of cases are self-limited
Etiology
Infectious:
Commonly referred to as “pink eye”:
- Bacterial:
- Viral:
- Adenovirus, most common:
- Some serotypes cause fulminant form - epidemic keratoconjunctivitis (EKC), ophthalmic emergency
- Herpes simplex virus (HSV) and varicella zoster virus (VZV):
Noninfectious
- Allergic:
- Pollen, animal dand er, environmental antigens
- Contact/toxic/chemical:
- May be due to chemical irritation, hypersensitivity from preservatives, medications, shampoo, chlorine, dust, smoke
- Pseudomonas commonly implicated organism in contact lens wearers
A diagnosis of exclusion
Signs and Symptoms
- General:
- Red eye (injection and irritation of the ENTIRE conjunctiva)
- Gritty, foreign body sensation
- Burning, itchy eyes
- Increased tearing
- Morning eyelid crusting or matting; discharge
- Conjunctival edema (chemosis); eyelid edema
- Gonococcal:
- Hyperacute, copious purulent discharge, onset typically 12 hr after inoculation
- Severe chemosis
- Preauricular lymphadenopathy typically absent
- Within 24 hr, development of ulcerations, scarring, and perforations leading to blindness
- Chlamydia:
- Mucopurulent discharge
- With or without photophobia
- Concomitant genital infection (>50%)
- Viral:
- Tearing, mucous or scant mucopurulent discharge
- Preauricular adenopathy
- Spreads to other eye in 24-48 hr
- Tarsal conjunctiva may have a bumpy appearance
- Associated with upper respiratory illness
- EKC:
- Conjunctival hyperemia
- Chemosis
- Corneal infiltrates
- Decreased vision
- HSV and VZV:
- Associated with pain or paresthesia of the nearby skin
- Skin lesions or vesicles along eyelid margin or periocular skin
- Corneal involvement - dendritic lesion
- Rarely vesicles or ulcers form on the conjunctiva
- Allergic:
- Hallmark: Itching
- Watery discharge
- Papillary hypertrophy
- Frequent history of allergy, atopy, rhinorrhea
- Chemical:
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
- Visual acuity testing
- Fluorescein staining and slit-lamp exam, if indicated
Diagnostic Tests & Interpretation
Lab
- Adenovirus rapid antigen test
- Gram stain and culture (not indicated in routine cases):
- Indications:
- Neonatal conjunctivitis
- Suspected gonococcal conjunctivitis
- Immunocompromised host
- Signs and symptoms of systemic disease
- Refractory to antibiotic treatment after 48-72 hr (with good compliance) as MRSA conjunctivitis is increasing
Differential Diagnosis
“Red flag” signs and symptoms including - photophobia, decreased visual acuity, headache and nausea, anisocoria, fixed pupil, ciliary flush - should prompt consideration of an alternative diagnosis
- Acute angle-closure glaucoma (most serious cause)
- Anterior uveitis
- Corneal abrasion
- Dry eye
- Foreign body
- Iritis
- Keratitis
- Nasolacrimal duct obstruction
- Scleritis or episcleritis
- Subconjunctival hemorrhage
Initial Stabilization/Therapy
- Initiate empiric antibiotic therapy with broad-spectrum topical agent (if concerned for bacterial cause)
- Add systemic therapy for gonococcal, chlamydial, and meningococcal conjunctivitis, neonatal conjunctivitis, and all severe infections regardless of cause
- Manage herpetic eye infections and EKC in consultation with an ophthalmologist
ED Treatment/Procedures
- General management and counseling:
- Frequent removal of discharge from eye with warm, moist single-use cloth
- Contact lens wearers should throw away affected contact lenses and discontinue use until:
- Symptoms have resolved - no redness, no discharge for 24 hr
- Antibiotic therapy is completed
- Frequent hand washing
- No sharing of towels, tissues, cosmetics, linens
- Bacterial conjunctivitis:
- Topical antibiotics (ointment preferred in pediatrics)
- Continue therapy for 48 hr after symptoms resolve
- Discontinue therapy and obtain cultures if no improvement in 48-72 hr (with good compliance)
- Antibiotics - systemic:
- Parenteral therapy mand atory for gonococcal infection
- Chlamydia requires systemic treatment of sexual partners and parents of neonates
- Viral conjunctivitis:
- No specific antiviral therapy
- Limit use of topical antihistamine or decongestant
- Nonantibiotic lubricating agent
- EKC:
- May require topical steroids; prescribed in consult with ophthalmology
- Allergic conjunctivitis (expect up to 2 wk for improvement):
- Antihistamine or decongestant
- Mast cell stabilizer/antihistamine or NSAID ophthalmic drops as second line
- Artificial tears
- Noninfectious:
- Nonantibiotic eye lubricant drops or ointment
Medication
- General:
- All contact lens wearers require pseudomonal coverage
- NO glucocorticoids in general management of conjunctivitis
- Bacterial, 5-7 d treatment course:
- Bacitracin 500 U/g ophthalmic ointment 0.5 in q.i.d
- Bacitracin-polymixin B 0.5 in q.i.d
- Ciprofloxacin: 0.3% 1 drop q.i.d (antipseudomonal)
- Erythromycin: 0.5% 0.5 in q.i.d (inexpensive)
- Ofloxacin 0.3% 1-2 drops q.i.d (antipseudomonal)
- Trimethoprim-polymixin B 1-2 drops q.i.d
- Chlamydia: (Topicals are NOT effective):
- Neonates/pediatrics:
- First line: Azithromycin 20 mg/kg PO per day × 3 d
- Second line: Erythromycin 12.5 mg/kg PO q.i.d × 14 d
- Adults:
- First line: Azithromycin 1 g PO once (include chlamydia coverage)
- Second line: Doxycycline: 100 mg PO b.i.d × 7 d
- Gonococcal: (Topicals are NOT effective):
- Neonates/pediatrics:
- First line: Cefotaxime 100 mg/kg IV
- Second line: Ceftriaxone 50 mg/kg IV/IM (risk of hyperbilirubinemia in neonates)
- Adults:
- Ceftriaxone: 250 mg IV once (include chlamydia coverage)
- Viral:
- Eye lubricant drops or ointment: Artificial tears or Lacri-Lube
- Naphcon-A or Visine AC 1 or 2 drops q.i.d p.r.n for no more than 1 wk
- HSV: (Topical and oral treatment has similar efficacy):
- First line: Ganciclovir 0.15% opth gel 5 times daily OR acyclovir PO 400 mg 5 times daily × 7-14 d
- Second line: Trifluorothymidine 1% 1 drop q2h × 14 d (risk of corneal epithelial toxicity)
- NO glucocorticoids
- VZV:
- First line: Valacyclovir PO 1 g t.i.d 7-14 d
- Second line: Acyclovir PO 400 mg 5 times daily OR famciclovir PO 500 mg t.i.d × 7 d (immunocompetent)
- Acyclovir PO 10 mg/kg t.i.d (immunosuppressed)
- PLUS prednisolone acetate 1% 1-2 drops q2h
- Allergic:
- First line: Naphazoline (Naphcon-A): 1 drop b.i.d-q.i.d or Opcon-A or Visine-A
- Second line: Cromolyn sodium 4% 1 drop q.i.d
- Short term (<2 wk) use only otherwise rebound hyperemia develops
- Noninfectious and nonallergic:
- Eye lubricant drops or ointment: Artificial tears or Lacri-Lube
- Empiric treatment:
- Erythromycin ointment 0.5% 0.5 in q.i.d
Pediatric Considerations |
- Often a manifestation of systemic disease in infants
- Ophthalmia neonatorum defined as conjunctivitis within the first 4 wk of life
- Chlamydia trachomatis is not eradicated by silver nitrate
- Some newborns treated with erythromycin still develop gonococcal conjunctivitis
- Conjunctivitis in the first 36 hr of life usually chemically induced caused by silver nitrate applied at birth
- Neonates infected via vertical transmission during passage through the birth canal - gonococcal, herpetic, chlamydial organisms most common
- Ointment is preferred over drops because of difficulty with administration of drops
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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 concern for bacterial conjunctivitis or other atypical exam finding inconsistent with simple conjunctivitis require PROMPT ophthalmology follow-up
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- SheikhA, HurwitzB, van SchayckCP, et al. Antibiotics versus placebo for acute bacterial conjunctivitis . Cochrane Database Syst Rev. 2012;12(9):CD001211.
- WilhelmusKR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis . Cochrane Database Syst Rev. 2015;1:CD002898.
See Also (Topic, Algorithm, Electronic Media Element)
Red Eye