Conjunctivitis Prevention/Conjunctivitis is any inflammation of the conjunctiva, generally characterised by irritation, itching, foreign body sensation, and watering or discharge. Treatment is often based on clinical suspicion that the conjunctivitis is bacterial, without waiting for the results of microbiological tests. In this review, therefore, we have distinguished the effects of empirical treatment from effects of treatment in people with culture-positive bacterial conjunctivitis. Bacterial conjunctivitis in contact lens wearers is of particular concern because of the risk of bacterial keratitis — an infection of the cornea accompanying acute or subacute corneal trauma, which is more difficult to treat than conjunctivitis and can threaten vision.
Conjunctivitis Types
1. Accordinf to the causes
Conjunctivitis may be classified either by cause or by extent of the inflamed area.
- Allergy
- Bacteria
- Viruses
- Chemicals
- Autoimmune
Neonatal conjunctivitis is often grouped separately from bacterial conjunctivitis because it is caused by different bacteria than the more common cases of bacterial conjunctivitis.
2. By extent of involvement
- Blepharoconjunctivitis – is the dual combination of conjunctivitis with blepharitis (inflammation of the eyelids).
- Keratoconjunctivitis – is the combination of conjunctivitis and keratitis (corneal inflammation).
- Blepharokeratoconjunctivitis – is the combination of conjunctivitis with blepharitis and keratitis. It is clinically defined by changes of the lid margin, meibomian gland dysfunction, redness of the eye, conjunctival chemosis and inflammation of the cornea.[rx]
3. Etiological
- Simple Allergic Conjunctivitis – Most cases are secondary to simple allergen exposure on the ocular surface.
- Vernal Keratoconjunctivitis – Exact etiology is not well understood but some combination of climate and allergen is believed to be responsible.
- Atopic Keratoconjunctivitis – Etiology is not clear but appears to be a combination of allergen exposure, atopic dermatitis (more than 90% of cases) andor genetic predisposition.
- Giant Papillary Conjunctivitis – Allergen exposure and subsequent response secondary to the ocular foreign body either harboring allergens on its surface or injuring ocular structures which facilitate allergen infiltration. It can be seen with many different ocular foreign bodies (eg., contact lenses, prostheses, cyanoacrylate glue, sutures).
- Allergic conjunctivitis – This pink eye caused by eye allergies is very common. Eye allergies, like other types, can be triggered by allergens including pollen, animal dander and dust mites. The most common symptom of allergic conjunctivitis is itchy eyes, which may be relieved with special eye drops containing antihistamines to control allergic reactions. Avoiding the allergen is also important in the treatment of allergic conjunctivitis. Allergic conjunctivitis can be seasonal or perennial (year-round), depending on the allergen causing the reaction.
- Giant papillary conjunctivitis – This pink eye usually impacts both eyes and often affects soft contact lens wearers. This condition may cause contact lens intolerance, itching, a heavy discharge, tearing and red bumps on the underside of the eyelids. You’ll need to stop wearing your contact lenses, at least for a little while. Your eye doctor may also recommend that you switch to a different type of contact lens, to reduce the chance of the conjunctivitis coming back.
- Non-infectious conjunctivitis – This conjunctivitis from eye irritation causing pink eye symptoms that can result from many sources, including smoke, diesel exhaust, perfumes and certain chemicals. Some forms of conjunctivitis also result from sensitivity to certain ingested substances, including herbs such as eyebright and turmeric.
Pathophysiology
Regardless of the etiology, most cases of conjunctivitis can be categorized as either papillary or follicular. Neither classification is pathognomonic for a particular disease entity. Papillary conjunctivitis produces a cobblestone arrangement of flattened nodules with central vascular cores. It is most commonly associated with an allergic immune response or is a response to a foreign body. Independent of the etiology, the histologic appearance of papillary conjunctivitis is the same: closely packed, flat-topped projections, with numerous eosinophils, lymphocytes, plasma cells, and mast cells in the stroma surrounding a central vascular channel.
Follicular conjunctivitis is seen in a variety of conditions, including inflammation caused by pathogens such as viruses, bacteria, toxins, and topical medications. In contrast to papillae, follicles are small, dome-shaped nodules without a prominent central vessel. Histologically, a lymphoid follicle is situated in the subepithelial region and consists of a germinal center with immature, proliferating lymphocytes surrounded by a ring of mature lymphocytes and plasma cells. The follicles in follicular conjunctivitis are typically most prominent in the inferior palpebral and forniceal conjunctiva.[rx]
Epidemiology
- Simple Allergic Conjunctivitis – It is difficult to estimate how many patients are affected as the symptoms are often under-appreciated, and many patients go without seeking medical care. Simple ocular allergy likely affects between 10% to 30% of the general population. In most cases, onset occurs in patients younger than 20 years old with decreasing prevalence in older populations. Allergic conjunctivitis can be seen as an isolated finding but is often associated with allergic rhinitis, atopic dermatitis, and/or asthma.
- Vernal Keratoconjunctivitis – More commonly seen in males (ratio 2:1 to 3:1) in dry, warm climates. Most cases occur in patients younger than ten who often have a history of atopy or asthma. Many patients have complete resolution without the return of symptoms after adolescence.
- Atopic Keratoconjunctivitis – Not usually seen before adolescence and peaks from 30 to 50 years of age. Most cases are seen in patients with atopic dermatitis. Like vernal keratoconjunctivitis, there is a male to female predominance
- Giant Papillary Conjunctivitis – Seen most commonly in teens and young adults, most likely because of a temporal relationship with contact lens use. Most commonly seen in conjunction with soft contact lens use and is present in approximately 5% of that population. Average onset is one to two years after starting soft contact lenses but varies widely with other ocular foreign bodies.[rx][rx][rx]
Conjunctivitis Causes
Infective conjunctivitis is most commonly caused by a virus.[rx] Bacterial infections, allergies, other irritants, and dryness are also common causes. Both bacterial and viral infections are contagious, passing from person to person or spread through contaminated objects or water. Contact with contaminated fingers is a common cause of conjunctivitis. Bacteria may also reach the conjunctiva from the edges of the eyelids and the surrounding skin, from the nasopharynx, from infected eye drops or contact lenses, from the genitals or the bloodstream.[rx] Infection by human adenovirus accounts for 65% to 90% of cases of viral conjunctivitis.[rx]
- Viral – Adenoviruses are the most common cause of viral conjunctivitis (adenoviral keratoconjunctivitis).[rx] Herpetic keratoconjunctivitis, caused by herpes simplex viruses, can be serious and requires treatment with aciclovir. Acute hemorrhagic conjunctivitis is a highly contagious disease caused by one of two enteroviruses, enterovirus 70 and coxsackievirus A24. These were first identified in an outbreak in Ghana in 1969, and have spread worldwide since then, causing several epidemics.[rx]
- Pharyngoconjunctival fever – Which is common, mild and often seen in children and young adults who have recently had a cold or respiratory infection. Symptoms may include sore throat, fever and headache.
- Epidemic keratoconjunctivitis – Which is less common, can be severe, affects the front of the eye (cornea) and may cause long-lasting vision difficulties. Also known as viral keratoconjunctivitis. Less common causes of viral conjunctivitis include
- Enteroviruses
- Herpes simplex virus, the cold sore virus, which usually affects only one eye
- Herpes zoster ophthalmicus, associated with shingles
- Molluscum contagiosum, also known as water warts
- Measles
- Mumps
- Rubella, also known as German measles
- Infectiou
- Bacterial – The most common causes of acute bacterial conjunctivitis are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.[rx][rx] Though very rare, hyperacute cases are usually caused by Neisseria gonorrhoeae or Neisseria meningitidis. Chronic cases of bacterial conjunctivitis are those lasting longer than 3 weeks, and are typically caused by S. aureus, Moraxella lacunata, or Gram-negative enteric flora.
- Allergic –Conjunctivitis may also be caused by allergens such as pollen, perfumes, cosmetics, smoke,[rx] dust mites, Balsam of Peru,[rx] or eye drops.[rx] The most frequent cause of conjunctivitis is allergic conjunctivitis and it affects 15% to 40% of the population.[rx] Allergic conjunctivitis accounts for 15% of eye related primary care consultations – most including seasonal exposures in the spring and summer or perpetual conditions. [rx]
- Blepharitis – This is a common inflammation of the eyelids that causes redness, irritation, and itching. There will also be dandruff-like scales on the eyelashes. Blepharitis is not contagious.
- Acute glaucoma – This is a rare form of glaucoma, in which pressure builds up in the eye. Symptoms can appear quickly and include pain, red eyes, and vision loss, which may become permanent without treatment.
- Keratitis – The cornea becomes inflamed and possibly ulcerated. If scarring of the cornea occurs, this can lead to permanent loss of vision. The cornea is the transparent part at the front of the eye.
- Iritis – The iris becomes inflamed. Untreated iritis can cause the iris to become stuck to the front surface of the lens, preventing fluid draining from the pupil. This can eventually lead to permanent eye damage. The iris is the colored part of the eye, the part that controls the amount of light that enters into the eye.
- Other – Conjunctivitis is part of the triad of reactive arthritis, which is thought to be caused by autoimmune cross-reactivity following certain bacterial infections. Reactive arthritis is highly associated with HLA-B27. Conjunctivitis is associated with the autoimmune disease relapsing polychondritis.[rx][rx]
Selected Nonconjunctivitis Causes of Red Eye
| Differential Diagnosis | Symptoms | Penlight Examination Findings |
|---|---|---|
| Dry eye disease | Burning and foreign-body sensation. Symptoms are usu- ally transient, worse with prolonged reading or watching television because of decreased blinking. Symptoms are worse in dry, cold, and windy environments because of increased evaporation. |
Bilateral redness |
| Blepharitis | Similar to dry eyes | Redness greater at the margins of eyelids |
| Uveitis | Photophobia, pain, blurred vision. Symptoms are usually bilateral. |
Decreased vision, poorly reacting pupils, constant eye pain radiating to temple and brow. Redness, severe photophobia, presence of inflammatory cells in the anterior chamber. |
| Angle closure glaucoma | Headaches, nausea, vomiting, ocular pain, decreased vision, light sensitivity, and seeing haloes around lights. Symptoms are usually unilateral. |
Firm eye on palpation, ocular redness with limbal injec- tion. Appearance of a hazy/steamy cornea, moderately dilated pupils that are unreactive to light. |
| Carotid cavernous fistula | Chronic red eye; may have a history of head trauma | Dilated tortuous vessels (corkscrew vessels), bruits on auscultation with a stethoscope |
| Endophthalmitis | Severe pain, photophobia, may have a history of eye sur- gery or ocular trauma |
Redness, pus in the anterior chamber, and photophobia |
| Cellulitis | Pain, double vision, and fullness | Redness and swelling of lids, may have restriction of the eye movements, may have a history of preceding sinus- itis (usually ethmoiditis) |
| Anterior segment tumors | Variable | Abnormal growth inside or on the surface of the eye |
| Scleritis | Decreased vision, moderate to severe pain | Redness, bluish sclera hue |
| Subconjunctival hemorrhage | May have foreign-body sensation and tearing or be asymptomatic |
Blood under the conjunctival membrane |
Conjunctivitis Symptoms
- Pink or red color in the white of the eye(s)
- Swelling of the conjunctiva (the thin layer that lines the white part of the eye and the inside of the eyelid) and/or eyelids
- Increased tear production
- Feeling like a foreign body is in the eye(s) or an urge to rub the eye(s)
- Itching, irritation, and/or burning
- Discharge (pus or mucus)
- Crusting of eyelids or lashes, especially in the morning
- Contact lenses that feel uncomfortable and/or do not stay in place on the eye
Depending on the cause, other symptoms may occur.
Viral Conjunctivitis
- Can occur with symptoms of a cold, flu, or other respiratory infection
- Usually begins in one eye and may spread to the other eye within days
- Discharge from the eye is usually watery rather than thick
Bacterial Conjunctivitis
- More commonly associated with discharge (pus), which can lead to eyelids sticking together
- Sometimes occurs with an ear infection
Allergic Conjunctivitis
- Usually occurs in both eyes
- Can produce intense itching, tearing, and swelling in the eyes
- May occur with symptoms of allergies, such as an itchy nose, sneezing, a scratchy throat, or asthma
Overall Symptoms
They depend on the cause of the inflammation, but may include:
- Redness in the white of the eye or inner eyelid
- Swollen conjunctiva
- More tears than usual
- Thick yellow discharge that crusts over the eyelashes, especially after sleep. It can make your eyelids stick shut when you wake up.
- Green or white discharge from the eye
- Itchy eyes
- Burning eyes
- Blurred vision
- More sensitive to light
- Swollen lymph nodes (often from a viral infection)
Clinical features of conjunctivitis, by cause
| Cause of conjunctivitis | Unilateral (U) or bilateral (B) | Discharge | Redness | Other symptoms or signs | Treatment |
|---|---|---|---|---|---|
| Viral, epidemic form | B | Watery | +++, +/− conj. haemorrhage | Fever, sore throat | Tetracycline eye ointment; povidone iodine eye drops |
| Viral – herpes | U | Watery | +/− | Vesicles on the eyelid | Topical antiviral |
| Viral – molluscum | U | Watery | +/− | Molluscum on lid | Remove molluscum |
| Bacterial – non-gonococcal | U or B | Purulent ++ | +++ | None | Tetracycline eye ointment or other antibiotic |
| Bacterial – gonococcal | B | Purulent +++++ | ++++ | Marked lid swelling. May have corneal ulcer | Frequent antibiotic REFER |
| Chlamydia – babies | B | Purulent ++ | ++ | Lid swelling | Tetracycline eye ointment |
| Chlamydia – trachoma | B | Purulent + | + | Signs on everted upper lid | Tetracycline eye ointment, or azithromyin |
| Chlamydia – adults | U or B | Purulent + | + | None | Tetracycline eye ointment |
| Allergy – acute | B | Watery ++++ | Minimal | Marked swelling of lids and conjunctiva | None – reassure |
| Allergy – chronic | B | Thick and stringy | + | Signs on everted upper lid. Discoloration of eye | Tetracycline eye ointment to eye lids – REFER |
| Chemical | U or B | Watery/purulent | Varies | May be lid reactions | Tetracycline eye ointment |
Comparison of key clinical characteristics between viral, bacterial and self-inflicted conjunctivitis
| Clinical characteristics/Etiology | Bacterial | Viral | Self-inflicted |
|---|---|---|---|
| Duration | Can be prolonged without treatment. Treatment hastens recovery | Days to weeks | Can be prolonged. Weeks to months |
| Bilateral/unilateral | Usually spreads to the other eye within days | Usually spreads to the other eye within days | Varies |
| Type of discharge | Mostly purulent discharge | Mostly aqueous, possibly mucoid discharge | Tearing and excessive discharge, fresh and dry purulent discharge on eyelids and periorbital skin |
| Swollen lymph glands | Not common | Common | Not common |
| Concomitant signs | None | Pyrexia , pharyngitis | Emotional or social stress, multiple physical complaints |
| Complications | Uncommon | Uncommon | Uncommon |
| Additional findings | Ocular irritation | Diffuse conjunctival involvement. Foreign body sensation | Mainly involvement of the lower conjunctiva. Discharge and edema are conspicuously prominent in relation to the conjunctival hyperemia |
| Response to treatment | Usually subsides without treatment. | Usually subsides without treatment. | Non-responsive to treatment |
| Responds well to antibiotics | |||
| Epidemiological characteristics | Contagious. Can lead to an outbreak | Very contagious. Can lead to an outbreak | Rarely the cause of an outbreak. Is usually diagnosed in a single soldier for secondary gain and not in a cluster |
Diagnosis of Conjunctivitis
- History and Physical – Allergic conjunctivitis frequently accompanies seasonal allergy symptoms, specifically known allergy exposures or a history of atopy. As such, recurrent episodes are commonly seen. Practitioners should elicit a personal history of allergies and atopy, as well as, a history of similar episodes in the past. Practitioners should ask about specific symptoms from the current and any past episodes. Itchiness and diffuse bulbar and tarsal conjunctival injection are the most commonly reported symptoms and are present in all subtypes of allergic conjunctivitis. Other histories and physical exam findings vary with the specific subtype of allergic conjunctivitis.
- Simple Allergic Conjunctivitis – Clear, watery discharge is the most commonly seen discharge and is usually bilateral with minimal crusting in the mornings. Pain and decreased visual acuity are not commonly reported in simple allergic conjunctivitis and should prompt the provider to consider another diagnosis. Eyelid edema and chemosis are not uncommon and can be quite marked.
- Vernal Keratoconjunctivitis – Symptoms are usually most severe in the spring and include thick mucus discharge, pain, photophobia and blurred vision. Patients will also often complain of foreign body sensation. On examination, corneal ulcers and conjunctival infiltrates can sometimes be found. Giant papillae on the tarsal conjunctiva are universally seen on examination.
- Atopic Keratoconjunctivitis – Symptoms are usually perennial and include pain, blurry vision, photophobia and foreign body sensation. Examination reveals findings similar to simple allergic conjunctivitis with the addition of chronic inflammatory changes to the ocular surface (corneal scarring and neovascularization) and varied changes to the eyelids (lower lid more commonly) and peri-orbital skin that range from mild atopy to lichenification.
- Giant Papillary Conjunctivitis – Symptoms consistent with simple allergic conjunctivitis often give way to worsening itch and discharge that becomes thick mucus instead of clear and watery. Patients usually report worsening pain and blurry vision with the increased sense of foreign body (contact lenses, sutures). The examination reveals findings consistent with simple allergic conjunctivitis as well as giant papillae covering the tarsal conjunctiva.
Selected Nonconjunctivitis Causes of Red Eye
| Differential Diagnosis | Symptoms | Penlight Examination Findings |
|---|---|---|
| Dry eye disease | Burning and foreign-body sensation. Symptoms are usu- ally transient, worse with prolonged reading or watching television because of decreased blinking. Symptoms are worse in dry, cold, and windy environments because of increased evaporation. |
Bilateral redness |
| Blepharitis | Similar to dry eyes | Redness greater at the margins of eyelids |
| Uveitis | Photophobia, pain, blurred vision. Symptoms are usually bilateral. |
Decreased vision, poorly reacting pupils, constant eye pain radiating to temple and brow. Redness, severe photophobia, presence of inflammatory cells in the anterior chamber. |
| Angle closure glaucoma | Headaches, nausea, vomiting, ocular pain, decreased vision, light sensitivity, and seeing haloes around lights. Symptoms are usually unilateral. |
Firm eye on palpation, ocular redness with limbal injec- tion. Appearance of a hazy/steamy cornea, moderately dilated pupils that are unreactive to light. |
| Carotid cavernous fistula | Chronic red eye; may have a history of head trauma | Dilated tortuous vessels (corkscrew vessels), bruits on auscultation with a stethoscope |
| Endophthalmitis | Severe pain, photophobia, may have a history of eye sur- gery or ocular trauma |
Redness, pus in the anterior chamber, and photophobia |
| Cellulitis | Pain, double vision, and fullness | Redness and swelling of lids, may have restriction of the eye movements, may have a history of preceding sinus- itis (usually ethmoiditis) |
| Anterior segment tumors | Variable | Abnormal growth inside or on the surface of the eye |
| Scleritis | Decreased vision, moderate to severe pain | Redness, bluish sclera hue |
| Subconjunctival hemorrhage | May have foreign-body sensation and tearing or be asymptomatic |
Blood under the conjunctival membrane |
GRADE evaluation of interventions for bacterial conjunctivitis.
| Important outcomes | Cure rates, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of empirical treatment in adults and children with suspected bacterial conjunctivitis? | |||||||||
| 8 (2515) | Cure rates | Topical antibiotics vplacebo or no immediate treatment | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for self-report of clinical cure by parents in 1 RCT. Consistency point deducted for conflicting results |
| 24 (at least 2754) | Cure rates | Topical antibiotics veach other | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and for weak methods in some RCTs |
| 1 (80) | Cure rates | Topical voral antibiotics | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for small number of comparators |
| 1 (104) | Cure rates | Different regimens of topical antibiotics veach other | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for small number of comparators |
| What are the effects of treatment in adults and children with bacteriologically confirmed bacterial conjunctivitis? | |||||||||
| 8 (1933) | Cure rates | Topical antibiotics vplacebo | 4 | 0 | 0 | −1 | 0 | Moderate | Directness point deducted for uncertainty about generalisability of results (to situations where treatment not initiated until culture results are known, because of the delay in treatment) |
| 9 (at least 1584) | Cure rates | Topical antibiotics v each other | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for inconsistent results between RCTs |
| 1 (86) | Cure rates | Different regimens of topical antibiotics veach other | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for small number of comparators |
| What are the effects of treatment in adults and children with clinically confirmed gonococcal conjunctivitis? | |||||||||
| 4 (239) | Cure rates | Parenteral antibiotics plus topical antibiotics vparenteral antibiotics alone or vparenteral antibiotics plus different topical antibiotic | 4 | −1 | −1 | −1 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for all studies in Africa, which may affect generalisability |
Type of evidence: 4 = RCT. Consistency: similarity of results across studies. Directness: generalisability of population or outcomes. Effect size: based on relative risk or odds ratio.
Treatment of
The appropriate treatment for conjunctivitis depends on its cause:
- Allergic conjunctivitis – The first step is to remove or avoid the irritant, if possible. Cool compresses and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, nonsteroidal anti-inflammatory medications and antihistamines may be prescribed. People with persistent allergic conjunctivitis may also require topical steroid eye drops.
- Bacterial conjunctivitis – This type of conjunctivitis is usually treated with antibiotic eye drops or ointments. Bacterial conjunctivitis may improve after three or four days of treatment, but patients need to take the entire course of antibiotics to prevent recurrence.
- Viral conjunctivitis – No drops or ointments can treat viral conjunctivitis. Antibiotics will not cure a viral infection. Like a common cold, the virus has to run its course, which may take up to two or three weeks. Symptoms can often be relieved with cool compresses and artificial tear solutions. For the worst cases, topical steroid drops may be prescribed to reduce the discomfort from inflammation. However, these drops will not shorten the infection.
- Chemical conjunctivitis – Careful flushing of the eyes with saline is a standard treatment for chemical conjunctivitis. People with chemical conjunctivitis also may need to use topical steroids. Severe chemical injuries, particularly alkali burns, are medical emergencies and can lead to scarring, damage to the eye or the sight, or even loss of the eye. If a chemical spills in your eye, flush the eye for several minutes with a lot of water before seeing your medical provider.
Topical antibiotics used to treat bacterial conjunctivitis
| Antibiotic | Class | Coverage | Mechanism | Availability |
|---|---|---|---|---|
| Azithromycin | Macrolide | Broad-spectrum | Baceriostatic | Azasite® 1% (Inspire Pharmaceuticals Inc) |
| Besifloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Besivance® 0.6% (Bausch and Lomb) |
| Chloramphenicol | Chloramphenicol | Broad-spectrum | Bacteriostatic | Topical drops not marketed in US Optrex Infected Eyes® 0.5% in UK |
| Ciprofloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Ciloxan® 0.3% (Alcon Laboratories Inc) Ointment or drops |
| Fusidic acid | Protein synthesis inhibitor | Primarily Gram-positive | Bacteriostatic | Not available in US Fucithalmic® 1% (Leo Pharma) in Canada and UK |
| Gatifloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Zymar 0.3% (Allergan Inc) |
| Gentamicin | Aminoglycoside | Primarily Gram-negative | Bactericidal | Generic 0.3% drops |
| Levofloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Iquix® 1.5% (Vistakon Pharmaceuticals) |
| Lomefloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Not available in US |
| Moxifloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Vigamox® 0.5% (Alcon Laboratories Inc) |
| Neomycin-polymyxin B-gramicidin | Aminoglycoside, polymyxin and gramicidin | Broad-spectrum | Bactericidal | Neosporin® (King Pharmaceuticals Inc) |
| Netilmicin | Aminoglycoside | Primarily Gram-negative | Bactericidal | Not available in US |
| Norfloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Chibroxin 0.3% (Merck and Co Inc) Not available in US |
| Ofloxacin | Fluoroquinolone | Broad-spectrum | Bactericidal | Generic 0.3% eye drops |
| Providone-iodine | Broad-spectrum | Bactericidal | Betadine 5% (Alcon Laboratories Inc) | |
| Rifamycin | Rifamycin | Broad-spectrum | Bactericidal | Not available in US |
| Tobramycin | Aminoglycoside | Primarily Gram-negative | Bactericidal | Tobrex® 0.3% (Alcon Laboratories Inc) ointment or drops |
Alternatives to Immediate Antibiotic Therapy
To our knowledge, no studies have been conducted to evaluate the efficacy of ocular decongestant, topical saline, or warm compresses for treating bacterial conjunctivitis.[rx] Topical steroids should be avoided because of the risk of potentially prolonging the course of the disease and potentiating the infection.[rx]
Summary of Recommendations for Managing Bacterial Conjunctivitis
In conclusion, benefits of antibiotic treatment include quicker recovery, decrease in transmissibility,[rx] and early return to school.[rx]Simultaneously, adverse effects are absent if antibiotics are not used in uncomplicated cases of bacterial conjunctivitis. Therefore, no treatment, a wait-and-see policy, and immediate treatment all appear to be reasonable approaches in cases of uncomplicated conjunctivitis. Antibiotic therapy should be considered in cases of purulent or mucopurulent conjunctivitis and for patients who have distinct discomfort, who wear contact lenses,[rx,rx] who are immunocompromised, and who have suspected chlamydial and gonococcal conjunctivitis.
Special Topics in Bacterial Conjunctivitis
Methicillin-Resistant S aureus Conjunctivitis
It is estimated that 3% to 64% of ocular staphylococcal infections are due to methicillin-resistant S aureus conjunctivitis; this condition is becoming more common and the organisms are resistant to many antibiotics.[rx] Patients with suspected cases need to be referred to an ophthalmologist and treated with fortified vancomycin.[rx]
Chlamydial Conjunctivitis
It is estimated that 1.8% to 5.6% of all acute conjunctivitis is caused by chlamydia,[rx–rx] and the majority of cases are unilateral and have concurrent genital infection.[rx]Conjunctival hyperemia, mucopurulent discharge, and lymphoid follicle formation[rx] are hallmarks of this condition. Discharge is often purulent or mucopurulent.[rx] How ever, patients more often present with mild symptoms for weeks to months. Up to 54% of men and 74% of women have concurrent genital chlamydial infection.[rx] The disease is often acquired via oculogenital spread or other intimate contact with infected individuals; in newborns the eyes can be infected after vaginal delivery by infected mothers.[rx] Treatment with systemic antibiotics such as oral azithromycin and doxycycline is efficacious; patients and their sexual partners must be treated and a coinfection with gonorrhea must be investigated. No data support the use of topical antibiotic therapy in addition to systemic treatment.[rx] Infants with chlamydial conjunctivitis require systemic therapy because more than 50% can have concurrent lung, nasopharynx, and genital tract infection.[rx]
Gonococcal Conjunctivitis
Conjunctivitis caused by N gonorrhoeae is a frequent source of hyperacute conjunctivas in neonates and sexually active adults and young adolescents.[rx] Treatment consists of both topical and oral antibiotics. Neisseria gonorrhoeae is associated with a high risk of cor-neal perforation.[rx]
Conjunctivitis Secondary to Trachoma
Trachoma is caused by Chlamydia trachomatis subtypes A through C and is the leading cause of blindness, affecting 40 million people worldwide in areas with poor hygiene.[rx,rx] Mucopurulent discharge and ocular discomfort may be the presenting signs and symptoms in this condition. Late complications such as scarring of the eyelid, conjunctiva, and cornea may lead to loss of vision. Treatment with a single dose of oral azithromycin (20 mg/kg) is effective. Patients may also be treated with topical antibiotic ointments for 6 weeks (ie, tetracycline or erythromycin). Systemic antibiotics other than azithromycin, such as tetracycline or erythromycin for 3 weeks, may be used alternatively.[rx,rx]
Ophthalmic Therapies for Conjunctivitis
| Category | Epidemiology | Type of Discharge |
Cause | Treatment | Level of Evidence for Treatment |
|---|---|---|---|---|---|
| Acute bacterial conjunctivitis |
135 case per 10 000 population in US[rx] 18.3%-57% of all acute conjunctivitis[rx–rx,rx,rx] |
Mucopurulent | S aureus, S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxellaspp |
Aminoglycosides | |
| Gentamicin Ointment: 4 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk |
B[rx]–[rx] | ||||
| Tobramycin ointment: 3 ×/d for 1 wk | A[rx–rx] | ||||
| Fluoroquinolones | |||||
| Besifloxacin: 1 drop 3 ×/d for 1 wk | A[rx–rx] | ||||
| Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk |
A[rx,rx,rx] | ||||
| Gatifloxacin: 3 ×/d for 1 week | B[rx] | ||||
| Levofloxacin: 1-2 drops 4 ×/d for 1 wk | Brx–[rx] | ||||
| Moxifloxacin: 3 ×/d for 1 wk | A[rx,rx,rx] | ||||
| Ofloxacin: 1-2 drops 4 ×/d for 1 wk | A[rx,rx,rx,rx] | ||||
| Macrolides | |||||
| Azithromycin: 2 ×/d for 2 d; then 1 drop daily for 5 d |
A[rx,rx,rx,rx] | ||||
| Erythromycin: 4 ×/d for 1 wk | B[rx] | ||||
| Sulfonamides | |||||
| Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk |
B[rx] | ||||
| Combination drops | |||||
| Trimethoprim/polymyxin B: 1 or 2 drops 4 ×/d for 1 wk |
A[rx,rx,rx] | ||||
| Hyperacute bacterial conjunctivitis in adults |
NA | Purulent | Neisseria gonorrhoeae | Ceftriaxone: 1 g IMonce | C[rx,rx] |
| Lavage of the infected eye | C[rx] | ||||
| Dual therapy to cover chlamydia is indicated | C[rx] | ||||
| Viral conjunctivitis |
9%-80.3% of all acute conjunctivitis[rx–rx] |
Serous | Up to 65% are due to adenovirus strains[rx] |
Cold compress Artificial tears Antihistamines |
C[rx],[rx] |
| Herpes zoster virus |
NA | Variable | Herpes zoster virus | Oral acyclovir 800 mg: 5 ×/d for 7-10 d | C[rx] |
| Oral famciclovir 500 mg: 3 ×/d for 7-10 d | C[x] | ||||
| Oral valacyclovir 1000 mg: 3 ×/d for 7-10 d | C[rx] | ||||
| Herpes simplex virus |
1.3-4.8 of all acute conjunctivitis[rxrx] |
Variable | Herpes simplex virus | Topical acyclovir: 1 drop 9 ×/d | C[rx] |
| Oral acyclovir 400 mg: 5 ×/d for 7-10 d | C[rx] | ||||
| Oral valacyclovir 500 mg: 3 ×/d for 7-10 d | C[rx] | ||||
| Adult inclusion conjunctivitis |
1.8%-5.6% of all acute conjunctivitis[rx,rx–rx] |
Variable | Chlamydia trachomatis | Azithromycin 1 g: orally once | B[rxrx] |
| Doxycycline 100 mg: orally 2 ×/d for 7 d | B[rx,rx] | ||||
| Allergic conjunctivitis |
90% of all allergic conjunctivitis[rx]; up to 40% of population may be affected[x] |
Serous or mucoid |
Pollens | Topical antihistamines | |
| Azelastine 0.05%: 1 drop 2 ×/d | A[rx] | ||||
| Emedastine 0.05%: 1 drop 4 ×/d | A[rx] | ||||
| Topical mast cell inhibitors | |||||
| Cromolyn sodium 4%: 1-2 drops every 4-6 h | A[rx] | ||||
| Lodoxamide 0.1%: 1-2 drops 4 ×/d | A[rx] | ||||
| Nedocromil 2%: 1-2 drops 2 ×/d | A[rx] | ||||
| NSAIDs | |||||
| Ketorolac: 1 drop 4 ×/d | B[rx,rx] | ||||
| Vasoconstrictor/antihistamine | |||||
| Naphazoline/pheniramine: 1-2 drops up to 4 ×/d |
B[rx] | ||||
| Combination drops | |||||
| Ketotifen 0.025%: 1 drop 2-3 ×/d | A[rx,rx] | ||||
| Olopatadine 0.1%: 1 drop 2 ×/d | A[rx,rx] |
Abbreviations: IM, intramuscularly; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs.
Allergic Conjunctivitis
Prevalence and Cause
Allergic conjunctivitis is the inflammatory response of the conjunctiva to allergens such as pollen, animal dander, and other environmental antigens[rx] and affects up to 40% of the population in the United States[rx]; only about 10% of individuals with allergic conjunctivitis seek medical attention, and the entity is often underdiagnosed.[rx] Redness and itching are the most consistent symptoms.[rx]Seasonal allergic conjunctivitis comprises 90% of all allergic conjunctivitis in the United States.[rx
Drug-, Chemical-, and Toxin-Induced Conjunctivitis
A variety of topical medications such as antibiotic eyedrops, topical antiviral medications, and lubricating eyedrops can induce allergic conjunctival responses largely because of the presence of benzalkonium chloride in eye drop preparations.[rx] Cessation of receiving the offending agent leads to resolution of symptoms.[rx]
Systemic Diseases Associated With Conjunctivitis
A variety of systemic diseases, including mucous membrane pemphigoid, Sjögren syndrome, Kawasaki disease,[rx] Stevens-Johnson syndrome,[rx] and carotid cavernous fistula,[rx] can present with signs and symptoms of conjunctivitis, such as conjunctival redness and discharge. Therefore, the above causes should be considered in patients presenting with conjunctivitis. For example, patients with low-grade carotid cavernous fistula can present with chronic conjunctivitis recalcitrant to medical therapy, which, if left untreated, can lead to death.
Ominous Signs
As recommended by the American Academy of Ophthalmology,[rx] patients with conjunctivitis who are evaluated by nonophthalmologist health care practitioners should be referred promptly to an ophthalmologist if any of the following develops: visual loss, moderate or severe pain, severe purulent discharge, corneal involvement, conjunctival scarring, lack of response to therapy, recurrent episodes of conjunctivitis, or history of herpes simplex virus eye disease. In addition, the following patients should be considered for referral: contact lens wearers, patients requiring steroids, and those with photophobia. Patients should be referred to an ophthalmologist if there is no improvement after 1 week.[x]
Importance of Not Using Antibiotic/Steroid Combination Drops
Steroid drops or combination drops containing steroids should not be used routinely. Steroids can increase the latency of the adeno-viruses, the refore prolonging the course of viral conjunctivitis. In addition, if an undiagnosed corneal ulcer secondary to herpes, bacteria, or fungus is present, steroids can worsen the condition, leading to corneal melt and blindness.
Randomized controlled trials comparing antibiotics with placebo
| Author | Number of patients randomized | Interventions | Outcome measures | Results |
|---|---|---|---|---|
| Abelson et al[rx] | 279 | One group received azithromycin One group received “vehicle” |
Clinical resolution and bacterial eradication | Higher rate of microbial and clinical cure with antibiotic. |
| Everitt et al[rx] | 307 | Two groups received chloramphenicol One group received placebo |
Symptomatic relief | Antibiotic decreased the duration of symptoms. |
| Hwang et al[rx] | 249 | One group received levofloxacin One group received placebo |
Clinical resolution and bacterial eradication | Higher rate of microbial and clinical cure with antibiotic. |
| Karpecki et al[rx] | 269 | One group received besifloxacin One group received “vehicle” |
Clinical resolution and bacterial eradication | Higher rate of microbial and clinical cure with antibiotic |
| Leibowitz[rx] | 177 | One group received ciprofloxacin One group received placebo |
Culture results | Higher rate of microbial cure with antibiotic. |
| Lichtenstein and Rinehart[rx] | 167 | One group received levofloxacin One group received ofloxacin One group received placebo |
Clinical resolution and bacterial eradication | Higher rate of microbial and clinical cure with antibiotics. |
| Miller et al[rx] | 284 | One group received norfloxacin One group received placebo |
Bacterial eradication and clinical resolution | Higher rate of microbial and clinical cure with antibiotic. |
| Rietveld et al[rx] | 181 | One group received fusidic acid One group received placebo |
Clinical resolution and bacterial eradication | No difference in clinical recovery rate but higher rate of microbial eradication with antibiotic |
| Rose et al[rx] | 326 | One group received chloramphenicol One group received placebo |
Clinical cure by day 7 | No significant difference between antibiotic and placebo |
| Tepedino et al[rx] | 957 | One group received besifloxacin One group received “vehicle” |
Clinical resolution and bacterial eradication | Higher rate of microbial and clinical cure with antibiotic |
Prevention
Here are nine simple precautions you can take to significantly reduce your risk of getting pink eye:
- Never share personal items – such as washcloths, hand towels or tissues.
- Cover your nose and mouth – when coughing or sneezing, and avoid rubbing or touching your eyes.
- Wash your hands frequently – especially when spending time at school or in other public places.
- Keep a hand sanitizer nearby – and use it frequently.
- Frequently clean – surfaces such as countertops, bathroom surfaces, faucet handles and shared phones with an antiseptic cleaner.
- If you know you suffer from seasonal allergies – ask your doctor what can be done to minimize your symptoms before they begin.
- If you wear contact lenses – follow your eye doctor’s instructions for lens care and replacement, and use contact lens solutions properly or consider switching to daily disposable contact lenses.
- When swimming – wear swim goggles to protect yourself from bacteria and other microorganisms in the water that can cause conjunctivitis.
- Before showering -remove your contact lenses to avoid trapping bacteria between your eyes and the lenses.
To help you cope with the signs and symptoms of pink eye until it goes away, try to
- Apply a compress to your eyes. To make a compress, soak a clean, lint-free cloth in water and wring it out before applying it gently to your closed eyelids. Generally, a cool water compress will feel the most soothing, but you can also use a warm compress if that feels better to you. If pink eye affects only one eye, don’t touch both eyes with the same cloth. This reduces the risk of spreading pink eye from one eye to the other.
- Try eyedrops. Over-the-counter eyedrops called artificial tears may relieve symptoms. Some eyedrops contain antihistamines or other medications that can be helpful for people with allergic conjunctivitis.
- Stop wearing contact lenses. If you wear contact lenses, you may need to stop wearing them until your eyes feel better. How long you’ll need to go without contact lenses depends on what’s causing your conjunctivitis. Ask your doctor whether you should throw away your disposable contacts, as well as your cleaning solution and lens case. If your lenses aren’t disposable, clean them thoroughly before reusing them.
References
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