2.02 Conjunctivitis (Pink Eye)
The patient complains of a red eye, a sensation of fullness, burning,
itching, or scratching, and perhaps a gritty or foreign body sensat ion and
tearing or purulent discharge and crusting or mattering. Examination
discloses generalized injection of the conjunctiva, thinning out towards the
cornea (localized inflammation suggests some other diagnosis such as a
foreign body, episcleritis, or a viral or bacterial ulcer). Vision and
pupillary reactions should be normal and the cornea and anterior chamber
should be clear. Any discomfort should be temporarily relieved by instilling
topical anesthetic solution. Deep pain, photophobia, decreased vision and
injection more pronnounced around the limbus (ciliary flush) suggest more
serious involvement of the cornea and iris.
Different symptoms suggest different etiologies. Tearing, preauricular
lymphadenopathy and upper respiratory symptoms suggest a viral conjunctivitis.
Pain upon awakening with lid crusting and a copious purulent exudate suggests
a bacterial conjunctivitis. Few symptoms upon awakening but discomfort
worsening during the day suggests a dry eye. Little conjunctival injection
with a seasonal recurrence of chemosis and itching, and cobblestone hypertrophy of the tarsal conjunctiva suggests allergic (vernal) conjunctivitis.
Physical and chemical conjunctivitis, caused by particles, solutions, vapors, natural or
occupational irritants that inflame the conjunctiva, should be evident from
What to do:
- Instill proparcaine anesthetic drops (Alcaine, Ophthaine) to allow for a
more comfortable exam and to help determine if the patient's discomfort is
limited to the conjunctiva and cornea or, if there is no pain relief, that
the pain comes from deeper eye structures.
- Examine the eye, including visual acuity, inspection for foreign bodies,
pupillary reaction fundoscopy, estimation of intraocular pressure by
palpation of the globe above the tarsal plate, slit lamp examination (when available), and fluorescein and ultraviolet or cobalt blue light to
assess the corneal epithelium.
- Ask about and look for any rash, arthritis, or mucous membrane involvement
which could point to Stevens-Johnson syndrome, Kawasaki's, Reiter's, or some
other syndrome that can present with conjunctivitis.
- For bacterial conjunctivitis, start the patient on warm compresses and
seven days of topical antibiotics such as erythromycin, sulfacetamide,
tobramycin or gentamycin ointment (which transiently blurs vision) every 4
hours, or solutions such as sulfacetamide 10%, tobramycin 0.3% or ciprofloxacin every 2 hours, with oral analgesics as needed. If it is unclear
whether the problem is viral or bacterial, it is safest to treat it as
- For viral and chemical conjunctivitis, use cold compresses and weak topical
vasoconstrictors such as naphazoline 0.1% (Naphcon) every 3-4 hours, unless
the patient has a shallow anterior chamber that would be prone to acute angle-
closure glaucoma with mydriatics.
- For allergic conjunctivitis, use cold compresses and topical decongestant-
antihistamine combinations such as drops of naphazoline with pheniramine
(Naphcon A) or naphazoline with antazoline (Vasocon A) every 3-4 hours.
Topical corticosteroid drops provide dramatic relief, but prolonged use
increases the risk of opportunistic viral, fungal and bacterial corneal
ulceration, cataract formation and glaucoma. If a severe contact dermatitis
is suspected, then a short course of oral prednisone would be indicated.
- If the problem is dry eyes (keratoconjunctivitis sicca) use methylcellulose
(Dacriose) artificial tear drops.
- Have the patient follow up with the ophthalmologist if the infection does
not clearly resolve in 2 days. Obtain early consultation there is any
involvement of cornea or iris.
What not to do:
- Do not forget to wash your hands and equipment after examining the patient,
or you may spread herpes simplex or epidemic keratoconjunctivitis to yourself
and other patients. Also, do not forget to instruct the patient on the
importance of hand washing and separation of towels and pillows for ten days
after the onset of symptoms.
- Do not patch an affected eye, as this interferes with the cleansing function
of tear flow.
- Do not give steroids without arranging for ophthalmologic consultation, and
never give steroids if a herpes simplex infection is suspected.
Warm compresses are soothing for all types of conjunctivitis, but antibiotic
drops and ointments should be reserved for when bacterial infection is likely.
Neomycin-containing ointments and drops should probably be avoided, because
allergic sensitization to this antibiotic is common. Any corneal ulceration
requires ophthalmological consultation. Most viral and bacterial conjunctivitis
will resolve spontaneously, with the possible exception of staphylococcus,
meningiococcus, and gonococcus infections, which can produce destructive
sequelae without treatment.
Most bacterial conjunctivitis is caused by Streptococcus pneumoniae,
Haemophilus aegyptus and Staphylococcus aureus. Routine conjunctival cultures
are seldom of value, but you should Gram stain and culture a copious purulent
exudate. Neisseria gonorrhoeae infection confirmed by Gram-negative intracellular
diplococci on Gram stain requires immediate ophthalmologic consultation. Corneal
ulceration, scarring and blindness can occur in a matter of hours. Chlamydial
conjunctivitis will usually present with lid droop, mucopurulent discharge,
photophobia and preauricular lymphadenopathy. Small white elevated
conglomerations of lymphoid tissue can be seen on the upper and lower tarsal
conjunctiva, and 90% of patients have concurrent genital infections.
Doxycycline 100mg bid or erythromycin 400mg tid by mouth plus topical
tetracycline (Achromycin Ophthalmic) for three weeks should control the
infection (also treat any sexual partner).
Epidemic keratoconjunctivitis is a bilateral, painful, highly contagious
conjunctivitis usually caused by an adenovirus. The eyes are extremely
erythematous, sometimes with subconjunctival hemorrhages. There is copious
watery discharge and preauricular lymphadenopathy. Treat the symptoms with
analgesics, cold compresses, and, if necessary, corticosteroids. Because the
infection can last as long as three weeks and may result in permanent corneal
scarring, provide ophthalmologic consultation and referral. Herpes simplex
conjunctivitis is usually unilateral. Symptoms include a red eye, photophobia,
eye pain and mucoid discharge. There may be periorbital vesicles, and a
branching (dendritic) pattern of fluorescein staining makes the diagnosis.
Treat with trifluridine 1% (Viroptic), analgesics and cold compresses.
Cycloplegics such as homatropine may help control pain from iridocyclitis.
Topical corticosteroids are contraindicated, because they can extend the
infection, and ophthalmological consultation is required.
Herpes zoster ophthalmicus is shingles of the opthalmic branch of the
trigeminal nerve, which innervates the cornea and the tip of the nose. It
begins with unilateral neuralgia, followed by a vesicular rash in the
distribution of nerve. Ophthalmic consultation is again required, because of
frequent ocular consultations, but topical corticosteroids may be used.
Prescribe systemic acyclovir (Zovirax) 800mg q4h (five times a day) for ten days or famcyclovir (Famvir) 500mg tid for seven days.
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