2. Definition
• Conjunctivitis: inflammation of the
conjunctiva
• Conjunctiva: thin, translucent, elastic tissue
layer with bulbar and palpebral portions
• Bulbar: lines the outer surface of the globe
to the limbus (junction of sclera and cornea)
• Palpebral: covers the inside of the eyelids
• Two layers: epithelium, substantia propria
6. Viral Conjunctivitis
• Most common viral cause is adenovirus
(enterovirus, HSV)
• Occurs in community epidemics (schools,
workplaces, physicians’ offices)
• Usual modes of transmission: contaminated
fingers, medical instruments, swimming pool
water
7. Viral Conjunctivitis
• Presentation: unilateral or
bilateral, acutely red eye,
watery or mucoserous
discharge, chemosis,
tender preauricular
node, burning/
sanding/gritty feeling in
eye(s), rarely photophobia
• May be part of viral
prodrome: adenopathy,
fever, pharyngitis, cough,
rhinorrhea
8. Acute Bacterial Conjunctivitis
• Common causes in neonates: Chlamydia
trachomatis, Neisseria gonorrhoeae
• In children: Haemophilus influenzae (80%),
Streptococcus pneumoniae (20%), and
Moraxella catarrhalis. Concurrent OM seen
in 25%.
• In adults: Staphylococcus aureus
9. Acute Bacterial Conjunctivitis
• Presentation: Unilateral or
bilateral, red eye,
mucopurulent or purulent
discharge continuously
throughout the day,
burning, irritation, mild
chemosis
• Neonates: symptoms
appear 5-14d after birth
(inclusion conjunctivitis
of the newborn)
• Highly contagious: spread
by direct contact or by
contaminated objects
10. Hyperacute Bacterial
Conjunctivitis
• Etiology: Neisseria species,
most commonly N. gonorrhoeae
• Presentation: profuse, purulent discharge with rapidly
progressive symptoms of marked conjunctival injection,
irritation, tenderness to palpation, chemosis, lid swelling,
and tender preauricular adenopathy
• Ophthalmia neonatorum: gonococcal ocular infection
with bilateral discharge 3-5d after birth from vaginal
transmission
• Sexually active teens: transmitted from genitalia to hands
to eyes, commonly see concurrent urethritis
• Sight-threatening
11. Chronic Bacterial Conjunctivitis
• Most common etiology: Staphylococcus species
• More common in adults and patients with acne
rosacea or facial seborrhea
• Presentation varies: redness, itching, burning,
foreign-body sensation, flaky debris, blepharitis
(common), eyelash loss
• Concurrently see styes and chalazia of the lid
margin from chronic inflammation of the
meibomian glands
12. Allergic Conjunctivitis
• Most commonly seasonal
allergic rhinoconjunctivitis,
also called hay fever
rhinoconjunctivitis
• IgE mediated
hypersensitivity reaction
precipitated by small
airborne allergens→ local
mast cell degranulation →
release of chemical
mediators (histamine,
eosinophil chemotactic
factors, PAF, etc.)
• Presentation: bilateral,
pruritis, redness,
watery discharge,
rhinorrhea/congestion
• Patients often have h/o
atopy, seasonal allergy
or specific allergy
13. Discharge
Discharge Associated with Conjunctivitis
Etiology Serous Mucoid Mucopurulent Purulent
Viral
Chlamydial
Bacterial
Allergic
Toxic
+
-
-
+
+
-
+
-
+
+
-
+
+
-
+
-
-
+
-
-
+=Present; -=absent.
Adapted with permission from Jackson WB. Differentiating conjunctivitis of diverse origins. Surv Ophthalmol
1993;38(Suppl):91-104
14. Diagnosis of Conjunctivitis
• Clinical diagnosis of exclusion
• Morning crusting of eye
unreliable for determining
etiology
• If focal pathology (hordeolum, cancerous lesion or
blepharitis), conjunctivitis is reactive rather than
primary
• If redness is localized rather than diffuse, consider
foreign body, pterygium or episcleritis
16. Cultures
• Not necessary for initial diagnosis and
therapy of acute conjunctivitis
• When to culture:
1. Neonates
2. Hyperacute purulent conjunctivitis
(immediate Gram staining)
3. Chronic or recurrent conjunctivitis
17. Treatment
• Viral, allergic, and nonspecific
conjunctivitis are self-limited
• Bacterial conjunctivitis is also likely to be
self-limited but abx treatment shortens the
course, reduces person-to-person spread,
and lowers the risk of sight-threatening
complications
18. Treatment of Viral Conjunctivitis
• Topical antibiotics not necessary because
secondary bacterial infection is uncommon
• Reassurance that the sxs may get worse for 3-5d
before getting better and persist for 2-3 weeks
• Some relief from cold compresses and topical
antihistamines/decongestants
• Do not use topical corticosteroids due to risk of
sight-threatening complications (scarring, corneal
melting, perforation), especially if etiology is
herpes simplex virus or bacterial keratitis
19. Treatment of Acute Bacterial
Conjunctivitis
• Topical broad-spectrum antibiotics: erythromycin
ointment, bacitracin-polymyxin B ointment (Polysporin),
trimethropim-polymyxin B (Polytrim), sulfa drops
• Most H. flu and S. pneumoniae resistant to macrolides
• Sulfa drops (Bleph-10): less effective and rare side effect
of Stevens-Johnson syndrome
• Rx: 1/2” ointment inside lower lid or 1-2 drops QID for 5-
7 days (response seen typically within 1-2d)
• Inclusion Conjunctivitis of the Newborn: treat with 2 week
course of erythromycin (50mg/kg/d po divided QID) or
sulfisoxazole (150mg/kg/d po divided QID), topical
unnecessary with systemic
20. Treatment of Hyperacute
Bacterial Conjunctivitis
• Immediate ophthalmic referral
• Systemic and topical antibiotics and saline irrigation
• Systemic antibiotic of choice due to penicillin-resistant N.
gonorrhoeae is single-dose Ceftriaxone (25-50mg/kg IV or
IM, not to exceed 125mg) or single-dose Cefotaxime
(100mg/kg IV or IM) in neonates
• If venereal disease present in teens, also treat with single-
dose of azithromycin (1g) because over 30% of these
patients will have concurrent chlamydial disease
• AAP and CDC recommendations for prevention of
ophthalmia neonatorum: silver nitrate 1% aqueous solution
(side effect of chemical conjunctivitis), erythromycin 0.5%
ophthalmic ointment, tetracycline 1% ophthalmic ointment
21. Treatment of Allergic
Conjunctivitis
• Self-limited
• Allergen avoidance, cold compresses,
topical antihistamines/vasoconstrictors (do
not use for greater than 2 weeks), artificial
tears, topical NSAIDS (low efficacy)
• Prophylaxis: oral antihistamines (onset of
action=days), mast cell stabilizers (onset of
action=5-14d)
22.
23. When to Refer to Ophthalmology
• Neonates
• Hyperacute Purulent Conjunctivitis
• Chronic Conjunctivitis
• Sxs of pain, blurred vision, and
photophobia
• Reactive conjunctivitis vs. primary
24. School/Daycare
• Bacterial and viral conjunctivitis are highly contagious
• Red Book 2003: Except when viral or bacterial
conjunctivitis is accompanied by systemic signs of illness,
infected children should be allowed to remain in school
once any indicated therapy is implemented, unless their
behavior is such that close contact with other students
cannot be avoided. Exclude from daycare if purulent d/c.
• Safest approach for a child with bacterial conjunctivitis is
to stay home until there is no longer purulent discharge (1-
2d after Rx started).
32. Other Eye Lesions
Hordoleum (sty)
• swelling of one or more
sebaceous glands of the eyelid
from bacterial infxn, internal or
external
• tx: warm compresses, I&D if no
drainage occurs, topical abx
Chalazion
• hard tumor formed by
distention of a meibomian
gland with secretion
• tx: warm compresses
33. Other Eye Lesions
Pterygium
• triangular thickening
of bulbar conjunctiva
extending from inner
canthus to border of
cornea with the apex
towards the pupil
• Tx: avoid UV
radiation and dust,
lubricating eye drops
34. References
• Conjunctivitis. UpToDate 4/23/03
• Conjunctivitis. American Family Physician, 2/15/98
• Red Book. 2003 Report of the Committee on Infectious Diseases
• Gonococcal infection in the newborn. UpToDate 7/22/02
• Chlamydia trachomatis infections in the newborn. UpToDate 3/27/03
• Rudolph’s Fundamentals of Pediatrics. 2nd edition, 1998
• Nelson’s Essentials of Pediatrics. 3rd edition, 1998
• “Should we prescribe antibiotics for acute conjunctivitis?”. Cochrane for
Clinicians: Putting Evidence into Practice, 10/03.
• Uveitis: Etiology; diagnosis; and treatment. UpToDate, 9/9/03.
• Episcleritis and scleritis. UpToDate, 6/8/01.
• Sexually Transmitted Diseases Treatment Guidelines. CDC, MMWR, 2002.
