Conjunctivitis

Published on 10/06/2015 by admin

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Last modified 22/04/2025

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Conjunctivitis

Lynn C. Garfunkel, MD

Basic Information

Definition

Conjunctivitis is any inflammatory condition of the columnar epithelial membranes that line the eyelids (i.e., tarsal or palpebral conjunctiva) or exposed surface of the sclera (i.e., bulbar conjunctiva). The corneal surface is composed of squamous epithelium, and inflammation of the cornea is called keratitis.

Synonyms

Pink eye
Red eye

ICD-9-CM Codes

077.98 Chlamydial conjunctivitis
077.99 Viral conjunctivitis
098.40 Neonatal conjunctivitis
372.0 Acute or allergic conjunctivitis
372.01 Chronic conjunctivitis

Epidemiology & Demographics

• Most common acute condition of the eye seen by pediatricians
• Neonate

image Occurs in 1.6% to 12% of all newborns
image Acute causes of ophthalmia neonatorum: chemical (e.g., silver nitrate), chlamydial, bacterial (including gonococcal), or rarely, viral (without other nonocular manifestations)

• Infants

image Chlamydial, bacterial causes
image Obstructed lacrimal duct

• Children

image Bacterial pathogen twice as likely as viral
image Haemophilus influenzae: 40% to 50% of cases
image Streptococcus pneumoniae: 10% to 15% of cases
image Moraxella Catarrhalis: 8% of cases
image Adenovirus: 20% to 30% of cases

• Allergic

image Hay fever conjunctivitis
image Vernal conjunctivitis

Clinical Presentation

History

• Viral: acute onset; may be associated with upper respiratory symptoms (i.e., fever and sore throat); unilateral but usually becomes bilateral within 24 to 48 hours; associated with gritty or sandy or burning feeling; associated with watery or mucoid discharge; some morning crusting common
• Bacterial: acute or hyperacute onset; significant crusting common; unilateral or bilateral; green, yellow, or white profuse discharge
• Allergic: usually bilateral; itching is hallmark

image Hay fever conjunctivitis: acute onset, short duration, and many recurrences
image Vernal conjunctivitis: onset at age 3 to 12 years, onset usually in spring, more common in warm climates, more common in boys than girls, often associated with history of atopy, rhinitis, or sinusitis
image Atopic keratitis
image Giant papillary conjunctivitis

• Chemical or toxic cause: medication history, work-related exposures, cosmetics
• Dry eyes: antidepressant use, collagen vascular diseases
• Foreign body: unilateral (may be bilateral in contact lens wearers)
• Time of onset: especially important in neonatal conjunctivitis

image In first 24 hours of life: chemical most likely
image Between 2 and 5 days of life: gonococcal (later onset if prophylaxis given)
image Between 5 and 23 days of life: chlamydial

Physical Examination

• Pattern of the conjunctivitis

image Papillary: allergic or contact irritant

image Large papules
image Tarsal conjunctiva, especially upper lids
image Not specific

image Follicular

image Lower lid lymphoid follicles
image Seen with adenoviral, chlamydial, topical medication, herpes simplex virus (HSV)

• Viral forms

image Conjunctival injection
image Watery, serous, or mucoid discharge
image Preauricular adenopathy
image Bilateral or unilateral
image Associated rashes
image If associated with pharyngitis, adenovirus likely
image If vesicles or corneal ulceration, HSV keratoconjunctivitis likely

• Bacterial forms

image Conjunctival injection
image Chemosis
image Mucopurulent or purulent discharge (green, white, or yellow)
image If associated with otitis media, H. influenzae likely

• Allergic forms

image Serous or mucoid discharge, often very stringy
image Prominent ocular itching
image Conjunctival injection
image Occurs with or without photophobia
image Hay fever conjunctivitis: mild conjunctival swelling, upper more than lower eyelid
image Vernal conjunctivitis: more severe infection than hay fever conjunctivitis

image Large papillary response of upper lid or perilimbal (i.e., margin between scleral and cornea)
image Keratitis: painful inflammation of the corneal surface
image Corneal opacification

image Atopic keratoconjunctivitis: lower lid papillary response more than upper lid and with associated keratitis

• Examination of ears to look for otitis media
• Physical examination to look for systemic disorders

Etiology

• Infectious causes

image Viral: adenovirus (most common viral cause), Coxsackievirus, HSV, varicella-zoster virus, Epstein-Barr virus, rubeola, rubella, mumps, enteroviral
image Bacterial: H. influenzae (most common bacterial cause), streptococcal, Moraxella, staphylococcal (including Staphylococcus epidermitis), Neisseria gonorrhoeae, Pseudomonas
image Chlamydial: Chlamydia trachomatis

• Allergic: hay fever conjunctivitis (e.g., pollens, molds, fungi, dust, foods), vernal conjunctivitis
• Chemical or toxic: ophthalmologic medications, work or environmental exposures, cosmetics
• Foreign body: contact lenses, other foreign bodies
• Idiopathic
• Other: graft-versus-host disease, Stevens-Johnson syndrome, Reiter’s syndrome, Kawasaki disease

Diagnosis

Differential Diagnosis

• Keratitis: inflammation of the cornea caused by infection, trauma (contact lens use), ultraviolet radiation exposure
• Uveitis, anterior uveitis (e.g., iritis, iridocyclitis): inflammation of iris and ciliary muscle, usually an autoimmune reaction
• Scleritis: focal or diffuse scleral inflammation, usually autoimmune
• Episcleritis: focal inflammation of deep subconjunctival (episcleral) tissues, autoimmune
• Acute angle-closure glaucoma: medical emergency caused by blockage of aqueous humor outflow leading to a sudden elevation in intraocular pressure; uncommon in pediatrics
• Corneal abrasion
• Styes (hordeolum): may irritate conjunctivae

Workup

• The diagnosis is usually made based on history and physical examination.
• Conjunctival culture and scraping with Gram stain is done for neonates to diagnose gonococcal and chlamydial disease.
• Culture and Gram stain may be helpful in other selected individuals.
• Many eosinophils (Giemsa stain) in eye discharge may indicate allergic cause.
• High serum and tear immunoglobulin E (IgE) levels are seen in vernal conjunctivitis and atopic keratitis.

Treatment

Nonpharmacologic Therapy

• Most cases of acute conjunctivitis are benign and self-limited.
• Apply warm or cool compresses to eyes.
• Avoid the irritant or allergen.

Acute General Rx

• Antibiotic therapy is necessary to help prevent the sight-threatening complications of gonococcal and chlamydial conjunctivitis.
• For other bacterial causes, topical antibiotic treatment hastens resolution of symptoms and prevents secondary cases, although most cases resolve without specific antibiotic therapy.

image Staphylococcal and streptococcal causes: topical ophthalmologic antibiotic preparation (drops or ointment)

• If systemic antibiotic treatment is used, topical treatment is not necessary.
• In neonates, the specific antibiotic is based on culture results and clinical suspicion.

image Gonococcal cause: ceftriaxone or cefotaxime for 1 to 7 days
image Chlamydial cause: systemically administered erythromycin (eliminates nasopharyngeal carriage and possibly subsequent pneumonia)

• Allergic conjunctivitis is treated with a topical ophthalmologic antihistamine or mast cell stabilizer.

Chronic Rx

Oral antihistamine may be helpful in chronic allergic diatheses.

Referral

• Referral to a pediatric ophthalmologist should be considered if the patient has severe pain, photophobia, or blurred vision that does not improve with blinking.
• Patients with HSV infections or other agents that produce corneal ulcerations should also be referred to a pediatric ophthalmologist.
• If other causes of pink eye are strongly considered (i.e., iritis, acute angle-closure glaucoma), ophthalmology referral is indicated.

Pearls & Considerations

Comments

• One fourth of patients have associated otitis media at the time of diagnosis, and another one fourth develop otitis media if treated with a topical antibiotic.
• Outside the neonatal period, conjunctivitis is often self-limited (7 to 10 days); antibiotic therapy helps hasten the amelioration of symptoms and prevents secondary cases caused by spread.

Prevention

• Neonatal prophylaxis: 1% silver nitrate, 0.5% erythromycin, or 1% tetracycline

image All are equally effective for prophylaxis of gonorrheal eye infections.
image The regimens are helpful in reducing chlamydial ophthalmic infections.

• Good hand-washing practice in families, in daycare settings, and for individuals with upper respiratory infections

Patient/Family Education

• Good hand-washing technique should be taught and used in family and daycare settings.
• The rapid spread and extreme contagiousness of infective conjunctivitis should be explained and understood.
• Known irritants or allergens should be avoided, if possible.

Suggested Readings

Alessandrini EA. The case of the red eye. Pediatr Ann. 2000;29:112.

Gigliotti F. Acute conjunctivitis. Pediatr Rev. 1995;16:203.

Gigliotti F, et al. Efficacy of topical therapy in acute conjunctivitis in children. J Pediatr. 1984;104:623.

Jacobs DS. Conjunctivitis. UpToDate Online 13:3. http://www.utdop.com, 2005. Available at

Silverman MA, et al. Conjunctivitis. E Medicine Instant Access to the Minds of Medicine. 2005. Available at http://www.emedicine.com/EMERG/topic110.htm Accessed March 3

Weber CM, Eichenbaum JW. The red eye: differentiating viral conjunctivitis from other, common causes. Postgrad Med. 1997;101:185.

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