• Conjunctivitis, aka “Pinkeye”, can affect people of all ages, and higher incidence in those who wear contact lenses, children, and those who are immuno-compromised.
• It is an inflammation of the conjunctiva (the thin, clear tissue that lines the inside of the eyelid and that covers the white part of the eye).
• Symptoms may include redness, itching, and discharge in the affected eye(s).
• Can be caused by infections (bacterial or viral), allergies, or irritants.
• Is often contagious, but usually a self-limited condition or easily treated.

Common symptoms include:

• Redness and swelling of the conjunctiva (the clear membrane that covers the white part of the eye and the inner surface of the eyelid).
• Discharge from the eye, which may be clear, white, or yellowish.
• Itching or burning sensation in the eye.
• Increased tearing.
• Sensitivity to light (photophobia).
• Blurred vision.
• Swelling of the eye or eyelid.
• Crusting of the eyelashes, especially after sleep.
• Swollen lymph nodes near the affected eye.
• Pain or discomfort in the affected eye (in severe cases).

Red flags to consider Ophthalmology consultation:

• Photophobia.
• Vision loss.
• Pain with eye movement.
• Poor response to ongoing treatment.
• History of foreign body / trauma prior to presentation.

This is primarily a clinical diagnosis and tests are not routine unless other diagnoses are suspected. To differentiate between the different etiologies, consider:

Viral:

• May be unilateral or bilateral.
• May be accompanied by symptoms of a upper respiratory tract infection, such as nasal congestion or pharyngitis.
• May cause watery discharge, sensation of grittiness, burning, and have crust on eyelid in the morning.
• Often self-limiting and goes away on its own within a week or two.

Bacterial:

• Caused by bacteria, such as staphylococcus or streptococcus – consider Gonococcus.
• Often starts in one eye, but can spread to the other eye.
• May cause thick, yellow or green discharge.
• May cause the eyelids to stick together, especially after sleep.

Allergic:

• Often bilateral.
• Caused by an allergic reaction to substances such as pollen, dust, or animal dander.
• May cause itching, redness, grittiness and swelling of the conjunctiva.
• May cause watery discharge and crust on eyelid in the morning.
• May be accompanied by other allergic symptoms such as sneezing and a runny nose.

Physical Exam

• Examine the eye and eyelids for swelling, conjunctival injection, discharge.
• Consider slit lamp exam +/- fluorescein for foreign bodies or trauma, signs of ulceration.
• Consider visual acuity exam, pupils, confrontational visual fields, intraocular pressure with tonometer, extraocular movements.
• Consider HEENT exam if suspicion for upper respiratory illness causing eye symptoms.

Differential Diagnosis:

• Dry eye syndrome.
• Blepharitis.
• Herpes Simplex Keratitis.
• Uveitis.
• Iritis.

Treatment for conjunctivitis depends on the cause of the infection. The most common types of conjunctivitis are viral and bacterial, and they can often be treated with different approaches.

Viral:

• No specific treatment, self-limiting. Can recommend the following at home remedies for symptom management:
  • Apply a warm or cold compress to the affected eye several times a day.
  • OTC artificial tears/decongestant/antihistamine drops 1-2 drops 4 times daily PRN for up to 3 weeks.
  • Avoid wearing contact lenses until the infection has cleared up.
  • Wash your hands frequently to prevent the spread of the virus.

Bacterial:

• Most of the time self-limiting, and in mild cases can consider conservative management.
• Antibiotic eye drops or ointment may shorten symptom duration.
• For contact lens wearers, antibiotic topical treatment is needed.
• Patients should respond to treatment in 1-2 days, and if persistent symptoms occur or representation to ED consider referral to ophthalmologist.
• Those who play sports should refrain from returning to sport until 24 hours after treatment is started.
• Options include:
  • Erythromycin 5mg/g ophthalmic ointment
    • 25cm four times daily for 5-7 days.
  • Polymyxin B/Trimethoprim 10000U/1mg/mL ophthalmic drops
    • 1-2 drops four times daily for 5-7 days.
  • Ciprofloxacin 0.3% ophthalmic drops (preferred in contact lens wearers)
    • 1-2 drops four times daily for 5-7 days.
  • Moxifloxacin 0.5% ophthalmic drops
    • 1 drop in the affected eye(s) 2 times daily for 7 days.

Allergic:

• OTC artificial tears/decongestant/antihistamine/mast cell stabilizer drops 1-2 drops 4 times daily PRN for up to 4 weeks.
• Avoiding the allergens that trigger the reaction.

1. American Academy of Ophthalmology Cornea/External Disease Panel: Preferred Practice Pattern Guidelines: Conjunctivitis. AAO website. Updated November 2018. Accessed December 06, 2022. https://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp-2018

   
   

2. Jacobs DS. Conjunctivitis. In: UpToDate. Waltham, MA. Accessed December 04, 2022. Available at: https://www.uptodate.com/contents/conjunctivitis?search=conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

   
   

3. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013 Oct 23;310(16):1721-9. doi: 10.1001/jama.2013.280318. Erratum in: JAMA. 2014 Jan 1;311(1):95. Dosage error in article text. PMID: 24150468; PMCID: PMC4049531.