Definition
A.Conjunctivitis is inflammation of the conjunctiva. All conjunctivitis is erythemic, but not all erythemic eyes are conjunctivitis. Differential diagnosis is key in diagnosis.
Incidence
A.Conjunctivitis may be subdivided into viral, bacterial, allergic, and nonallergic subcategories. Viral conjunctivitis is the most common type of conjunctivitis.
Pathogenesis
Primarily, four types of conjunctivitis are observed:
A.Bacterial (Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Neisseria gonorrhoeae, and Chlamydia).
B.Viral (adenovirus, coxsackievirus, herpes zoster ophthalmicus, and enteric cytopathic human orphan [ECHO] viruses).
C.Allergic (seasonal pollens or allergic exposure).
D.Nonallergic (commonly related to mechanical or chemical trauma).
Predisposing Factors
A.Contact with another person with the diagnosis of conjunctivitis.
B.Exposure to sexually transmitted infection (STI).
C.Other atopic conditions (allergies).
D.Mechanical or chemical injury.
Common Complaints
A.Red eyes.
B.Eye drainage.
C.Itching (with allergic conjunctivitis).
D.Matting upon awakening.
Other Signs and Symptoms
A.Bacterial:
1.Fast onset, 12 to 24 hours of copious purulent or mucopurulent discharge.
2.Burning, stinging, or gritty sensation in eyes.
3.Crusted eyelids upon awakening, with swelling of eyelid.
4.Usually starts out unilaterally; may progress to bacterial infection.
5.Bacterial conjunctivitis may present as beefy red conjunctiva.
B.Viral:
1.Symptoms may begin in one eye and progress to both eyes.
2.Tearing of eyes.
3.Sensation of foreign body.
4.Systemic symptoms of upper respiratory infection (runny nose, sore throat, sneezing, fever).
5.Preauricular or submandibular lymphadenopathy.
6.Photophobia, impaired vision
7.Primary herpetic infection: Vesicular skin lesion, corneal epithelial defect in form of dendrite, uveitis
C.Allergic:
1.Itchy, watery eyes, bilateral.
2.Seasonal symptoms.
3.Edema of eyelids without visual change.
4.With allergic conjunctivitis, hyperemia of eyes is always bilateral, and giant papillae on tarsa may be seen.
5.May also see eczema, urticaria, and asthma flare.
D.Nonallergic (mechanical or chemical).
1.Itchy, watery eyes, unilateral or bilateral.
2.Frequent causes may include smoke, dust, vapors, and foreign objects.
3.Tearing.
4.Vision obstructed from blurring or tearing.
Subjective Data
A.Elicit onset, duration, and course of symptoms.
B.Question patient regarding presence of discharge upon awakening.
C.Elicit changes in vision since symptoms began.
D.Determine whether there has been any injury or trauma to the eye, including foreign body.
E.Assess whether these symptoms have appeared before.
F.Rule out exposure to anyone with conjunctivitis.
G.Ask patient about any new events, such as use of contact lenses or change in contact lenses or solutions.
H.Review patient and family history of allergies.
I.Question the patient regarding pain and rate on pain scale.
Physical Examination
A.Check temperature.
B.Inspect:
1.Observe eyes for color and foreign objects. Perform complete eye exam including acuity exam.
2.Note lid edema.
3.Assess pupillary reflexes.
4.Examine eyelids and periorbital skin for erythema, vesicles, inflammation, or tenderness.
5.Inspect ears, nose, and throat.
C.Auscultate:
1.Auscultate heart and lungs.
D.Palpate:
1.Palpate preauricular lymph nodes and anterior and posterior cervical chain lymph nodes.
Diagnostic Tests
A.Gram stain testing for discharge/exudate extracted from eyes if gonococcal infection is suspected.
B.Culture for chlamydia, if suspected.
C.Perform fluorescein stain of eye if foreign body is suspected or corneal abrasion/ulceration is suspected.
D.Test visual acuity with the Snellen chart. Assess peripheral vision and extraocular eye movements (EOMs).
Differential Diagnoses
A.Conjunctivitis.
B.Corneal abrasion.
C.Blepharitis.
D.Drug-related conjunctivitis.
E.Herpetic keratoconjunctivitis.
F.Iritis.
G.Gonococcal or chlamydial conjunctivitis.
H.Angle-closure glaucoma.
I.Keratitis.
J.Foreign body.
Plan
A.General interventions:
1.Distinguish between bacterial, allergic, nonallergic, or viral infection.
2.Consider other diagnoses as earlier if eye pain is noted.
B. 
See Section III: Patient Teaching Guide How to Administer Eye Medications.
1.Cool compresses to affected eye should be applied several times a day.
2.Clean eyes with warm, moist cloth from inner to outer canthus to prevent spreading infection.
3.Encourage good handwashing with antibacterial soap.
4.Instruct on the proper method of instilling medication into eye.
5.Instruct the female patient to discard all eye makeup, including mascara, eyeliner, and eye shadow, worn at the time of the infection.
6.Teach the patient the difference between bacterial, allergic, nonallergic, and viral infections. Educate according to appropriate diagnosis.
7.If using aminoglycoside or neomycin ointments or drops, use caution and monitor closely for reactive keratoconjunctivitis.
8.Bacterial conjunctivitis is contagious until 24 hours after beginning medication.
9.Viral conjunctivitis is contagious for 48 to 72 hours, but it may last up to 2 weeks.
10.Discuss general eye protection against recurrent exposures or trauma.
C.Pharmaceutical therapy:
1.Bacterial:
a.Aminoglycosides: These should be avoided because of risk of reactive keratoconjunctivitis.
b.Polymyxin B: Trimethoprim/polymyxin B sulfate (Polytrim) ophthalmic ointment in each eye four times daily for 7 days. Polymyxin B/bacitracin (Polysporin) drops may also be used, 1 gtt every 3 hours for 7 to 10 days.
c.Macrolides: Erythromycin (Ilotycin) ophthalmic ointment 0.5% in each eye four times daily for 7 days.
d.Fluoroquinolones: Ciprofloxacin 0.3%: every 2 hours for 2 days, then every 4 hours for 5 days. Moxifloxacin (Vigamox) 0.5% 1 gtt three times a day for 7 days. (Because of concerns of resistance, fluoroquinolones should be reserved for treatment of bacterial conjunctivitis primarily in contact wearers.)
2.Viral:
a.Antiviral medications:
i.Trifluridine 1% drops are indicated for ocular herpes. Patients suspected with ocular herpes should benefit from a same-day referral to an ophthalmologist as permanent vision loss can be a sequela of herpes conjunctivitis.
ii.Oral antiviral medications (trifluridine, valacyclovir) may be used for herpes simplex keratitis. Herpes zoster ophthalmicus is often treated with acyclovir, famciclovir, or valacyclovir and lessens symptoms if started within 72 hours of onset of symptoms. Patients should receive same-day referral for consideration of treatment of ocular herpes.
3.Allergic:
a.Topical antihistamines/mast cell stabilizer:
i.Azelastine HCl (Optivar): Adults: One drop to the affected eye twice a day.
ii.Olopatadine HCl (Pataday) 0.2%: One drop to the affected eye daily.
iii.Olopatadine HCl (Patanol) 0.1%: One drop twice a day to the affected eye.
b.Mast cell stabilizer:
i.Cromolyn sodium (Crolom) ophthalmic solution: One to two drops four to six times daily.
c.Topical NSAID:
i.Ketorolac tromethamine (Acular) 0.5%: Adults: One drop four times a day. This is used for severe symptoms of atopic keratoconjunctivitis.
d.Artificial tears can be used four to five times daily.
e.Oral antihistamines may be used in severe cases (loratadine or diphenhydramine HCl).
4.Concurrent conjunctivitis and otitis media should be treated with a systemic antibiotic; no topical eye antibiotic is needed.
Follow-Up
A.If complete resolution occurs within 5 to 7 days after proper treatment, follow-up is not needed.
B.If patient continues to have equal or worsening symptoms after 48 to 72 hours of treatment or if different symptoms appear, then follow-up and a same-day referral to an ophthalmologist are recommended.
Consultation/Referral
A.Consult or refer patient to physician if patient is not responding to treatment within 48 to 72 hours.
B.Same-day referral if patient is suspected of having periorbital cellulitis, iritis, keratitis, herpes zoster ophthalmicus, or acute angle-closure glaucoma.
C.Refer to eye specialist if patient has vision change or eye pain, is not responding to treatment, or if sight-threatening red flags are present.
Individual Considerations
A.Partners:
1.Check partners for gonorrhea and chlamydia when adolescent or adult presents with gonococcal or chlamydial conjunctivitis.
B.Special considerations: Sight-threatening red flags:
1.Reduced visual acuity with onset of symptoms.
2.Observation of a ciliary flush.
3.Photophobia.
4.Severe foreign-body sensation.
5.Corneal opacity.
6.Fixed pupil.
7.Severe headache associated with nausea.
C.Geriatrics:
1.Lid or lacrimal sac edema or proptosis with conjunctivitis is a red flag to further investigate for cellulitis or an orbital tumor.
2.First-line treatment for conjunctivitis in geriatrics is erythromycin ointment/drops. Second-line is ciprofloxacin 0.3% solution.
3.If signs/symptoms of purulent discharge do not improve within 48 hours after initiating antibiotics, then refer to ophthalmologist.