Acute conjunctivitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

It is important to differentiate the subtypes of conjunctivitis to enable the most effective treatment.

Patients with infectious conjunctivitis should be informed about the contagious nature of their condition. Patients with bacterial conjunctivitis may return to work/school/daycare after 24 to 48 hours of antibiotic treatment, but viral conjunctivitis requires at least 1 week out of work/school/daycare. Advice regarding strict hand washing and not sharing any towels or bedding may help prevent spread of infection. Typically, viral conjunctivitis is contagious until the eye is no longer red and tearing.

Allergic conjunctivitis (seasonal/perennial)

Typically, most allergic conjunctivitis is initially treated as mild unless there is a treatment failure and it elevates it to moderate. Mild-to-moderate disease typically has a swollen conjunctiva (chemosis) with a mild papillary conjunctival reaction with scant mucoid discharge. More severe cases have large ("giant") papillae on the palpebral conjunctiva, limbal follicles, and a shield (sterile) corneal ulcer.

Seasonal/perennial allergic conjunctivitis is an acute disorder with a recurrent course, whereas atopic and vernal conjunctivitis are chronic diseases with acute exacerbations.[1][7][12] The management of atopic and vernal conjunctivitis is distinct from seasonal/perennial allergic conjunctivitis and is not covered in detail in this topic. Patients with suspected atopic or vernal conjunctivitis should be referred to an ophthalmic clinician.

Allergic: mild

Mild allergic conjunctivitis refers to itchy, watery, red eyes occurring seasonally and responding to supportive measures, including artificial tears and cool compresses. Artificial tears help to dilute various allergens and inflammatory mediators that may be present on the ocular surface.

Patients can also wear sunglasses as a barrier against allergens, avoid rubbing their eyes, and avoid known allergens. Hypoallergenic bedding, eyelid cleansers, bathing/showering before bedtime, and frequent washing of clothes may also be helpful. These supportive measures are suitable for all patients with allergic conjunctivitis.[1]

Allergic: moderate

Moderate allergic conjunctivitis refers to itchy, watery, red eyes that usually occur seasonally and respond to topical antihistamines and/or mast cell stabilizers.[64] Short-term use of oral antihistamines may also be required.[64] Although commonly used, oral antihistamines may lead to or worsen dry eye syndrome, and impair the tear film, and so worsen allergic conjunctivitis. Simultaneous use of artificial tears may improve tear deficiency and dilute allergens and inflammatory mediators on the eye's surface.[1][31][65]

Mast cell stabilizers prevent mast cell degranulation; commonly used examples include cromolyn and lodoxamide.

Topical antihistamines (e.g., alcaftadine, pheniramine) are short-acting to relieve itching and redness and have few adverse effects.[66][67]

Oral antihistamines, which are longer-acting, may be used with, or instead of, topical antihistamines.

Vasoconstrictors (e.g., naphazoline) are available in combination with topical antihistamines, which provide added short-term relief of vascular injection, but they may cause rebound conjunctival injection and inflammation.

Drugs with both antihistamine and mast cell stabilizing activity include azelastine, bepotastine, epinastine, olopatadine, and ketotifen.[68][69][70][71] One review has found olopatadine and ketotifen to be more efficacious than placebo in relieving the signs and symptoms of allergic conjunctivitis.[72]

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are also used for moderate-to-severe allergic conjunctivitis if additional anti-inflammatory effect is required.[73]

Allergic: severe

Severe allergic disease is regarded as the presence of symptoms year round and is associated with greater inflammation than moderate disease.

Specialist referral should be considered in cases of severe or resistant allergic disease, as this may require additional treatment with a brief course (1 to 2 weeks) of topical corticosteroids.[1][74] Only ophthalmic clinicians should prescribe topical corticosteroids.

Corticosteroids can be used together with topical or oral antihistamines and mast cell stabilizers. Topical NSAIDs can be added if further anti-inflammatory effect is required.

Corticosteroids have several long-term ocular risks, including delayed wound healing, secondary infection, elevated intraocular pressure, and formation of cataract. The corticosteroid loteprednol appears to have fewer adverse effects than prednisolone. It has demonstrated similar efficacy to prednisolone in treating patients with vernal conjunctivitis, and has been shown to be noninferior to olopatadine in treating seasonal allergic conjunctivitis.[74][75][76] One randomized controlled trial with three parallel treatment groups showed that daily intranasal corticosteroids for the treatment of allergic rhinoconjunctivitis was not superior to intranasal corticosteroids on demand, or to antihistamine on demand, with regard to the number of symptom-free days.[77]

Topical cyclosporine provides relief with corticosteroid-sparing effects and may be considered as second line to corticosteroids. It may also be particularly useful as second-line treatment in severe atopic or vernal conjunctivitis.[1][7][8][78][79][80][81]

Allergen-specific immunotherapy may be an option for patients who have disease that cannot be controlled by topical medications and oral antihistamines.[1]

Bacterial: mild-to-moderate

Mild bacterial conjunctivitis is usually self-limiting and may not require antibiotic therapy.[1] However, compared with placebo, antibiotics are associated with modestly improved resolution of symptoms or signs by days 4 to 9.[82][83][84][85] [ ]

Broad-spectrum topical antibiotics such as erythromycin, azithromycin, or polymyxin/trimethoprim are suitable as first-line therapy in mild-to-moderate bacterial conjunctivitis.[82][86][87][88] Alternatives include bacitracin, bacitracin/polymyxin, or sulfacetamide.[82]

Aminoglycosides such as gentamicin and tobramycin are not recommended treatments, because they are corneal toxic and may delay healing and cause hyperemia.[84][89][90]

Bacterial: moderate-to-severe

Severe forms of bacterial conjunctivitis are associated with more pronounced symptoms such as increased discharge, greater inflammation, and longer duration than milder forms of the disease. Topical fluoroquinolones, such as besifloxacin, are effective and well tolerated and are the treatment of choice for treating more severe bacterial eye infections.[91] They can also be used if bacterial resistance to other antibacterials is known. Because of this, topical fluoroquinolones are increasingly being used as a first-line therapy. All immunocompromised patients should be started on a topical fluoroquinolone as a first-line therapy.[84][89][90][92][93][94][95][96]

Bacterial: hyperacute (gonococcal)

Hyperacute bacterial conjunctivitis (gonococcal) requires systemic treatment with single-dose ceftriaxone and simultaneous treatment for chlamydial coinfection with oral doxycycline or azithromycin.[1][97] Topical treatment with bacitracin or ciprofloxacin is usually used in conjunction with the oral therapy.[1]

Bacterial: chlamydial (inclusion conjunctivitis)

Chlamydial conjunctivitis that occurs in developed countries is also known as "inclusion conjunctivitis." It is caused by Chlamydia trachomatis serotypes D to K and is transmitted sexually. Chlamydial conjunctivitis caused by C trachomatis serotypes A, B, and C is known as trachoma and is mainly limited to areas without adequate access to clean water and sanitation.[1] For more information on management of trachoma, see Trachoma. Chlamydial conjunctivitis (inclusion conjunctivitis) requires treatment with oral antibiotics. Topical antibiotics are also usually used.[1]

Viral: adenoviral

Most cases of acute, infectious conjunctivitis in adults are caused by an adenovirus, and are self-limiting and do not need treatment with an antimicrobial agent.[1] Some patients derive symptomatic relief from topical antihistamine/decongestants and artificial tears, which may relieve itching. Cool compresses gently applied around the eye area may provide additional symptomatic relief, as can oral analgesics.[1] Systemic agents play no role in adenoviral conjunctivitis.[1][84][89][90]

Adenoviral conjunctivitis associated with the presence of a pseudomembrane or corneal subepithelial infiltrates requires treatment with topical corticosteroids. Only ophthalmic clinicians should prescribe topical corticosteroids. Topical ganciclovir may be considered for confirmed adenovirus, although this use is off label.[98][99]

Viral: herpes simplex

Herpes simplex virus (HSV) conjunctivitis is usually self-limiting, but may need treatment with topical or oral antivirals in more severe disease, particularly if corneal involvement is suspected.[1] For the management of HSV keratitis, see Keratitis.

Viral: varicella zoster

Prompt referral to an ophthalmologist is required for all patients who have eye manifestations of herpes zoster infection.[100] See Herpes zoster infection.

Viral: molluscum contagiosum

Lesions generally resolve over time; the natural course of infection is spontaneous clearance in 1-2 years in most immunocompetent patients, with more prolonged illness in immunocompromised patients. The lesions may need to be removed in symptomatic patients.[1]

Neonatal conjunctivitis

This is conjunctival inflammation occurring within the first 30 days of life. It is also known as ophthalmia neonatorum. It is usually a mild illness. However, untreated infection (for example, with gonococcus, chlamydia, pseudomonas, or herpes) can lead to sight-threatening complications and potentially serious systemic infection.[101] Complications of neonatal conjunctivitis due to chlamydia include superficial corneal vascularization, conjunctival scarring, and pneumonia. Complications due to gonorrheal infections include corneal scarring, ulceration, panophthalmitis, perforation of the globe, and permanent visual impairment.[101][102] Patients with suspected neonatal conjunctivitis should be referred immediately to an ophthalmologist.[1]

Contact lens related

Contact lens wear should be discontinued for 2 or more weeks, and the lens care regimen should be reviewed and changed to a preservative-free lens care system. A brief course (1 to 2 weeks) of a topical corticosteroid may be prescribed to reduce irritation and inflammation. Only ophthalmic clinicians should prescribe topical corticosteroids. If bacterial, topical fluoroquinolones should be prescribed.[1][84][89][90][91][95][96] Contact lens-related keratoconjunctivitis can potentially impact visual function, so referral to an eye specialist should be considered.[1]

Mechanical

Temporary relief of floppy eyelid syndrome may be achieved by taping the patient's eyelids shut or by having the patient wear a protective shield while sleeping.[1] Ocuar lubricants may help in managing mild cases.[1] Surgical procedures such as full-thickness horizontal shortening of the upper eyelid, to prevent the upper eyelid from overlapping, can be considered for more severe cases.[1]

Toxic/chemical

Reduce exposure to the chemical irritants. The eye should be immediately flushed following any exposure and the pH of the tears checked. Flushing should occur until the pH is 7. Artificial tears should be used frequently to provide symptomatic relief. A short course of topical corticosteroids can be considered if inflammation persists. Only ophthalmic clinicians should prescribe topical corticosteroids.

Medication related

Discontinuation of the drug causing medication-induced conjunctivitis usually results in gradual resolution of symptoms over several weeks or months. Preservative-free artificial tears may provide symptomatic relief. If severe inflammation of the conjunctiva or eyelid is present, a brief course of topical corticosteroids can be considered. However, only ophthalmic clinicians should prescribe topical corticosteroids.

Specialist referral

Consider referring to a specialist eye physician if symptoms persist for more than 7 to 10 days after initiating treatment, or the patient develops significant pain, light sensitivity, or visual loss.

Use of this content is subject to our disclaimer