> Table of Contents > Conjunctivitis, Acute
Conjunctivitis, Acute
Frances Yung-tao Wu, MD
image BASICS
  • Inflammation of the bulbar and/or palpebral conjunctiva of <4 weeks' duration
  • System(s) affected: nervous, skin/exocrine
  • Synonym(s): pink eye
Geriatric Considerations
  • Suspect autoimmune, systemic, or irritative conditions.
  • If purulent, risk of bacterial cause increases with age, the combo of age >65 years and bilateral lid adherence = risk >70% (1)[B].
Pediatric Considerations
  • Neonatal conjunctivitis may be gonococcal, chlamydial, irritative, or related to dacryocystitis.
  • Pediatric ER study; 78% positive bacterial culture, mostly Haemophilus influenzae; 13% no growth; other studies showed >50% adenovirus.
  • Children <5 years were 7 times more likely to be bacterial than were older children or adults.
  • Daycare regulations sometimes require any child with presumed conjunctivitis to be treated with a topical antibiotic, despite lack of evidence (2)[A].
  • Predominant age
    • Pediatric: viral, bacterial
    • Adult: viral, bacterial, allergic
  • Predominant sex: male = female
In the United States: variable, but accounts for 1-2% of all ambulatory office visits
  • Viral
    • Adenovirus (common cold), coxsackievirus (implicated in recent hemorrhagic conjunctivitis epidemics in Asia and Middle East)
    • Enterovirus (acute hemorrhagic conjunctivitis)
    • Herpes simplex
    • Herpes zoster or varicella
    • Measles, mumps, or influenza
  • Bacterial
    • Staphylococcus aureus or epidermidis
    • Streptococcus pneumoniae
    • H. influenzae (children)
    • Pseudomonas spp. or anaerobes (in contact lens users)
    • Acanthamoeba from contaminated contact lens solution may cause keratitis.
    • Neisseria gonorrhoeae and meningitidis
    • Chlamydia trachomatis: gradual onset >4 weeks
  • Allergic
    • Hay fever, seasonal allergies, atopy
  • Nonspecific
    • Irritative: topical medications, wind, dry eye, UV light exposure, smoke
    • Autoimmune: Sjögren syndrome, pemphigoid, Wegener granulomatosis
    • Rare: Rickettsia, fungal, parasitic, tuberculosis, syphilis, Kawasaki disease, chikungunya, Graves, gout, carcinoid, sarcoid, psoriasis, Stevens-Johnson, Reiter syndrome
  • History of contact with infected persons
  • Sexually trasmitted disease (STD) contact: gonococcal, chlamydial, syphilis, or herpes
  • Contact lenses: pseudomonal or acanthamoeba keratitis
  • Epidemic bacterial (streptococcal) conjunctivitis reported in school settings
  • Wash hands frequently.
  • Demonstrate eyedropper technique: While eye is closed and head back, several drops over nasal canthus; then open eyes to allow liquid to enter. Never touch tip of dropper to skin or eye.
  • Viral infection (e.g., common cold)
  • Possible STD
  • General: common to all types of conjunctivitis
    • Red eye, conjunctival injection
    • Foreign body sensation
    • Eyelid sticking or crusting, discharge
    • Normal visual acuity and pupillary reactivity
  • Viral
    • Palpable preauricular lymphadenopathy may be present.
    • Hemorrhagic coxsackievirus-related epidemics were reported.
    • Severe viral: herpes simplex or zoster:
      • Burning sensation, rarely itching
      • Unilateral, herpetic skin vesicles in herpes zoster
      • Palpable preauricular node
  • Bacterial (non-STD): may be epidemic
    • Mild pruritus, discharge mild to heavy
    • Conjunctival chemosis/edema
    • If contact lens user, must rule out pseudomonal (or other bacterial) keratitis.
  • Bacterial: gonococcal (or meningococcal) hyperacute infection
    • Rapid onset 12 to 24 hours
    • Severe purulent discharge
    • Chemosis/conjunctival/eyelid edema
    • Rapid growth of superior corneal ulceration
    • Preauricular adenopathy
    • Signs of STDs (chlamydia, GC, HIV, etc.)
  • Allergic
    • Itching predominant
    • Seasonal or dander allergies
    • Chemosis/conjunctival/eyelid edema
  • Nonspecific irritative
    • Dry eyes, intermittent redness, chemical/drug exposure
    • Foreign body: may have redness and discharge 24 hours after removal
  • Must document normal visual acuity.
  • Cornea should be clear and without fluorescein uptake. Cloudy or ulcerated signifies keratitis; consult ophthalmologist.
  • Recommend fluorescein exam: Evert lid to inspect for foreign bodies.
  • Skin: Look for herpetic vesicles, nits on lashes (lice), scaliness (seborrhea), or styes.
  • Limbal flush at corneal margin if uveitis
  • If pupil is irregular (i.e., penetrating foreign body), emergent referral is warranted.
  • Discharge but no conjunctival injection: blepharitis
  • Uveitis (iritis, iridocyclitis, choroiditis): limbal flush (red band at corneal margin), hazy anterior chamber, and decreased visual acuity
  • Penetrating ocular trauma: emergently hospitalize
  • Acute glaucoma (emergency): headache, corneal clouding, poor visual acuity
  • Corneal ulcer(s) or foreign body: lesions on fluorescein exam
  • Dacryocystitis: tenderness and swelling over tear sac (below medial canthus)
  • Scleritis and episcleritis: red injected vessels radially oriented, sectoral (pie wedge), nodularity of sclera
  • Pingueculitis: inflammation of a yellow nodular or wedge-like area of chronic conjunctival degeneration (pinguecula)
  • Ophthalmia neonatorum: neonates in the first 2 days of life (gonococcal; 5 to 12 days of life): chlamydial, HSV, very rare N. meningitidis. Consider specialty consultation for required systemic therapy.
  • Blepharitis: Lid margins are inflamed producing itching, scale, or discharge, but no conjunctival injection.
  • Usually not needed initially for the most common causes
  • Culture swab if STD is suspected, very severe symptoms, or patient is a contact lens user
  • Viral swab for detection of adenovirus is not yet in common use.
Diagnostic Procedures/Other
  • Fluorescein exam for ulcer or abrasion on cornea
  • Small superficial foreign bodies may be removed with irrigation or moistened swab.
  • Infectious conjunctivitis rarely needs antibiotics and resolve on their own.
  • Clean eyelid with wet cloth up to QID.
  • Stop use of contact lenses while red.
  • Patching of eye is not beneficial.

First Line
  • Viral (nonherpetic)
    • Artificial tears for symptomatic relief
    • Vasoconstrictor/antihistamine (e.g., naphazoline/pheniramine) QID for severe itching
    • May consider topical antibiotic (see bacterial below) if return to daycare requires treatment
  • Viral (herpetic) (by ophthalmologist)
    • Ganciclovir gel: 0.15%, 5 times per day for 7 days (3)[B]
    • Acyclovir: PO 400 mg 5 times per day for herpes simplex virus (HSV); 800 mg for zoster for 7 days
  • Bacterial (non-STI): 3 days cool compress before starting any antibiotic showed no adverse consequences and decreased unnecessary Rx (4)[A].
    • After 3 days, consider topical antibiotics (NNT 7 at day 6) as a reasonable option for delayed treatment: Polymyxin B-Bacitracin ophthalmic ointment: Apply 4 times per day for 5 to 7 days.
    • Polymyxin B-trimethoprim solution 1 gtt 4 times per day for 5 to 7 days
    • Erythromycin ophthalmic ointment: 1/2 inch BID-QID for 5 days
    • Sodium sulfacetamide (10% solution) (Bleph-10): 2 drops q4h (while awake) for 5 days
    • Tobramycin or gentamicin: 0.3% ophthalmic drops/ointment q4h (drops) to q8h (ointment) for 7 days
  • Bacterial (gonococcal)
    • Neonates: Hospitalize for IV therapy.
    • Adults: ceftriaxone: 1 g IM as single dose and topical bacitracin ophthalmic ointment 1/2 inch QID. Neonates 25 to 50 mg/kg IV or IM, not to exceed 125 mg, as a single dose. Chlamydia in neonates requires oral erythromycin ethylsuccinate: 50 mg/kg/day divided q6h PO for 14 days, max 3 g/day.
  • Allergic and atopic (listed by approximate, increasing cost, from lowest to highest): All are efficacious, but evidence favoring one over another is inconclusive (5)[A].
    • Ketotifen (Zaditor, Alaway, and other generics over-the-counter [OTC]): 0.25% 1 drop BID
    • Cromolyn (Opticrom): 4% QID
    • Azelastine: 0.05% 1 gtt BID
    • Pemirolast (Alamast): 0.1% 1 gtt QID
    • Alcaftadine (Lastacaft): 0.25% 1 gtt QD
    • Emedastine: 0.05% 1 drop QID
    • Epinastine (Elestat): 0.05% BID
    • Ketorolac (Acular): 0.1% 1 drop QID
    • Olopatadine (Pataday, Patanol): 0.1% 1 drop BID or 0.2% 1 drop daily
    • Bepotastine (Bepreve): 1.5% 1 gtt BID
    • Lodoxamide tromethamine (Alomide): 0.1% 1 gtt QID
    • Nedocromil (Alocril): 2% 1 gtt BID
    • Oral nonsedating antihistamines (cetirizine [Zyrtec] 10 mg/day, fexofenadine [Allegra] 60 mg BID, etc.) may treat nasal symptoms but cause ocular drying. Oral antihistamine (e.g., diphenhydramine 25 mg TID) in severe cases of itching
  • Contraindications: Avoid topical steroids unless able to monitor intraocular pressure. Also, case report of HSV keratitis presenting without distinguishing findings from viral conjunctivitis would discourage initial use of steroids. Steroids were not beneficial in treatment of bacterial keratitis (6)[A]. Topical immune modulators (tacrolimus, cyclosporine) should be reserved for specialist use only in the most difficult cases.
  • Precautions
    • Do not allow dropper to touch the eye.
    • Case reports of eye irritation from gentamicin in infants, moxifloxacin in adults, sulfacetamide in allergic individuals
    • Vasoconstrictor/antihistamine: rebound vasodilation after prolonged use
Second Line
  • Viral and allergic: numerous OTC products
  • Bacterial: second line (quinolones used as postop or known resistant organisms)
    • Ofloxacin: 0.3% 1 gtt 4 times per day for 7 days
    • Ciprofloxacin: 0.3% 1 gtt 4 times per day for 7 days
    • Levofloxacin: 0.3% 1 gtt 4 times per day for 7 days
    • Gatifloxacin: 0.3% 1 gtt 3 times per day for 7 days
    • Moxifloxacin: 0.5% 1 gtt 3 times per day for 7 days
    • Besifloxacin: 0.6% 1 gtt 3 times per day for 7 days
    • Azithromycin: 1.5% 2 times per day for 3 days
Any significantly decreased visual acuity, herpetic keratitis, or contact lens-related bacterial conjunctivitis warrants ophthalmologic consultation.
As condition is usually benign and self-limited, saline flushes, cool compresses, and similar treatments help.
Acute gonococcal conjunctivitis (or very rare case of meningococcal conjunctivitis) requires inpatient treatment with ceftriaxone 50 mg/kg IV everyday (pediatric), 1 g IM for 1 (adult) along with ophthalmologic consultation.
Admission Criteria/Initial Stabilization
Penetrating ocular trauma, gonococcal conjunctivitis
  • If not resolved within 5 to 7 days, alternate diagnoses should be considered or consultation obtained, although some epidemic keratoconjunctivitis and other adenoviral conjunctivitis typically last 1 to 2 weeks.
  • Children may be excluded from school until eye is no longer red, if viral or bacterial, depending on school policy. Allergic conjunctivitis should be able to return to school with doctor's note.
  • Patients should not wear contacts until their eyes are fully healed (typically 1 week).
  • Patients should discard current pair of contacts.
  • Patients should discard any eye makeup that they have been using, especially mascara.
  • Cool, moist compress can ease irritation and itch.
  • Viral: 5 to 10 days for pharyngitis with conjunctivitis, 2 weeks with adenovirus
  • Herpes simplex: 2 to 3 weeks
  • Most common bacterial-H flu, staph, strep: self-limited; 74-80% resolution within 7 days, whether treated or not
1. van Weert HC, Tellegen E, Ter Riet G. A new diagnostic index for bacterial conjunctivitis in primary care. A re-derivation study. Eur J Gen Pract. 2014; 20(3):202-208.
2. Steeples L, Mercieca K. Acute conjunctivitis in primary care: antibiotics and placebo associated with small increase in proportion cured by 7 days compared with no treatment. Evid Based Med. 2012;17(6):177-178.
3. Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simples virus epithelial keratitis. Cochrane Database Syst Rev. 2015;(1):CD002898.
4. Sheikh A, Hurwitz B, van Schayck CP, et al. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012;(9):CD001211.
5. Castillo M, Scott NW, Mustafa MZ, et al. Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis. Cochrane Database Syst Rev. 2015;(6):CD009566.
6. Herretes S, Wang X, Reyes JM. Topical corticosteroids as adjunctive therapy for bacterial keratitis. Cochrane Database Syst Rev. 2014;(10):CD005430.
Additional Reading
Narayana S, McGee S. Bedside diagnosis of the “red eye” a systematic review. Am J Med. 2015;28(11):1220.e1-1224.e1.
See Also
  • Rhinitis, Allergic
  • Algorithm: Eye Pain
  • H10.30 Unspecified acute conjunctivitis, unspecified eye
  • H10.33 Unspecified acute conjunctivitis, bilateral
  • H10.32 Unspecified acute conjunctivitis, left eye
Clinical Pearls
  • Conjunctivitis does not alter visual acuity; decreased acuity or photophobia should prompt consideration of more serious ophthalmic disorders.
  • Culture discharge in all contact lens wearers, consider referral, and remind patient to throw away current contacts and avoid contacts until eyes are fully healed.
  • Antibiotic therapy is of no value in viral conjunctivitis (most cases of infectious conjunctivitis) and does not significantly alter the course of most types of bacterial conjunctivitis (therefore, it is optional in these cases).