Conjunctival inflammation typically results from infection, allergy, or irritation. Symptoms are conjunctival hyperemia and ocular discharge and, depending on the etiology, discomfort and itching. Diagnosis is clinical; sometimes cultures are indicated. Treatment depends on etiology and may include topical antibiotics, antihistamines, mast cell stabilizers, and corticosteroids.

Infectious conjunctivitis is most commonly viral or bacterial and is contagious. Rarely, mixed or unidentifiable pathogens are present. Numerous allergens can cause allergic conjunctivitis (see Conjunctival and Scleral Disorders: Allergic Conjunctivitis). Nonallergic conjunctival irritation can result from foreign bodies; wind, dust, smoke, fumes, chemical vapors, and other types of air pollution; and intense ultraviolet light of electric arcs, sunlamps, and reflection from snow.

Conjunctivitis is typically acute, but both infectious and allergic conditions can be chronic. Conditions that cause chronic conjunctivitis include ectropion, entropion, blepharitis, and chronic dacryocystitis.

Symptoms and Signs

Any source of inflammation causes lacrimation or discharge and diffuse conjunctival vascular dilation. Discharge may cause the eyes to crust overnight. Thick discharge may blur vision, but once discharge is cleared, visual acuity should be unaffected.

Itching and watery discharge predominate in allergic conjunctivitis. Chemosis and papillary hyperplasia also suggest allergic conjunctivitis. Irritation or foreign body sensation, photophobia, and discharge suggest infectious conjunctivitis; purulent discharge suggests a bacterial cause. Severe eye pain suggests scleritis (see Conjunctival and Scleral Disorders: Scleritis).

Diagnosis

• Clinical evaluation
• Sometimes culture

Usually, diagnosis is made by history and examination (see also Table 1: Conjunctival and Scleral Disorders: Differentiating Features in Acute Conjunctivitis), usually including slit-lamp examination with fluorescein staining of the cornea and, if glaucoma is suspected, measurement of intraocular pressure. Meticulous disinfection of equipment that touches the eye is particularly important in patients who could have conjunctivitis.

Other disorders can cause a red eye (see Symptoms of Ophthalmologic Disorders: Red Eye). Deep pain in the affected eye when a light is shone in the unaffected eye (true photophobia) does not occur in uncomplicated conjunctivitis and suggests a disorder of the cornea or anterior uvea. Circumcorneal conjunctival hyperemia (sometimes described as ciliary flush) is caused by dilated, fine, straight, deep vessels that radiate out 1 to 3 mm from the limbus, without significant hyperemia of the bulbar and tarsal conjunctivae. Ciliary flush occurs with uveitis, acute glaucoma, and some types of keratitis but not with uncomplicated conjunctivitis.

Pearls & Pitfalls Suspect another cause of red eye (eg, uveitis, glaucoma, keratitis) if patients have true photophobia, loss of vision, or ciliary flush.

The cause of conjunctivitis is suggested by clinical findings. However, cultures are indicated for patients with severe symptoms, immunocompromise, a vulnerable eye (eg, after a corneal transplant, in exophthalmos due to Graves disease), or poor response to initial therapy.

Clinical differentiation between viral and bacterial infectious conjunctivitis is not highly accurate. However, if the history and examination strongly suggest viral conjunctivitis, withholding antibiotics initially is appropriate. Antibiotics can be prescribed later if the clinical picture changes or if symptoms persist.

Table 1
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Differentiating Features in Acute Conjunctivitis Etiology Discharge/Cell Type Eyelid Edema Node Involvement Itching Bacterial Purulent/polymorphonuclear leukocytes Moderate Usually none None Viral Clear/mononuclear cells Minimal Often present None Allergic Clear, mucoid, ropy/eosinophils Moderate to severe None Mild to intense Differentiating Features in Acute Conjunctivitis Etiology Discharge/Cell Type Eyelid Edema Node Involvement Itching Bacterial Purulent/polymorphonuclear leukocytes Moderate Usually none None Viral Clear/mononuclear cells Minimal Often present None Allergic Clear, mucoid, ropy/eosinophils Moderate to severe None Mild to intense

Treatment

• Prevention of spread
• Treatment of symptoms

Most infectious conjunctivitis is highly contagious and spreads by droplet, fomites, and hand-to-eye inoculation. To avoid transmitting infection, physicians must wash their hands thoroughly and disinfect equipment after examining patients. Patients should wash their hands thoroughly after touching their eyes or nasal secretions, avoid touching the noninfected eye after touching the infected eye, avoid sharing towels or pillows, and avoid swimming in pools. Eyes should be kept free of discharge and should not be patched. Small children with conjunctivitis should be kept home from school to avoid spread. Cool washcloths applied to the eyes may help relieve local burning and itching. Antimicrobials are used for certain infections.

Key Points

• Conjunctivitis typically results from infection, allergy, or irritation.
• Infectious conjunctivitis is usually highly contagious.
• Typical findings are redness (without ciliary flush) and discharge, without significant pain or loss of vision.
• Diagnosis is usually clinical.
• Treatment includes measures to prevent spread and treatment of the cause (sometimes antimicrobials).

Last full review/revision October 2012 by Melvin I. Roat, MD, FACS