Diagnosis
●Conjunctivitis is a common condition. The diagnosis can be made in a patient with a red eye and discharge only if the vision is normal and there is no evidence of keratitis, iritis, or angle closure glaucoma. Warning signs for these conditions are discussed above.
●Conjunctivitis may be infectious (bacterial or viral) or noninfectious (allergic, toxic, dryness, and others). Most infectious conjunctivitis is probably viral, although bacterial conjunctivitis is more common in children than in adults. Viral and bacterial conjunctivitis are both highly contagious. All etiologies of conjunctivitis can cause symptoms of the eyes being stuck closed in the morning.
●A diagnosis of bacterial conjunctivitis should only be made in patients with thick purulent discharge that continues throughout the day. The discharge can generally be seen at the lid margins and at the corner of the eye. Bacterial conjunctivitis is usually unilateral but can be bilateral. Neisseria species can cause a hyperacute bacterial conjunctivitis that is severe and sight-threatening, requiring immediate ophthalmologic referral.
●Viral conjunctivitis typically presents as injection, mucoid or serous discharge, and a burning, sandy, or gritty feeling in one eye. It may be part of a viral prodrome or systemic viral illness, or it may be an isolated manifestation of viral illness. The second eye usually becomes involved within 24 to 48 hours, although unilateral signs and symptoms do not rule out a viral process. On examination there typically is only mucoid discharge if one pulls down the lower lid or looks very closely in the corner of the eye. Usually there is profuse tearing rather than discharge. The tarsal conjunctiva may have a follicular or "bumpy" appearance. There may be an enlarged and tender preauricular node. The clinical course parallels that of the common cold. The symptoms generally get worse for the first three to five days, with very gradual resolution over the following one to two weeks for a total course of two to three weeks.
●Allergic conjunctivitis typically presents as bilateral redness, watery discharge, and itching. Itching is the cardinal symptom of allergy, distinguishing it from a viral etiology, which is more typically described as grittiness, burning, or irritation; the clinical findings are the same as with viral conjunctivitis. Patients with allergic conjunctivitis often have a history of atopy, seasonal allergy, or specific allergy (eg, to cats).
●Other noninfectious conjunctivitis presents as a red eye and mucoid discharge. The usual causes are mechanical or chemical insult, or a dry eye from exposure or lack of tear production.
Treatment
●Bacterial conjunctivitis should be treated with inexpensive nontoxic topical antibiotics such as erythromycin ophthalmic ointment or trimethoprim-polymyxin drops (table 1). The dose is 0.5 inch (1.25 cm) of ointment inside the lower lid or 1 to 2 drops four times daily for five to seven days. The dose may be reduced to twice daily if there is improvement in symptoms after a few days.
Ointment is preferred over drops for children, those with poor compliance, and those in whom it is difficult to administer eye medications. However, ointments blur vision for 20 minutes after the dose is administered.
Fluoroquinolones are the preferred agent in contact lens wearers; once keratitis has been ruled out, it is reasonable to treat these individuals with a fluoroquinolone due to the high incidence of pseudomonas infection.
●Patients with bacterial conjunctivitis should respond in one to two days with a decrease in discharge, redness, and irritation. Patients who do not respond should be referred to an ophthalmologist.
●There is no specific therapy for viral conjunctivitis, although patients may receive symptomatic benefit from topical antihistamine/decongestants or from lubricating agents like those used for noninfectious conjunctivitis (table 1).
●The management of allergic conjunctivitis is discussed separately.
●Patients with noninfectious conjunctivitis may feel better with topical lubricants that can be used as often as hourly (table 1).
●Primary care clinicians should not prescribe topical glucocorticoids for acute conjunctivitis.
●Although we do not recommend antibiotic therapy for nonbacterial conjunctivitis, if this is required for the patient to return to school or daycare, providers should select an inexpensive topical antibiotic such as erythromycinointment or trimethoprim-polymyxin B drops.
Bacterial conjunctivitis
The discharge of bacterial conjunctivitis is thick and globular; it may be yellow, white, or green.
Reproduced with permission from: Trobe, JD. The Eyes Have It: An interactive teaching and assessment program on vision care. WK Kellog Eye Center, University of Michigan. Copyright © Jonathan D Trobe, MD.
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Viral conjunctivitis
Viral conjunctivitis typically presents as injection, watery or mucoserous discharge, and a burning, sandy, or gritty feeling in one eye.
Reproduced with permission from: Trobe JD. The Eyes Have It: An interactive teaching and assessment program on vision care. WK Kellog Eye Center, University of Michigan. Copyright © Jonathan D Trobe, MD.
Graphic 56481 Version 3.0
Allergic conjunctivitis
Allergic conjunctivitis typically presents as bilateral redness, watery discharge, and itching.
Reproduced with permission from: Trobe, JD. The Eyes Have It: An interactive teaching and assessment program on vision care. WK Kellog Eye Center, University of Michigan. Copyright © Jonathan D Trobe, MD.
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Blepharitis
Lids demonstrate findings of blepharitis: diffuse eyelid margin thickening and hyperemia with lash crusts.
Reproduced with permission from: Trobe, JD. The Eyes Have It: An interactive teaching and assessment program on vision care. WK Kellogg Eye Center, University of Michigan. Copyright © Jonathan D Trobe, MD.
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Effect of antibiotics on cure
This figure shows the rates of cure in children with acute infectious conjunctivitis treated with chloramphenicol eye drops or placebo drops. Data are reported on intention-to-treat analysis and children lost to follow-up are included in the denominator in calculating percentages. Children clinically cured after 7 days were censored from the study. With exclusion of children lost to follow-up, the cumulative cure rate at 7 days was 86 percent in the chloramphenicol group and 83 percent in the placebo group. Day zero is the day of recruitment.
Reproduced with permission from: Rose, P, Harnden, A, Brueggemann, A, et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomized double-blind placebo-controlled trial. Lancet 2005; 366:41. Copyright © Elsevier.
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Therapy of conjunctivitis
| Dose | |
| Empiric approach | |
| Erythromycin 5 mg/gram ophthalmic ointment | One-half inch (1.25 cm) four times daily for 5 to 7 days |
| OR | |
| Trimethoprim-polymyxin B 0.1%-10,000 units/mL ophthalmic drops | 1 to 2 drops four times daily for 5 to 7 days |
| OR | |
| Ofloxacin 0.3% ophthalmic drops (preferred agent in contact lens wearer) | 1 to 2 drops four times daily for 5 to 7 days |
| OR | |
| Ciprofloxacin 0.3% ophthalmic drops (preferred agent in contact lens wearer) | 1 to 2 drops four times daily for 5 to 7 days |
| Specific approach | |
| Bacterial conjunctivitis | |
| Erythromycin 5 mg/gram ophthalmic ointment | One-half inch (1.25 cm) four times daily for 5 to 7 days |
| OR | |
| Trimethoprim-polymyxin B 0.1%-10,000 units/mL ophthalmic drops | 1 to 2 drops four times daily for 5 to 7 days |
| OR | |
| Bacitracin-polymyxin B 500 units-10,000 units/gram ophthalmic ointment | One-half inch (1.25 cm) four to six times daily for 5 to 7 days |
| OR | |
| Bacitracin 500 units/gram ophthalmic ointment | One-half inch (1.25 cm) four to six times daily for 5 to 7 days |
| OR | |
| Ofloxacin 0.3% (preferred agent in contact lens wearers) | 1 to 2 drops four times daily for 5 to 7 days |
| OR | |
| Ciprofloxacin 0.3% ophthalmic drops (preferred agent in contact lens wearer) | 1 to 2 drops four times daily for 5 to 7 days |
| OR | |
| Azithromycin 1% ophthalmic drops | 1 drop twice a day for 2 days; then 1 drop daily for 5 days |
| Viral conjunctivitis | |
| Antihistamine/decongestant drops (OTC) | 1 to 2 drops four times daily as needed for no more than three weeks |
| Allergic conjunctivitis | |
| Antihistamine/decongestant drops (OTC) | 1 to 2 drops four times daily as needed for no more than three weeks |
| Mast cell stabilizer/antihistamine drops | Generally, 1 to 2 drops one to three times daily (regimens vary by medication) |
| Non-specific conjunctivitis | |
| Eye lubricant drops (OTC) | 1 to 2 drops every 1 to 6 hours as needed |
| AND/OR | |
| Eye lubricant ointment (OTC) | One-half inch (1.25 cm) at bedtime or four times daily as needed |
OTC: over-the-counter (available without a prescription in the United States).
Courtesy of Deborah S. Jacobs, MD with additional data from: The Wills Eye Manual, Chapter 5, "Conjunctiva/Sclera/Iris/External Disease," 4th ed, Kunimoto DY, Kanitkar KD, and Makar MS, eds, Philadelphia, PA: Lippincott Williams & Wilkins, 2004.
Chlamydia trachomatis infections in the newborn
Infants who are born vaginally to mothers with untreated genital Chlamydia trachomatis (C. trachomatis) infection are at risk for developing C. trachomatis conjunctivitis (15 to 50 percent) and/or pneumonia (5 to 20 percent).
●The most common clinical manifestation of neonatal C. trachomatis infection is conjunctivitis, which usually presents between 5 and 14 days of life. Symptoms range from mild swelling with a watery eye discharge, which becomes mucopurulent, to marked swelling of the eyelids with red and thickened conjunctivae (chemosis). Untreated infants may have persistent conjunctivitis for months that may result in corneal and conjunctival scarring.
●Neonatal C. trachomatis pneumonia presents between 4 and 12 weeks of age, although most infants are symptomatic before eight weeks. Patients are usually afebrile or have minimal fever with a staccato cough. Many infants also have conjunctivitis. Apnea may be seen in infected preterm infants.
●The "gold standard" for diagnosis of neonatal C. trachomatis is culture. Nucleic acid amplification tests are non-culture diagnostic tools with a high sensitivity and specificity compared with culture. However, there are insufficient data for these tests to replace culture as a primary means of diagnosis in newborns.
●Initial treatment for chlamydial conjunctivitis should be based upon a positive diagnostic test. By contrast, initial therapy for chlamydial pneumonia should be initiated on a presumptive diagnosis, based upon clinical and radiographic findings, until diagnostic tests results are available.
●There have been few studies examining the optimal treatment for C. trachomatis in the newborn; the greatest amount of clinical experience is with macrolides, in particular erythromycin. The American Academy of Pediatrics (AAP) Committee on Infectious Disease and the Centers for Disease Control (CDC) recommend erythromycin for either chlamydial conjunctivitis or pneumonia. A typical dose of erythromycin is 50 mg/kg per day given orally in four divided doses for 14 days. Azithromycin (20 mg/kg given orally once daily for a three-day course) may be used as an alternative to erythromycin.
•We recommend a course of oral rather than topical erythromycin for treatment of neonatal C. trachomatis conjunctivitis (Grade 1B). Topical therapy is ineffective and not necessary if a patient is treated systemically.
•We suggest a course of oral erythromycin for pneumonia (Grade 2C).
●A systematic program that identifies and treats all pregnant women with genital C. trachomatis infection is the most effective way to prevent perinatal chlamydial infection.
●The currently recommended topical therapies for prevention of neonatal gonococcal conjunctivitis are not effective for preventing chlamydial conjunctivitis. Because of the relatively low risk of clinically significant disease in infants born to mothers with active chlamydial infection, and the potential risk of pyloric stenosis with erythromycin therapy, we do NOT recommend administering oral prophylactic antibiotics to asymptomatic infants exposed to maternal C. trachomatis (Grade 1C).
Neonatal chlamydia conjunctivitis
Twelve-day-old with five-day history of progressive lid swelling and discharge typical of chlamydial conjunctivitis.
Reproduced with permission from: Tasman W, Jaeger E. The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd Edition. Lippincott Williams & Wilkins, 2001. Copyright © 2001 Lippincott Williams & Wilkins.
Gonococcal infection in the newborn
Newborns acquire gonococcal infection during delivery. The perinatal transmission rate is about 30 to 40 percent in women with cervical infection.
●In the newborn, the eye is the most frequent site of gonococcal infection and is typically characterized by a purulent conjunctivitis with profuse exudate and swelling of the eyelids. Without treatment, the infection can extend from the superficial epithelial layers into the subconjunctival connective tissue and the cornea, leading to ulceration, scarring, and visual impairment. The diagnosis is confirmed by culture of the exudate.
●Empirical antibiotic therapy of a single dose of ceftriaxone (25 to 50 mg/kg, not to exceed 125 mg, intravenously or intramuscularly) is administered in any infant with suspected gonococcal ophthalmia neonatorum. Infants with confirmed gonococcal disease should also be evaluated for coinfection with Chlamydia trachomatis.
●The incidence of gonococcal ophthalmia neonatorum has decreased with the use of routine antibiotic prophylaxis and maternal screening for sexually transmitted disease.
●Other localized gonococcal infections include infections of other mucosal surfaces, which are treated with a single dose of ceftriaxone (25 to 50 mg/kg, not to exceed 125 mg, administered intravenously or intramuscularly) or cefotaxime (100 mg/kg, administered intravenously or intramuscularly).
●In newborns, systemic gonococcal infection (eg, septic arthritis, sepsis, and/or meningitis) is rare and is usually a complication of localized infection. Infants with arthritis, septicemia, and/or scalp abscess should be treated for seven days with ceftriaxone (50 mg/kg per dose every 24 hours, intravenously or intramuscularly) or cefotaxime (50 mg/kg per dose every 12 hours, intravenously or intramuscularly). Cefotaxime is recommended for infants with hyperbilirubinemia and those receiving calcium-containing intravenous fluids. In patients with meningitis, the duration of therapy is extended to a minimum of 10 days.
Gonococcal ophthalmia neonatorum
Reproduced from: The Public Health Image Library, Centers for Disease Control and Prevention. Photo by Dr. J Pledger.
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