Infectious Conjunctivitis

Infectious conjunctivitis is one of the most common causes of red eye. Infectious conjunctivitis is commonly caused
by bacterial or viral infection.

I. Pathophysiology
A. The clinical term "red eye" is applied to a variety of distinct infectious or inflammatory diseases of the eye.
Conjunctivitis is the most common cause of red eye. Conjunctivitis consists of inflammation of the conjunctiva,
which is caused by a broad group of conditions. The inflammation can be infectious or noninfectious in origin.
B. Most frequently, conjunctivitis is caused by a bacterial or viral infection. Sexually transmitted diseases such as
chlamydial infection and gonorrhea are less common causes of conjunctivitis. Ocular allergy is a major cause
of chronic conjunctivitis.

Differential Diagnosis of a Red Eye

Conjunctivitis Keratitis
Infectious Infectious. Bacterial, viral, fungal
Viral
Noninfectious. Recurrent epithelial erosion, foreign body
Bacterial (eg, staphylococcus, Chlamydia)
Uveitis
Noninfectious
Episcleritis/scleritis
Allergic conjunctivitis
Acute glaucoma
Dry eye
Eyelid abnormalities
Toxic or chemical reaction
Orbital disorders
Contact lens use
Preseptal and orbital cellulitis
Foreign body
Idiopathic orbital inflammation (pseudotumor)
Factitious conjunctivitis

II. Clinical Evaluation of Conjunctivitis

A. An ocular, medical and medication history should establish whether the condition is acute, subacute, chronic or
recurrent, whether it is unilateral or bilateral.
B. Discharge
1. A serous discharge (watery) is most commonly associated with viral or allergic ocular conditions.
2. A mucoid (stringy or ropy) discharge is highly characteristic of allergy or dry eyes.
3. A mucopurulent or purulent discharge, often associated with morning crusting and difficulty opening the
eyelids, strongly suggests a bacterial infection. The possibility of Neisseria gonorrhoeae infection should be
considered when the discharge is copiously purulent.
C. Itching is highly suggestive of allergic conjunctivitis. In general, a red eye in the absence of itching is not caused
by ocular allergy. A history of recurrent itching or a personal or family history of hay fever, allergic rhinitis,
asthma or atopic dermatitis is also consistent with an ocular allergy.
D. Unilateral or Bilateral Conjunctivitis
1. Allergic conjunctivitis is almost always secondary to environmental allergens and, therefore, usually presents
with bilateral symptoms. Infections caused by viruses and bacteria are transmissible by eye-hand contact.
Often, these infections initially present in one eye, with the second eye becoming involved a few days later.
2. Pain, Photophobia and Blurred Vision
a. Pain and photophobia do not usually occur with conjunctivitis, and these findings suggest an ocular or
orbital disease processes, including uveitis, keratitis, acute glaucoma and orbital cellulitis.

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b. Blurred vision that fails to clear with a blink is not characteristic of conjunctivitis. This finding is indicative
of corneal or intraocular pathology.
E. Recent contact with an individual with an upper respiratory tract infection suggests adenoviral
conjunctivitis. Chlamydial or gonococcal infection may be suggested by the patient's sexual history, including
a history of urethral discharge. Use of topical medications (eg, vasoconstrictors or artificial tears), unusual
cosmetics and contact lenses should be sought because they may cause conjunctivitis.
III. Examination of the Eye
A. Visual acuity should be tested before the examination. Regional lymphadenopathy should be sought and the face
and eyelids should be examined. Viral or chlamydial inclusion conjunctivitis typically presents with a small,
tender, preauricular or submandibular lymph node. Palpable adenopathy is rare in acute bacterial conjunctivitis.
B. Herpes labialis or a dermatomal vesicular eruption is suggestive of shingles, indicative of a herpetic
conjunctivitis.
C. Purulent discharge suggests a bacterial infection, especially if the conjunctival injection is severe. Stringy mucoid
discharge suggests allergy. Clear watery discharge can be associated with a viral infection, particularly if
preauricular adenopathy is present.

Discharge Associated with Conjunctivitis

Etiology Serous Mucoid Mucopurulent Purulent

Viral + - - -
Chlamydial - + + -
Bacterial - - + +
Allergic + + - -

IV. Laboratory Studies

A. Cultures and Gram stain usually are not required in patients with mild conjunctivitis of suspected viral, bacterial
or allergic origin. However, bacterial cultures should be obtained in patients who have severe inflammation or
chronic or recurrent conjunctivitis. Cultures also should be obtained in patients who do not respond to treatment.
V. Treatment of Bacterial Conjunctivitis
A. Acute bacterial conjunctivitis typically presents with burning, irritation, tearing and, usually, a mucopurulent or
purulent discharge. Patients often report that their eyelids are matted together on awakening.
B. The three most common pathogens in bacterial conjunctivitis are Streptococcus pneumoniae, Haemophilus
influenzae and Staphylococcus aureus. Infections with S. pneumoniae and H. influenzae are more common in
children, while S. aureus most frequently affects adults.
C. Topical broad-spectrum antibiotics such as erythromycin ointment and bacitracin-polymyxin B ointment (eg,
Polysporin ophthalmic ointment), as well as combination solutions such as trimethoprim-polymyxin B (eg,
Polytrim), are well tolerated, and they provide excellent coverage for most conjunctival pathogens. Ointments
are better tolerated by young children. Solutions are preferred by most adolescents and adults.
1. Erythromycin ointment, apply to affected eye(s) q3-4h
2. Bacitracin-polymyxin B ointment (Polysporin), ointment or solution, apply to affected eye(s) q3-4h

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3. Trimethoprim-polymyxin B (Polytrim), ointment or solution, apply to affected eye(s) q3-4h

D. Conjunctivitis due to H. influenzae, N. gonorrhoeae, and N. meningitidis requires systemic antibiotic therapy in
addition to topical treatment. In patients with gonococcal conjunctivitis. If the cornea is not affected, gonococcal
conjunctivitis may be treated with ceftriaxone (Rocephin) 1 g IM and topical erythromycin or bacitracin.
E. Chlamydial conjunctivitis can occur as a result of contact with infected genital secretions. It can be present in
newborns, in sexually active teenagers and in adults. Diagnosis is by antibody staining of ocular samples.
Symptoms often include a mucopurulent discharge, moderate eyelid edema and injection. Treatment includes
oral tetracycline, doxycycline (Vibramycin) or erythromycin for two weeks.
F. Contact lenses should be discontinued until symptoms and signs have completely resolved. All ocular solutions
should be discarded and lenses disinfected. The lenses or lens solution may be cultured.
VI. Viral Conjunctivitis
A. Adenovirus is the most common cause of viral conjunctivitis. Viral conjunctivitis often occurs in epidemics, with
the virus transmitted in schools, workplaces and physicians' offices by contaminated fingers, medical instruments
and swimming pool water.
B. Viral conjunctivitis typically presents with an acutely red eye, watery discharge, conjunctival swelling, a tender
preauricular node, and, in some cases, photophobia and a foreign-body sensation. Some patients have an
associated upper respiratory tract infection.
C. Treatment consists of cold compresses and topical vasoconstrictors. Patients should avoid direct contact with
other persons for at least one week after the onset of symptoms.
D. Ocular herpes simplex and herpes zoster is managed with topical agents, including trifluridine (Viroptic) and
systemic antiviral agents, including acyclovir (Zovirax), famciclovir (Famvir) and valacyclovir (Valtrex). §

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