Conjunctivitis

Michael A Silverman, MD, Instructor of Emergency Medicine, The Johns Hopkins University School of Medicine; Chairman,
Department of Emergency Medicine, Harbor Hospital
Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant
Professor, Department of Emergency Medicine, Johns Hopkins University
Updated: Apr 27, 2010
Introduction
Background
Conjunctivitis is one of the most common nontraumatic eye complaints resulting in presentation to the ED. The term describes any
inflammatory process that involves the conjunctiva; however, to most patients, conjunctivitis (often called pink eye) is a diagnosis in
its own right. Most causes of conjunctivitis are benign, and the role of the emergency physician is to separate those few conditions
requiring more vigorous treatment from the majority that can be handled satisfactorily in the ED.

Cellular infiltration and exudation characterize conjunctivitis on a cellular level. Classification usually is based on cause, including
viral, bacterial, fungal, parasitic, toxic, chlamydial, chemical, and allergic agents. It also can be based on age of occurrence or
course of disease. Etiology often can be distinguished on clinical grounds. In keratoconjunctivitis, an associated corneal
involvement is present.
Pathophysiology
The conjunctiva is a loose connective tissue that covers the surface of the eyeball (bulbar conjunctiva) and reflects back upon itself
to form the inner layer of the eyelid (palpebral conjunctiva). The conjunctiva firmly adheres to the sclera at the limbus, where it
meets the cornea. The accessory lacrimal glands (Krause and Wolfring), along with goblet cells, are contained within the
conjunctiva and are responsible for keeping the eye lubricated. As with any mucous membrane, infectious agents may adhere to
the conjunctiva, thus overwhelming normal defense mechanisms and producing clinical symptoms of redness, discharge, irritation,
and possibly photophobia. Viral etiologies are more common than bacterial, and incidence of viral conjunctivitis increases in the
late fall and early spring.
Frequency
United States
Conjunctivitis is considered extremely common in the United States. Three percent of all ED visits are ocular related, and
conjunctivitis is responsible for approximately 30% of all eye complaints. Approximately 15% of the population will have an allergic
conjunctivitis episode at some time.
International
Conjunctivitis is extremely common.
Mortality/Morbidity
Conjunctivitis typically is a self-limited process; however, depending on the immune status of the patient and the etiology,
conjunctivitis can progress to increasingly severe and sight-threatening infections.
 Purulent bacterial conjunctivitis in the neonate usually is caused by Neisseria gonorrhoeae. This type of conjunctivitis can
be invasive and can lead to rapid corneal perforation.
 Chlamydial conjunctivitis can lead to conjunctival scarring (cicatrix) that can be severe enough to cause lid derangement
and ingrown eyelashes.
 Trachoma is a more chronic, insidious form of Chlamydia trachomatis infection. The condition affects 500 million people
worldwide and is considered the leading cause of blindness in the world, blinding approximately 10% of those affected.
 Chlamydial pneumonia can occur in infants up to 6 months after their conjunctivitis.
 Three major agents associated with follicular conjunctivitis, preauricular adenopathy, and superficial keratitis are
adenovirus, chlamydia, and herpes simplex. Neisserial species can be associated with adenopathy, but the keratitis is
ulcerative and not superficial. Frequently, a history of viral syndrome, sexually transmitted disease (STD), or fever blister
can be elicited, which can aid in diagnosing the condition. Adenovirus is extremely contagious. Advise individuals to be
diligent with hand washing and to avoid contact with their tears. Sharing pillows, towels, computer keyboards, and
anything in contact with infected secretion helps spread the infection, a major cause of missed work hours.
Race
No racial predilection exists.
Sex
No sex predilection exists, although 90% of women with chlamydial eye infections have associated genital infections, and as many
as 60% of men have associated genitourinary symptoms.
Age
Conjunctivitis occurs in all ages.
 Conjunctivitis of the newborn is the term used by the World Health Organization (WHO) for any conjunctivitis with
discharge occurring during the first 28 days of life. Ophthalmia neonatorum was the term used to describe a hyperacute
purulent conjunctivitis, usually caused by gonococci, in the first 10 days of life. In this instance, transmission is vertical.
 Any individual with follicular conjunctivitis or preauricular adenopathy with or without keratitis should be questioned about
the possibility of STD; high-risk individuals should be treated empirically for chlamydia.
Clinical
History
In classic presentations, patients complain of eyelids sticking together on waking. They may describe itching and burning or a gritty
foreign-body sensation. Pus sliding across the eye may distort vision, though visual acuity is normal. Photophobia is minimal.
Family members with similar complaints typically present with conjunctivitis from an infectious cause. A history of a recent upper
respiratory infection (URI) typically is associated with a viral cause.
 Bacterial conjunctivitis is characterized by acute onset, minimal pain, occasional pruritus, and, sometimes, exposure
history.
o Ocular surface disease (eg, keratitis sicca, trichiasis, chronic blepharitis) predisposes the patient to bacterial
conjunctivitis.
o Staphylococcal and streptococcal species are the most common pathogens.
 Viral conjunctivitis is characterized by acute or subacute onset, minimal pain level, and, often, exposure history.
o Pruritus is common. A clear, watery discharge is typical.
o Occasionally, severe photophobia and foreign-body sensation occurs, usually caused by adenovirus (epidemic
keratoconjunctivitis [EKC]), when associated with keratitis.
o Check for preauricular adenopathy and a follicular conjunctival change, particularly on the palpebral conjunctiva.
If present, the likely diagnosis is EKC.
o Be aware that herpes simplex and chlamydia also cause follicular conjunctivitis and preauricular adenopathy.
 Chlamydial conjunctivitis is characterized by chronic onset, minimal pain level, occasional pruritus, and STD history.
 Allergic conjunctivitis is characterized by acute or subacute onset, no pain, and no exposure history.
o Pruritus is extremely common. Clear, watery discharge is typical with or without a moderate amount of mucous
production.
o An aggressive form of allergic conjunctivitis is vernal conjunctivitis in children and atopic conjunctivitis in adults.
Vernal disease often is associated with shield corneal ulcers. Perilimbal accumulation of eosinophils (Horner-
Trantas dots) typifies vernal disease. Vernal keratoconjunctivitis (VKC), usually affecting young boys, tends to be
bilateral and occurs in warm weather. VKC is presumed to be a hypersensitivity to exogenous antigens and may
be associated with or accompanied by keratoconus.
 Giant papillary conjunctivitis resembles vernal disease.
o This condition occurs mainly in contact lens wearers who develop a syndrome of excessive pruritus, mucous
production, and increasing intolerance to contact use.
o The giant papillae are predominantly on the upper palpebral conjunctiva and can be seen only on lid eversion.
Physical
On any patient with ocular complaints, perform a complete physical examination of the eye, including visual acuity, fluorescein
staining, slit-lamp examination, and tonometry.

In prospective observational cohort study of 368 patients, Meltzer et al sought to identify children at low risk for bacterial
conjunctivitis. The combination of 4 clinical factors, (1) age 6 years or older, (2) presentation in April through November, (3) no or
watery discharge, and (4)no glued eye in the morning, were found to be independently associated with a negative conjunctival
culture result. When 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture, and
when 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture result.[1 ]
Specific helpful clues in differentiating the causes of conjunctivitis are listed below.
 Bacterial conjunctivitis
o Preauricular adenopathy sometimes occurs; chemosis (thickened, boggy conjunctiva) is common.
o Discharge is copious; discharge quality is thick and purulent. Conjunctival injection is moderate or marked.
 Viral conjunctivitis
o Preauricular adenopathy is common in EKC and herpes; chemosis is variable.
o Discharge amount is moderate, stringy, or sparse; discharge quality is thin and seropurulent. Conjunctival
injection is moderate or marked.
 Chlamydial conjunctivitis tends to be chronic with exacerbation and remission.
o Preauricular adenopathy is occasional; chemosis is rare.
o Discharge amount is minimal; discharge quality is seropurulent. Conjunctival injection is moderate.
 Allergic conjunctivitis occurs with pruritus as the hallmark symptom.
o Preauricular adenopathy is absent; chemosis is common.
o Discharge amount is moderate, stringy, or sparse; discharge quality is clear. Conjunctival injection is moderate.
 Marginal ulcers (small white ulcers that appear on the cornea at the limbus) may indicate an allergic reaction to
staphylococcal antigen.
o This is a toxin-related complication of staphylococcal species that frequently cause blepharitis.
o Pain, photophobia, and a foreign-body sensation are common. The ulcers are sterile and respond to topical
steroids.
 Bilateral disease typically is infectious or allergic.
 Unilateral disease suggests toxic, chemical, mechanical, or lacrimal origin.
o Intraocular pressure, pupil size, and light response are all normal.
o Ciliary flush, corneal staining, and anterior chamber reaction is absent unless a significant amount of keratitis is
associated (as seen in EKC).
Causes
Several studies demonstrate that acute conjunctivitis occurs with almost equal frequency between bacterial and viral causes. Fitch
et al noted that viral conjunctivitis occurs more frequently in the summer, and bacterial conjunctivitis occurs more often in the winter
and spring.
 Mucopurulent conjunctivitis is caused by bacterial organisms.
o Gram-positive for the following cocci -Staphylococcus epidermidis, Streptococcus pyogenes, and Streptococcus
pneumoniae
o Gram-negative for the following cocci -Neisseria meningitidis and Moraxella lacunata
o Gram-negative for the following rods - genus Haemophilus and family Enterobacteriaceae
 Approximately one-third of children had an anaerobic bacterial etiology in studies that used adequate recovery
methods. Predominant anaerobic organisms include Clostridium species, gram-negative anaerobic bacilli,
and Peptostreptococcus species. 
 Hyperpurulent conjunctivitis usually is caused by N gonorrhoeae.
 N gonorrhoeae, C trachomatis, and other bacteria (mainly staphylococcal species and S pneumoniae) cause conjunctivitis
of the newborn. (Approximately 90% of infants receiving Credé prophylaxis [ie, silver nitrate application] for gonorrheal
ophthalmologic problems experience a mild, transient conjunctival injection and tearing with variable purulence that
typically resolves in 24-48 hours.)
 Many types of viruses, most commonly adenovirus, cause viral conjunctivitis.
 Atopic conjunctivitis typically occurs in male teenagers who have a history of childhood atopic dermatitis. The condition
resembles vernal conjunctivitis but is not seasonal.
 Vernal conjunctivitis is a bilateral recurrent hypersensitivity that occurs during the warm months of the year, particularly in
hot climates.
  Giant papillary conjunctivitis predominantly is associated with contact lens wear.
 Toxic conjunctivitis occurs with airborne irritants or a direct splash of liquid or powder to the eye.
 Unusual causes may be considered in patients with atypical presentations, including parasitic (eg, Loa loa, Trichinella,
Onchocerca), autoimmune (eg, sicca, pemphigoid), and systemic diseases (eg, sarcoidosis, tuberculosis, Reiter
syndrome, Kawasaki disease).
Differential Diagnoses
Corneal Abrasion
Glaucoma, Acute Angle-Closure
Herpes Zoster
Herpes Zoster Ophthalmicus
Iritis and Uveitis
Scleritis
Other Problems to Be Considered
Episcleritis, an inflammatory condition of the episclera, usually is sectorial and self-limiting. The eye is often tender and mildly
photophobic. Topical phenylephrine (Neo-Synephrine [2.5%]) can be used diagnostically; the conjunctival vessels blanch, but the
episcleral vessels remain engorged in episcleritis as opposed to conjunctivitis, in which most vessels blanch.
Workup
Laboratory Studies
 Conjunctivitis usually is diagnosed by history and physical examination. Lab tests typically are reserved for patients that
do not improve in 48-72 hours despite treatment. Lab studies include the following:
o Gram stain is considered the criterion standard for determining the bacterial cause of conjunctivitis. Simple
conjunctivitis does not require a Gram stain. Eosinophils seen on Gram stain are indicative of allergic
conjunctivitis but can be seen in parasitic causes.
o Culture and sensitivity of conjunctival scrapings typically are not performed for simple conjunctivitis. Obtain
cultures in all newborns, neonates, persons who are immunosuppressed, or when N gonorrhoeae is under
consideration as the etiology. When performed, collect exudate from the lower conjunctival fornix with a calcium
alginate swab moistened with saline. Sheep blood and mannitol agar plates routinely are used. Expect viral and
chlamydial causes in culture-negative conjunctivitis.
o Giemsa staining is performed to look for the inclusion bodies of Chlamydia versus a viral etiology in culture-
negative conjunctivitis. This technique has a low yield, except in neonatal inclusion conjunctivitis. The presence
of eosinophils is diagnostic of allergic conjunctivitis.
o Immunofluorescent antibody testing of the conjunctival discharge can be performed to detect the immunoglobulin
G (IgG) or immunoglobulin M (IgM) antibodies to Chlamydia. Consider chlamydial etiology when conjunctivitis
persists beyond 14 days and in all sexually active individuals. A high index of suspicion is necessary in patients
aged 15-50 years.
Treatment
Prehospital Care
Prehospital transport rarely is indicated for patients with conjunctivitis. More serious concerns may warrant emergency medical
services (EMS) transport. Prehospital personnel should not overlook more serious comorbidity; they should focus on preventing
transmission. Thorough hand washing by EMS personnel and glove use are necessary.
Treatment often is supportive. Artificial tears help the discomfort of keratitis and photophobia. Cold compresses improve the
swelling and discomfort of the lids. Antibiotic drops help prevent a secondary bacterial infection. Reserve topical corticosteroids for
use by an ophthalmologist when substantial inflammation is present and herpes simplex is excluded. Broad-spectrum antibiotics,
such as Ciloxan (ciprofloxacin) or Ocuflox (ofloxacin), are good choices. Sulfacetamide is also acceptable. Aminoglycoside is toxic
to epithelia and retards healing. Polytrim (trimethoprim/sulfamethoxazole) is a reasonable choice particularly in children.
Emergency Department Care
Physicians and other medical personnel must be careful not to transmit this infection. Prevention of transmission includes thorough
hand washing and using eye drops in individual or unit dose containers. Patients can be given moist compresses for comfort.

For treatment guidelines, see the American Academy of Ophthalmology's guidelines.[2 ]

Consultations
Consult with an ophthalmologist for all serious eye complaints. Simple conjunctivitis usually can be followed up by the patient's
primary care provider. Discuss with an ophthalmologist solutions to questions or equivocal diagnosis. Neisserial conjunctivitis is an
ocular emergency and should be viewed as an ocular finding of systemic disease. Ophthalmologic consultation is essential.
Medication
Treatment with antimicrobials and symptomatic therapy is recommended for all patients initially presenting to the ED with simple
conjunctivitis. Numerous topical antimicrobial agents may be used, including topical sulfacetamide, erythromycin, gentamicin,
ciprofloxacin, or ofloxacin. Avoid neomycin-containing solutions because 8-15% of patients have hypersensitivity reactions. Instill
drops every 2 hours. An ointment can be used at night or every 4-6 hours throughout the day.
Consider gonococcal conjunctivitis part of a systemic disease, thus requiring systemic treatment. Inpatient medical regimens
include cefoxitin, ceftriaxone, cefotaxime, or spectinomycin. Treat all patients who have chlamydia with tetracycline, doxycycline,
azithromycin, or erythromycin. Outpatient therapy is acceptable in less serious cases in which compliance can be ensured and
includes ceftriaxone (50 mg/kg, not to exceed 1 g) IV followed by doxycycline 100 mg twice a day or erythromycin 500 mg qid.
Identify and treat patients' sexual partners.
Chlamydial conjunctivitis can be treated with doxycycline 100 mg twice a day for 10 days or azithromycin 1 g. Erythromycin can be
used in pregnant patients and infants.
Topical therapy with erythromycin also is recommended and may speed resolution. As with gonococcal infections, identify and treat
patients' sexual partners.
Antibiotics, ophthalmic
Used for infectious conjunctivitis. Therapy must cover all likely pathogens in the context of the clinical setting. However, when
prescribing the antibiotic, the care provider must take into account that the incidence of MRSA has continued to increase in recent
years.

The FDA has approved a new drug, besifloxacin, for the treatment of bacterial conjunctivitis.[ 3 ]Clinical studies showed that patients
randomized to besifloxacin ophthalmic suspension 0.6% experienced significantly higher rates of clinical resolution and microbial
eradication than patients randomized to vehicle. Besifloxacin was found to be as effective and well tolerated as moxifloxacin
ophthalmic solution 0.5%.[ 4 ]In addition, a study by Comstock et al also showed besifloxacin ophthalmic suspension 0.6% to be safe
and effective for the treatment of bacterial conjunctivitis.[ 5 ]

Ciprofloxacin 3% (Ciloxan)
Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase in susceptible
organisms. Broad-spectrum antibiotic with good gram-positive and gram-negative coverage.
Dosing
Adult
1-2 gtt q2h in conjunctival sac(s) during waking hours for 2 d, then 1-2 gtt q4h during waking hours for the next 5 d
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
A white crystalline precipitate located in superficial portion of corneal defect may occur (onset in 1-7 d); precipitate usually is
cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become
systemic; superinfections may occur with prolonged or repeated antibiotic therapy

Gatifloxacin ophthalmic solution 0.3% (Zymar)

Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. Elicits a dual mechanism of action by
possessing an 8-methoxy group, thereby inhibiting the enzymes DNA-gyrase and topoisomerase IV. DNA gyrase is involved in
bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial
cell division.
Indicated for bacterial conjunctivitis due to C propinquum, S aureus, S epidermidis, S mitis, S pneumoniae, or H influenzae.
Dosing
Adult
Days 1-2: Instill 1 gtt into affected eye q2h while awake; not to exceed 8 administrations per day
Days 3-7: Instill 1 gtt into affected eye up to qid while awake
Pediatric
<1 year: Not established
>1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For ophthalmic use only; commonly causes conjunctival irritation, increased lacrimation, corneal inflammation, or papillary
conjunctivitis; less common adverse effects include conjunctival hemorrhage, dry eye, eye discharge, eye irritation, eye pain, eyelid
swelling, headache, red eye, reduced visual acuity, or taste disturbance

Norfloxacin ophthalmic (Noroxin, Chibroxin)

Inhibits bacterial growth by inhibiting DNA gyrase. Has limited use and is not readily available. Ciprofloxacin and ofloxacin are
superior in spectrum and effectiveness. Approved for pediatric use in children >1 y.
Dosing
Adult
1-2 gtt qid to affected eye for 7 d
Pediatric
<1 year: Not established
>1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in deep ocular infections likely to become systemic; prolonged use of antibiotics may result in bacterial or fungal
overgrowth of nonsusceptible organisms

Besifloxacin ophthalmic (Besivance)

Quinolone antimicrobial ophthalmic susp indicated for bacterial conjunctivitis. Susceptible bacteria include CDC coryneform group
G (Corynebacterium pseudodiphtheriticum, Corynebacterium stratum), Haemophilus influenza, Moraxella lacunata,
Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Streptococcus mitis,
Streptococcus oralis, Streptococcus pneumoniae,and Streptococcus salivarius. Available as a 0.6% ophthalmic susp.
Dosing
Adult
Instill 1 gtt in affected eye(s) tid (4-12 h between doses) for 7 d
Pediatric
<1 year: Not established
>1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In clinical trials, adverse effects occurred in <3% of patients and included redness of eyes, blurred vision, eye pain, eye irritation,
eye itching, and headache; do not use with contact lens (remove and do not wear contacts during course of therapy and with
symptoms of bacterial conjunctivitis); for topical ophthalmic use only; prolonged use may lead to bacterial resistance

Bacitracin ointment 500 U/g (AK-Tracin, Baciguent)

Prevents transfer of mucopeptides into the growing cell wall, which results in inhibition of cell wall synthesis and, as a result,
bacterial growth. Gram-positive better than gram-negative coverage.
Dosing
Adult
Severe infections: Apply 0.25- to 0.5-in ribbon q3-4h into conjunctival sac for 7-10 d
Mild-to-moderate infections: Apply bid/tid
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity; vaccinia; varicella, epithelial herpes simplex keratitis; mycobacterial infections; fungal diseases of the
eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Ophthalmic ointments may delay healing of corneal epithelia; in deep-seated infections of the eye, supplement with systemic
medications; prolonged use may result in overgrowth of nonsusceptible organisms

Erythromycin ophthalmic (Ilosone, E-Mycin)

Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival
infections. Good gram-positive coverage.
Dosing
Adult
Apply 0.5-in (1.25-cm) ribbon to affected eye 2-8 times/d, depending on severity of infection
Pediatric
Administer as in adults
Prophylaxis of neonatal gonorrhea and chlamydia: Apply 0.5- to 1.25-cm ribbon to each conjunctival sac
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; patients using steroid combinations after
uncomplicated removal of a corneal foreign body
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may
result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate
measures if superinfection occurs)

Azithromycin ophthalmic (Azasite)

Ophthalmic macrolide antibiotic. Indicated for bacterial conjunctivitis caused by CDC coryneform group G bacteria, Haemophilus
influenzae, Staphylococcus aureus, Streptococcus mitis group, and Streptococcus pneumoniae.
Dosing
Adult
Instill 1 gtt in affected eye(s) bid (administer doses 8-12 h apart) for 2 d, then 1 gtt qd for next 5 d
Pediatric
<1 year: Not established
>1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Thoroughly wash hands before using; for topical ophthalmic use only; prolonged use may result in resistant organisms; do not wear
contact lenses until infection resolves; may cause eye irritation; less common adverse effects include burning, stinging, and/or
irritation when instilled; other less common adverse effects include contact dermatitis, corneal erosion, dry eyes, dysgeusia, nasal
congestion, ocular discharge, punctate keratitis, and sinusitis

Gentamicin ophthalmic (Garamycin, Genoptic)

Aminoglycoside antibiotic (ointment or solution) used for gram-negative bacterial coverage. Tends to be toxic to epithelia and
retards healing.
Dosing
Adult
Solution: 1-2 gtt q4h to affected eye
Ointment: Apply 0.5-in (1.25-cm) ribbon bid/tid q3-4h to affected eye
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; patients using steroid combinations after
uncomplicated removal of a corneal foreign body
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or
fungal overgrowth of nonsusceptible organisms and may lead to a secondary infections

Tobramycin ophthalmic (Tobrex, AKTob)

Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell
membrane. Available as a solution, ointment, and lotion. Superior to gentamicin in that streptococcal species are often resistant to
gentamicin.
Dosing
Adult
Solution: 1-2 gtt q4h to affected eye during waking hours and less frequently at night; in severe infections, instill 2 gtt q30-60 min
initially, followed by less frequent intervals
Ointment: Apply 0.5-in ribbon bid/tid in conjunctival sac; in severe infections, apply q3-4h
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Interactions
Effects of this drug diminish when used concurrently with gentamicin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics may result in
bacterial or fungal overgrowth of nonsusceptible organisms

Sulfacetamide 10% (Bleph-10, Sodium Sulamyd)

Inhibits folic acid synthesis, which results in inhibition of bacterial growth. Has better gram-positive than gram-negative coverage.
Available as solution, ointment, and lotion.
Dosing
Adult
Solution: 1-3 gtt q2-3h in affected eye while awake, with less frequent administration at night
Ointment: Apply 0.5-in (1.25-cm) ribbon 1-4 times/d into conjunctival sac
Pediatric
<2 months: Not established
>2 months: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in severely dried eye; ointment may retard corneal epithelial healing; significant percentage of staphylococcal isolates are
completely resistant; may sting when applied; do not use in deep ocular infections likely to become systemic; prolonged use of
antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms
Decongestants
Generally have vasoconstricting effects with ability to control pruritus.

Naphazoline ophthalmic (Clear Eyes, AK-Con, Opcon)

OTC drug for temporary relief of pruritus and hyperemia associated with mild allergic conjunctivitis. Has alpha-adrenergic effects in
the arterioles of the conjunctiva and nasal mucosa to produce vasoconstriction.
Dosing
Adult
1-2 gtt q2h prn; not to exceed qid; do not administer for more than 3-5 d
Pediatric
<6 years: Not recommended
>6 years: Administer as in adults
Interactions
None reported with ophthalmic use; in systemic use, risk of hypertensive reactions increases when used concurrently with tricyclic
antidepressants or MAOIs; toxicity increases when used concurrently with anesthetics
Contraindications
Documented hypersensitivity; narrow-angle glaucoma; do not use before a peripheral iridectomy is performed
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may cause rebound congestion; caution in diabetes, hypertension, heart disease, cerebral arteriosclerosis,
hyperthyroidism, and asthma
Levocabastine (Livostin)
Most potent topical antihistamine available. Has rapid onset and sustained effect. Can be used as many as 4 times daily or prn.
Dosing
Adult
1 gtt qid to affected eye
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in patients wearing soft contact lenses; not for injection
Mast cell stabilizers
Inhibit degranulation of sensitized mast cells following exposure to specific antigens.

Cromolyn 4%, (Intal)

Long-term use by patients with seasonal allergies; not used for short-term treatment. Alomide is a far more potent mast cell
stabilizer. Patanol is a combination antihistamine and mast cell stabilizer and is used either bid/tid.
Dosing
Adult
1-2 gtt q4-6h to each eye; use at regular intervals
Pediatric
<4 years: Not established
>4 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use with soft contact lenses in place; may experience a transient stinging or burning sensation after application; caution
when withdrawing drug because symptoms may recur
Nonsteroidal anti-inflammatory agents (NSAIDs)
These agents are used for the treatment of allergic conjunctivitis. Although most NSAIDs are used primarily for anti-inflammatory
effects, they are effective analgesics and are useful for the relief of mild-to-moderate pruritus. Ketorolac 0.4% has also been shown
as effective in treating allergic conjunctivitis.[6 ]
Ketorolac 0.5%, (Acular, Toradol)
Approved for temporary relief of pruritus associated with allergic conjunctivitis. Inhibits prostaglandin synthesis by decreasing the
activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Dosing
Adult
1 gtt qid to affected eye
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity; patients wearing soft contact lenses
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted;
changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision,
and macular degeneration
Follow-up
Further Inpatient Care
 Patients with gonorrheal infections, neonates with infections, and patients who are immunocompromised should be
admitted for administration of IV antibiotics.
Further Outpatient Care
 Refer patients to their primary care provider for follow-up in 2-3 days to ensure they are responding to treatment. Viral
conjunctivitis usually is self-limited to 10-14 days, but symptoms may persist for as many as 6 weeks.
Inpatient & Outpatient Medications
 Prescribe one of the previously mentioned antibiotics for discharged patients. For copious ocular secretions, patients may
use frequent saline irrigation or artificial tears. Avoid eye patching.
Transfer
 Manage simple conjunctivitis in the ED. Transfer may be appropriate for patients with complications from chronic or
gonococcal conjunctivitis when an ophthalmologist is unavailable.
Deterrence/Prevention
 Careful and frequent hand washing is necessary to reduce transmission from one eye to the other in the patient and from
contacts.
Complications
 Pneumonia can occur in 10-20% of infants with chlamydial conjunctivitis as many as 6 months later. Untreated chlamydial
conjunctivitis in adults can lead to conjunctival scarring.
 Penetration of the cornea can occur within 2 days in patients with untreated N gonorrhoeae.
 Infections with N meningitidis may require systemic antibiotics to prevent meningitis.
Prognosis
 Prognosis is good. Conjunctivitis typically is self-limited and without long-term complications.
Patient Education
 Warm compresses and washing eyelids with diluted baby shampoo may speed resolution when blepharitis is an
associated factor. Patients should not use eye makeup. Frequent hand washing is essential to prevent further
transmission.
  For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient
education article Pinkeye.
Miscellaneous
Medicolegal Pitfalls
 Failure to recognize a gonococcal infection in someone with ocular and GU symptoms
 Failure to recognize herpes simplex conjunctivitis and keratitis and prescribing corticosteroids
 Failure to consider other causes in a patient with an acutely red eye (eg, iritis, uveitis, angle-closure glaucoma, ocular
ischemic syndrome, penetrating or perforating ocular injury)
Special Concerns
 During birth, risk of transmission of Gonococcus, Streptococcus, or Chlamydia to the fetus exists. Obtain cervical cultures
if indicated.
 Risk of chlamydial pneumonia exists. Any of the bacterial organisms that cause conjunctivitis, particularly in a premature
infant, can lead to sepsis and death. Neonates are at risk for secondary meningitis, cellulitis, and septicemia, particularly if
the conjunctivitis is caused by Escherichia coli, Staphylococcus aureus, or Haemophilus influenzae.

Conjunctivitis, Allergic
Parag A Majmudar, MD, Fellowship Co-Director, Department of Ophthalmology, Cornea and Refractive Surgery Service,
Assistant Professor, Rush-Presbyterian-St Luke's Medical Center
Updated: Aug 4, 2010
Introduction
Background
Immunologic reactions of conjunctiva and cornea
The ocular surface may exhibit a wide variety of immunologic responses that may result in conjunctival and corneal inflammation.
In the Gell and Coombs classification system for various immunologic hypersensitivity reactions, 5 classes of reactions are
recognized.
Type I (immediate) hypersensitivity reactions occur when a sensitized individual comes in contact with a specific antigen.
Immunoglobulin E (IgE) has a strong affinity for mast cells, and the cross-linking of 2 adjacent IgE molecules by the antigen
triggers mast cell degranulation. This, in turn, causes the release of various preformed and newly formed mediators of the
inflammatory cascade, including histamine, tryptase, chymase, heparin, chondroitin sulfate, prostaglandins, thromboxanes, and
leukotrienes. These various inflammatory mediators, together with various chemotactic factors, result in increased vascular
permeability and migration of eosinophils and neutrophils. The principal ocular type I hypersensitivity reaction is allergic
conjunctivitis, which is discussed in further detail in this article.
Type II hypersensitivity reactions are autoimmune reactions and may be complement mediated. These reactions may be the
underlying cause of various ocular conditions, such as cicatricial pemphigoid and Mooren ulcer.
Type III hypersensitivity reactions result in antigen-antibody immune complexes, which deposit in tissues and cause inflammation.
Classic type III reaction systemically is the Arthus reaction, and ocular type III hypersensitivity reactions include Stevens-Johnson
syndrome and marginal infiltrates of the cornea. Corneal immune (Wesley) rings are also an example of type III reactions.
Type IV hypersensitivity reactions, also known as cell-mediated immunity, are mediated by T lymphocytes. While type I reaction is
immediate hypersensitivity, this reaction is also known as delayed-type hypersensitivity, since its onset is generally after 48 hours.
Type IV hypersensitivity reactions imply immunocompetence on the part of the individual since an intact immune system is required
to mount the cell-mediated response. Ocular examples of type IV hypersensitivity include phlyctenular keratoconjunctivitis, corneal
allograft rejection, contact dermatitis, and drug allergies.
This section focuses primarily on the major type I hypersensitivity reactions involving the conjunctiva, more commonly referred to
as allergic conjunctivitis.
Types of allergic conjunctivitis
Allergic conjunctivitis may be divided into 5 major subcategories. Seasonal allergic conjunctivitis (SAC) and perennial allergic
conjunctivitis (PAC) are commonly grouped together. Vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and giant
papillary conjunctivitis (GPC) constitute the remaining subtypes of allergic conjunctivitis.
Pathophysiology
Seasonal and perennial allergic conjunctivitis
Since conjunctiva is a mucosal surface similar to the nasal mucosa, the same allergens that trigger allergic rhinitis may be involved
in the pathogenesis of allergic conjunctivitis. Common airborne antigens, including pollen, grass, and weeds, may provoke the
symptoms of acute allergic conjunctivitis, such as ocular itching, redness, burning, and tearing. The main distinction between SAC
and PAC, as implied by the name, is the timing of symptoms.
Individuals with SAC typically have symptoms of acute allergic conjunctivitis for a defined period of time, that is, in spring, when the
predominant airborne allergen is tree pollen; in summer, when the predominant allergen is grass pollen; or in fall, when the
predominant allergen is weed pollen. Typically, persons with SAC are symptom-free during the winter months in cooler climates
because of the decreased airborne transmission of these allergens.
In contrast, individuals with PAC may have symptoms that last the whole year; thus, PAC may not be caused exclusively by
seasonal allergens, although they may play a role. Other common household allergens, such as dust mite, cockroaches, and pet
dander, may be responsible for the symptoms of PAC.
Vernal keratoconjunctivitis
VKC is a chronic bilateral inflammation of the conjunctiva, commonly associated with a personal and/or family history of atopy.
More than 90% of patients with VKC exhibit one or more atopic conditions, such as asthma, eczema, or seasonal allergic rhinitis.
Atopic keratoconjunctivitis
AKC is a bilateral inflammation of conjunctiva and eyelids, which has a strong association with atopic dermatitis. It is also a type I
hypersensitivity disorder with many similarities to VKC, yet AKC is distinct in a number of ways.
In 1953, Hogan first described the association between atopic dermatitis and conjunctival inflammation.[1 ]He reported 5 cases of
conjunctival inflammation in male patients with atopic dermatitis.[1 ]Atopic dermatitis is a common hereditary disorder that usually
has its onset in childhood; symptoms may regress with advancing age. Approximately 3% of the population is afflicted with atopic
dermatitis, and, of these, approximately 25% have ocular involvement.
Giant papillary conjunctivitis
GPC is an immune-mediated inflammatory disorder of superior tarsal conjunctiva. As the name implies, the primary finding is the
presence of "giant" papillae, which are typically greater than 0.3 mm in diameter. It is believed that GPC represents an
immunologic reaction to a variety of foreign bodies, which may cause prolonged mechanical irritation to the superior tarsal
conjunctiva. Although contact lenses (hard and soft) are the most common irritant, ocular prostheses, extruded scleral buckles, and
exposed sutures following previous surgical intervention may precipitate GPC.
Frequency
United States
Allergic conjunctivitis occurs very frequently and is seen most commonly in areas with high seasonal allergens.
Mortality/Morbidity
Allergic conjunctivitis rarely causes any visual loss.
Race
VKC occurs predominantly in areas with tropical and temperate climates, such as the Mediterranean, the Middle East, and Africa.
The limbal form of VKC commonly occurs in dark-skinned individuals from Africa and India.
Sex
VKC has a significant male preponderance.
Age
VKC typically affects young males with onset generally in the first decade and with duration up to one decade. Its symptoms
usually peak prior to the onset of puberty and then subside.
Clinical
History
Seasonal and perennial allergic conjunctivitis 

Diagnosis of allergic conjunctivitis generally is made by taking a thorough history and by careful clinical observation.

Important features of history include a personal or family history of atopic disease, such as allergic rhinitis, bronchial asthma,
and/or atopic dermatitis. Perhaps the most important feature in the clinical history is the symptom of itching. Without itching, the
diagnosis of allergic conjunctivitis is suspect.
Vernal keratoconjunctivitis

As with other allergic or type I hypersensitivity disorders, itching is the most important and most common symptom.

Other commonly reported symptoms are photophobia, foreign body sensation, tearing, and blepharospasm.
Ocular signs of VKC commonly are seen in the cornea and conjunctiva. In contrast to AKC, the eyelid skin usually is not involved.
Atopic keratoconjunctivitis

In contrast to the symptoms of VKC, the symptoms in AKC are perennial. However, there may be seasonal variation with
worsening symptoms during winter months.
The single most common symptom is bilateral itching of the eyelids, but watery discharge, redness, photophobia, and pain may be
associated.
Giant papillary conjunctivitis

Primary symptoms in GPC are ocular itching with a mucoid or ropy discharge, very similar to that seen in VKC.

Another symptom may be a persistent foreign body sensation when using contact lenses, resulting in an inability to wear contact
lenses for the desired length of time.
Physical
Seasonal and perennial allergic conjunctivitis

Classic signs of allergic conjunctivitis include injection of conjunctival vessels as well as varying degrees of chemosis (conjunctival
edema) and eyelid edema.
The conjunctiva often has a milky appearance due to obscuration of superficial blood vessels by edema within the substantia
propria of the conjunctiva. Edema is generally believed to be the direct result of increased vascular permeability caused by release
of histamine from conjunctival mast cells.
Vernal keratoconjunctivitis

VKC may be subdivided into 2 varieties, as follows: palpebral and limbal. The classic conjunctival sign in palpebral VKC is the
presence of giant papillae. They most commonly occur on the superior tarsal conjunctiva; usually, the inferior tarsal conjunctiva is
unaffected. Giant papillae assume a flattop appearance, which often is described as "cobblestone papillae." In severe cases, large
papillae may cause mechanical ptosis.

A ropy mucous discharge may be present, which commonly is associated with tarsal papillae. Large numbers of eosinophils are
present in the discharge.
The limbal form of VKC commonly occurs in dark-skinned individuals, such as those from Africa or India. As the name implies,
papillae tend to occur at the limbus and have a thick gelatinous appearance. They commonly are associated with multiple white
spots (Horner-Trantas dots), which are collections of degenerated epithelial cells and eosinophils. Horner-Trantas dots are
transient, with each appearance rarely lasting more than 1 week.
While corneal vascularization is rare, the cornea may be affected in a variety of ways. Punctate epithelial keratopathy (PEK) may
be due to the toxic effect of inflammatory mediators released from the conjunctiva and may be a precursor of the characteristic
shield ulcer, which is pathognomonic of VKC. As the areas of PEK coalesce, they may result in frank epithelial erosion resulting in
shield ulcer, which is typically shallow with white irregular epithelial borders. Although the pathogenesis of shield ulcer is not well
understood, a major factor in promoting development may be chronic mechanical irritation from the giant tarsal papillae. Some
evidence suggests that the major basic protein released from eosinophils may promote ulceration.
Another type of corneal involvement is vernal pseudogerontoxon, which is a degenerative lesion in the peripheral cornea
resembling corneal arcus. Keratoconus may be seen in chronic cases, which may be associated with chronic eye rubbing.
Atopic keratoconjunctivitis

AKC may affect eyelid skin and lid margin, conjunctiva, cornea, and lens. Skin of the eyelids may exhibit eczematoid dermatitis
with dry, scaly, and inflamed skin. Lid margins may show meibomian gland dysfunction and keratinization. Staphylococcal
colonization of eyelid margins is very common and may result in blepharitis. Conjunctiva may show chemosis and typically a
papillary reaction, which is more prominent in the inferior tarsal conjunctiva, in contrast to that seen in vernal keratoconjunctivitis.

Hyperplasia of limbal regions may result in a gelatinous thickening, similar to the limbal variant of VKC, and Horner-Trantas dots
also may be present, although rarely. Fibrosis or scarring of the conjunctiva may result in a shortened fornix or symblepharon
formation with chronic inflammation. Corneal involvement ranges from punctate epithelial keratopathy early in the course of the
disease, to neovascularization, stromal scarring, and possibly ulceration. There is a strong association between herpes simplex
viral keratitis and AKC.
Another corneal finding, which may be associated with AKC, is keratoconus, which may stem from chronic eye rubbing.
Characteristic lenticular changes in AKC include anterior or posterior subcapsular cataract formation. Lens opacities are usually
bilateral and present in the second decade of life but progress very slowly. There may be an association with the long-term use of
topical corticosteroids. Note that there is an increased incidence of retinal detachment following surgical removal of cataracts in
patients with atopic dermatitis; the exact mechanism is unknown.
Table. Major Differentiating Factors Between VKC and AKC
Characteristics VKC AKC

Age at onset Generally presents at a younger age -

Sex Males are affected preferentially. No sex predilection

Seasonal variation Typically occurs during spring months Generally perennial

Discharge Thick mucoid discharge Watery and clear discharge

Conjunctival scarring - Higher incidence of conjunctival

scarring

Horner-Trantas dots Horner-Trantas dots and shield ulcers are commonly Presence of Horner-Trantas dots is
seen. rare.

Corneal neovascularization Not present Tends to develop deep corneal

neovascularization

Presence of eosinophils in Conjunctival scraping reveals eosinophils to a greater Presence of eosinophils is less likely.
conjunctival scraping degree in VKC than in AKC.
Giant papillary conjunctivitis

Examination of superior tarsal conjunctiva reveals the presence of large cobblestone papillae, which are generally 0.3 mm or
greater in diameter and, in severe cases, may cause mechanical ptosis of the upper lid.

In his original description of GPC in 1977, Allansmith described 3 zones of superior tarsal conjunctiva.[2 ]Zone 1 is located closest to
the fornix and is the most inferior portion of the tarsal conjunctiva seen when the upper eyelid is everted. Zone 3 is located closest
to the eyelid margin. Zone 2 is located between zone 1 and zone 3.

Papillae typically associated with soft contact lens–related GPC initially appear in zone 1 and progress toward zone 3, while those
associated with rigid gas permeable contact lenses exhibit a reverse pattern, with zone 3 affected first. GPC associated with a
localized irritant, such as an exposed suture or a filtering bleb, is typically localized to the area overlying these inciting lesions.
Another clinical sign of GPC may be chronic bulbar conjunctival injection and inflammation due to prolonged and persistent use of
contact lenses.
Causes
See Pathophysiology.
Differential Diagnoses
Conjunctivitis, Bacterial
Conjunctivitis, Giant Papillary
Conjunctivitis, Viral
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Superior Limbic
Keratoconus
Workup
Laboratory Studies
Seasonal and perennial allergic conjunctivitis 

Superficial conjunctival scrapings may help to establish the diagnosis by revealing eosinophils, but only in the most severe cases,
since eosinophils are typically present in the deeper layers of the substantia propria of the conjunctiva. Therefore, the absence of
eosinophils on conjunctival scraping does not rule out the diagnosis of allergic conjunctivitis.

Many investigators have described measurement of tear levels of various inflammatory mediators, such as IgE, histamine, and
tryptase, as indicators of allergic activity.
Additionally, skin testing by an allergist may provide definitive diagnosis and pinpoint the offending allergen(s).
Vernal keratoconjunctivitis
 
Conjunctival scrapings of the superior tarsal conjunctiva and of Horner-Trantas dots show an abundance of eosinophils.
Histologic Findings
Vernal keratoconjunctivitis
Conjunctival scrapings of the superior tarsal conjunctiva show an abundance of eosinophils. Conjunctival biopsy reveals that there
are a large number of mast cells within the substantia propria. Histochemical analysis of mast cells present in VKC reveals neutral
proteases tryptase and chymase. There is enhanced fibroblast proliferation, which leads to deposition of collagen within the
substantia propria resulting in conjunctival thickening.
B-cell and T-cell lymphocytes are present locally, which combine to produce IgE. Specific IgE and IgG as well as the inflammatory
mediators histamine and tryptase have been isolated from tears of patients with VKC. Although VKC is typically recognized as a
type I hypersensitivity reaction, evidence has been found that supports some involvement of type IV hypersensitivity reaction.
Atopic keratoconjunctivitis
Conjunctival scrapings of patients with AKC may demonstrate the presence of eosinophils, although the number is not as
significant as that seen in VKC. Additionally, free eosinophilic granules, which are seen in VKC, are not seen in AKC. Mast cells
also may be found within the substantia propria of the conjunctiva in greater numbers.
There is an increased amount of IgE in the tears of patients with AKC. Although AKC is typically recognized as a type I
hypersensitivity reaction, evidence has been found that supports some involvement of type IV hypersensitivity reaction, as is the
case in VKC.
Giant papillary conjunctivitis
Histologic findings in GPC consist of cellular infiltration of the conjunctiva by a number of cell types. Plasma cells, lymphocytes,
mast cells, eosinophils, and basophils have been identified within the substantia propria. Mast cells also may be found in the
epithelium.
Tear levels of immunoglobulin, especially IgE and tryptase also are elevated, as in AKC and VKC, indicating that a combination of
type I and type IV hypersensitivity reactions may be responsible for the pathogenesis of GPC. It is believed that the stimulus for
development of GPC is an immunologic reaction to a specific antigen in predisposed individuals. Mechanical trauma to the
conjunctiva may be a contributing factor.
Treatment
Medical Care
Seasonal and perennial allergic conjunctivitis

Pharmacologic intervention may help alleviate the symptoms of acute allergic conjunctivitis. Various classes of medication may be
effective against the symptoms of acute allergic conjunctivitis; each is directed at a specific point in the inflammatory and allergic
cascade.

Artificial tear substitutes provide a barrier function and help to improve the first-line defense at the level of conjunctival mucosa.
These agents help to dilute various allergens and inflammatory mediators that may be present on the ocular surface, and they help
flush the ocular surface of these agents.

Systemic and/or topical antihistamines may be given to relieve acute symptoms due to interaction of histamine at ocular H1 and H2
receptors. While systemic antihistamines often relieve ocular allergic symptoms, patients may experience systemic adverse affects,
such as drowsiness and dry mouth.
Topical antihistamines competitively and reversibly block histamine receptors and relieve itching and redness but only for a short
time. These medications do not affect other proinflammatory mediators, such as prostaglandins and leukotrienes, which remain
uninhibited. A number of topical antihistamines are available, including epinastine (Elestat) and azelastine (Optivar). Both are
potent antihistamines that have a rapid onset and are effective in relieving the signs and symptoms of allergic conjunctivitis.
Vasoconstrictors are available either alone or in conjunction with antihistamines to provide short-term relief of vascular injection
and redness. Common vasoconstrictors include naphazoline, phenylephrine, oxymetazoline, and tetrahydrozoline. Generally, the
common problem with vasoconstrictors is that they may cause rebound conjunctival injection and inflammation. These
pharmacologic agents are ineffective against severe ocular allergies and against other more severe forms of allergic conjunctivitis,
such as atopic and vernal disease.
Mast cell stabilizers have a mechanism of action that is unclear. They may aid in the phosphorylation of a 78,000-d protein that
terminates secretion of mast cell granules; they may increase calcium influx into the cell preventing membrane changes; and/or
they may reduce membrane fluidity prior to mast cell degranulation. End result is a decrease in degranulation of mast cells, which
prevents release of histamine and other chemotactic factors that are present in the preformed and newly formed state. Note that
mast cell stabilizers do not relieve existing symptoms and are to be used on a prophylactic basis to prevent mast cell degranulation
with subsequent exposure to the allergen. Therefore, they need to be used long term in conjunction with various other classes of
medications. Common mast cell stabilizers include cromolyn sodium and lodoxamide (Alomide). Olopatadine (Patanol), nedocromil
(Alocril), and ketotifen (Zaditor) are mast cell stabilizers and inhibit histamine release.
Nonsteroidal anti-inflammatory drugs (NSAIDs) act on the cyclooxygenase metabolic pathway and inhibit production of
prostaglandins and thromboxanes. They have no role in blocking mediators formed by the lipoxygenase pathway, such as
leukotrienes. Common NSAIDs that are approved for allergic indications include ketorolac tromethamine (Acular).
Corticosteroids remain one of the most potent pharmacologic agents used in the treatment of ocular allergy. They act at the first
step of the arachidonic acid pathway by inhibiting phospholipase, which is responsible for converting membrane phospholipid into
arachidonic acid. By preventing the formation of arachidonic acid, corticosteroids effectively block both cyclooxygenase and
lipoxygenase pathways, in contrast to NSAIDs, which act only on the cyclooxygenase pathway. Corticosteroids do have limitations,
including ocular adverse effects, such as delayed wound healing, secondary infection, elevated intraocular pressure, and formation
of cataract. In addition, the anti-inflammatory and immunosuppressive affects are nonspecific.
Corticosteroids exist in various forms and potencies. Relatively weak steroids, such as rimexolone, medrysone, and
fluorometholone, tend to have less potency with fewer ocular adverse effects. In contrast, agents, such as prednisolone acetate,
are more potent and have a higher incidence of adverse effects. Loteprednol etabonate (Lotemax 0.05% and Alrex 0.02%), a
steroid, is rapidly metabolized once it enters the anterior chamber of the eye. Therefore, it is extremely useful in treating ocular
surface and superficial corneal inflammations. Alrex has a specific indication for ocular allergy and has been shown in clinical
studies to have fewer ocular adverse effects. However, a general rule-of-thumb is that topical steroids should be prescribed only for
a short period of time and for severe cases that do not respond to conventional therapy.
Vernal keratoconjunctivitis

Various pharmacologic agents may be used to provide varying degrees of relief. Mucolytic agents, such as acetylcysteine, may
help minimize the discharge and provide temporary relief. Vasoconstrictors may reduce hyperemia but are not effective in severe
cases on a long-term basis. Similarly, topical antihistamines have no significant long-term benefit.

Mast cell stabilizers are perhaps the mainstay of treatment of VKC and are safe for long-term use. However, topical corticosteroids
generally become necessary for most patients with significant symptoms. Because of their potential adverse effects, topical
steroids should be prescribed at the lowest effective concentration and for the shortest duration possible. Pulsed-therapy regimen
is generally recommended, such as 1% prednisolone acetate every 2 hours for the first week followed by a rapid taper; this may be
repeated if symptoms recur. Systemic steroids may be used but generally are not necessary for moderate cases of VKC.
Several reports have shown that topical cyclosporine (Restasis) may be effective in reducing some of the signs and symptoms of
VKC without adverse effects. Oral aspirin has been shown to be effective. Treatment of corneal shield ulcer may require antibiotic-
steroid ointments.
Atopic keratoconjunctivitis

Treatment of patients with AKC is similar to that of VKC, in that it includes controlling the environment and avoiding allergens and
may require topical and systemic medications to provide symptomatic relief. As with VKC, topical vasoconstrictors and
antihistamines may provide very limited, short-term relief; they are not the mainstay of treatment.

As with VKC, topical mast cell stabilizers and topical corticosteroids provide significant relief of symptoms. Mast cell stabilizers
have to be used for several weeks prior to seeing a clinical effect, and, in the interim, topical steroids used in a pulsed fashion may
help to control symptoms. Systemic antihistamines that are specific for H1 histamine receptors have been found to be helpful.
Systemic steroids rarely are required, except in cases of vision-threatening complications.

Systemic cyclosporine, which has been shown to be effective in the treatment of atopic dermatitis, has shown promise in
controlling ocular inflammation in AKC. Postulated mechanism of action is inhibition of the ability of T lymphocytes to produce
interleukin 2 (IL-2), which is responsible for recruiting and activating new T cells. However, as with any systemic therapy, adverse
effects may be significant; therefore, monitoring of serum levels and renal function is essential.
Concomitant herpes simplex virus infection should be treated with either topical or oral antiviral agents as needed. A subset of
patients with recalcitrant and debilitating AKC may benefit from plasmapheresis, as was described by Aswad in 2 patients, one of
whom had hyperimmunoglobulinemia E.[3 ]
Giant papillary conjunctivitis

Goal of treatment in GPC is resolution of symptoms and restoration of functional use of contact lenses or ocular prosthetics.
Although removal of the responsible foreign body is the definitive treatment, and while that may be appropriate for exposed sutures
or scleral buckles, complete discontinuation of contact lenses or ocular prosthetics may be met with some degree of resistance
from patients. Fortunately, contact lens wear does not need to be completely discontinued to minimize the symptoms of GPC.

Significant reduction in the signs and symptoms may be achieved by changing the contact lens care routine. Disinfecting solutions
that contain chemical preservatives should be discontinued. Converting a patient from soft daily-wear contact lenses to disposable
or daily-disposable soft contact lenses may prevent the accumulation of proteinaceous deposits, which may be the antigenic
stimulus for GPC. Rigid gas permeable contact lenses may provide further relief from symptoms if disposable lenses do not
provide adequate response. This relief is because of the decreased proclivity of the rigid gas permeable contact lenses to develop
adherent deposits and coatings.
Pharmacologic treatment of GPC includes the use of mast cell stabilizers, topical corticosteroids, and antihistamines similar to that
in the other immunologic conjunctival disorders discussed previously. As always, care must be taken when using topical
corticosteroids; pulsed regimen is recommended to minimize adverse reactions.
Surgical Care
Vernal keratoconjunctivitis

Severe cases of corneal shield ulcer may require superficial keratectomy to promote epithelial regeneration. Generally, shield
ulcers are chronic conditions that are often refractory to conventional therapy. There have been reports of excimer laser
phototherapeutic keratectomy (PTK) being used to remove fibrin deposits on the Bowman layer and theoretically facilitate epithelial
healing.
Other surgical procedures, such as cryoablation of giant papillae or surgical removal of papillae with mucosal grafting, generally
are not required, but they may be helpful in extremely advanced cases. Remember that since VKC is a self-limited disease,
extensive reconstructive surgery may not have an acceptable risk-benefit ratio.
Atopic keratoconjunctivitis 

Penetrating keratoplasty may be undertaken in cases of severe corneal scarring or thinning, but great attention to control ocular
surface inflammation is required.
Consultations
Allergists may help in identifying the responsible allergen(s).
Medication
Allergic conjunctivitis can be treated with a variety of drugs, which include topical antihistamines, mast cell stabilizers, NSAIDs, and
corticosteroids.
Antihistamine, Ophthalmic
Act by competitive inhibition of histamine at the H1 receptor. Block effects of endogenously released histamine.

Emedastine difumarate (Emadine)

Relatively selective H-receptor antagonist for topical administration. The 0.05% ophthalmic solution contains 0.884 mg/mL of
emedastine difumarate.
Dosing
Adult
1 gtt in affected eye(s) qid
Pediatric
<3 years: Not established
>3 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Contact lens should not be worn for 10 min after instillation of emedastine as the preservative, benzalkonium chloride, can be
absorbed; not for injection or oral use; caution in breastfeeding (effects unknown)

Levocabastine (Livostin)
Selective histamine H1 receptor antagonist. Active ingredient is 0.54 mg levocabastine hydrochloride.
Dosing
Adult
1 gtt in affected eye(s) qid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; should not be used in people wearing soft contact lenses
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Should be shaken well before use; should not be used if discolored; not for internal (systemic) use

Epinastine (Elestat)
Direct histamine-1 receptor antagonist. Does not penetrate blood-brain barrier and therefore should not induce adverse CNS
effects. Indicated for symptoms due to allergic conjunctivitis.
Dosing
Adult
1 gtt OU bid until exposure to offending allergen is terminated
Pediatric
<3 years: Not established
>3 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Only for topical ophthalmic use; remove contact lenses before instillation; use caution when handling the container to avoid touch
contamination; may cause burning sensation, folliculosis, hyperemia, or pruritus

Azelastine ophthalmic (Optivar)

Competes with H1-receptor sites on effector cells and inhibits release of histamine and other mediators involved in allergic
response.
Dosing
Adult
1 gtt into affected eye(s) bid
Pediatric
<3 years: Not established
>3 years: Administer as in adults
Interactions
Increases CNS toxicity of CNS depressant medications
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Wait 10 min after instilling solution to insert soft contact lenses (do not use contact lenses if eyes are red)

Bepotastine besilate ophthalmic solution (Bepreve)

Topically active antihistamine that directly antagonizes H1-receptors and inhibits release of histamine from mast cells. Indicated for
itching associated with allergic conjunctivitis.
Dosing
Adult
Instill 1 gtt into affected eye(s) bid
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Interactions
None reported; minimal systemic absorption, therefore low potential for drug interactions; administer other ophthalmic agents
separately
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For topical ophthalmic use only; remove contact lenses prior to installation, may reinsert contact lenses 10 min after administration;
may cause abnormal taste sensation, ocular irritation, headache, and nasopharyngitis

Alcaftadine ophthalmic (Lastacaft)

H1-receptor antagonist indicated for prevention of itching associated with allergic conjunctivitis. Inhibits histamine release from
mast cells, decreases chemotaxis, and inhibits eosinophil activation. Available as 0.25% ophthalmic sol.
Dosing
Adult
Instill 1 gtt to each eye qd
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Common ocular adverse effects include eye irritation, burning/stinging after application, redness, and pruritus; common nonocular
adverse effects include nasopharyngitis, headache, and influenza
To minimize contamination risk, do not touch dropper tip to any surface; keep bottle tightly closed when not in use; do not use for
contact lens–related irritation; remove contact lenses before instillation
Mast Cell Stabilizers
Inhibit sensitized mast cell degeneration when exposed to specific antigens by inhibiting the release of mediators from the mast
cells. Block calcium ions from entering the mast cell.

Lodoxamide tromethamine (Alomide)

Mast cell stabilizer. Active ingredient is 1.78 mg lodoxamide tromethamine.
Dosing
Adult
1-2 gtt in affected eye(s) qid for up to 4 mo
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for injection; should be discontinued if transient burning or stinging persists; soft contact lens wearers should refrain from using
them while under treatment

Olopatadine (Patanol, Pataday)

Relatively selective H1 receptor antagonist and inhibitor of histamine release from mast cell. Active ingredient of Patanol is 1.11 mg
olopatadine hydrochloride; Pataday is 2.22 mg olopatadine hydrochloride.
Dosing
Adult
Patanol: 1 gtt in affected eye(s) bid q6-8h
Pataday: 1 gtt in affected eye(s) qd
Pediatric
<3 years: Not established
>3 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Should not be used to treat irritation caused by contact lenses; contact lenses to be worn 10 min after instillation

Ketotifen (Zaditor)
Over-the-counter (OTC) antihistamine eye drop. Noncompetitive H1-receptor antagonist and mast cell stabilizer. Inhibits release of
mediators from cells involved in hypersensitivity reactions.
Dosing
Adult
1 gtt into affected eye(s) q8-12h
Pediatric
<3 years: Not established
>3 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For topical ophthalmic use only; not for treatment of contact lens-related inflammation; wait 10 min before inserting contact lenses
after ketotifen use; do not contaminate dropper tip or solution when placing drops into eyes

Nedocromil ophthalmic (Alocril)

Interferes with mast cell degranulation, specifically with release of leukotrienes and platelet activating factor.
Dosing
Adult
1-2 gtt into affected eye(s) bid
Pediatric
<3 years: Not established
>3 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse events include ocular irritation/burning, headache, nasal congestion, and unpleasant taste in 10-40% of patients
Corticosteroids
Have both anti-inflammatory (glucocorticoid) and salt retaining (mineralocorticoid) properties. Glucocorticoids have profound and
varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Loteprednol etabonate (Lotemax, Alrex)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Topical ester steroid drop with decreased risk of glaucoma. Available in 0.2% and 0.5% drops.
Dosing
Adult
1-2 gtt into affected eye(s) qid
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, fungal, or tubercular infections
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor intraocular pressure if used for more than 10 d; long-term use of topical steroids is associated with development of
cataracts; caution in hypertension; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been
used or is in use (obtain fungal cultures when appropriate)
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Their mechanism of action is believed to be through inhibition of the cyclooxygenase enzyme that is essential in the biosynthesis of
prostaglandins, which results in vasoconstriction, decrease in vascular permeability and leukocytosis, and a decrease on
intraocular pressure.

Ketorolac tromethamine (Acular)

Pyrrolo-pyrrole group of NSAIDs. Inhibits prostaglandin synthesis by decreasing activity of the enzyme, cyclooxygenase, which
results in decreased formation of prostaglandin precursors, which, in turn, results in reduced inflammation. Active ingredient is
0.5% ketorolac tromethamine.
Dosing
Adult
1 gtt into affected eye(s) qid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted;
changes may include blurred or diminished vision, corneal deposits, retinal disturbances, scotomata, changes in color vision, and
macular degeneration; should not be used while wearing contact lenses
Follow-up
Further Outpatient Care
Intermittent follow-up care may be necessary as seasonal allergies occur.
Deterrence/Prevention
Seasonal and perennial allergic conjunctivitis
 
Avoidance of the offending antigen is the primary behavioral modification; specific testing by an allergist will identify the responsible
allergen(s) and help the individual to establish ways to avoid the allergen, whether it is an environmental allergen or a household
allergen, such as dust mite or pet dander. In addition, contact reactions caused by medications or cosmetics are treated best by
avoidance.
Vernal keratoconjunctivitis

As with most type I hypersensitivity disorders, allergen avoidance should be emphasized as the first-line treatment. Although
permanent relocation to a cooler climate is not feasible in many cases, it remains a very effective therapy for VKC.
Maintenance of an air-conditioned environment and control of dust particles at home and work also may be helpful. Local
measures, such as cold compresses and periodic installation of artificial tears, may provide temporary relief.
Complications
Complications are very rare, with corneal ulcers or keratoconus occurring rarely.
Prognosis
Prognosis is favorable. This condition generally clears up readily but may reoccur.
Conjunctivitis, Viral
 Ingrid U Scott, MD, MPH, Professor, Department of Ophthalmology and Public Health Sciences, Penn State College of Medicine
Kevin Luu, MD, Consulting Staff, Pediatric Anesthesia Associates Medical Group Inc; Consulting Staff, Children's Hospital
Central California
Updated: Oct 25, 2010
Introduction
Background
Viruses are a common cause of conjunctivitis in patients of all ages. A variety of viruses can be responsible for conjunctival
infection; however, adenovirus is by far the most common cause, and herpes simplex virus (HSV) is the most problematic. Less
common causes include varicella-zoster virus (VZV), picornavirus (enterovirus 70, Coxsackie A24), poxvirus (molluscum
contagiosum, vaccinia), and human immunodeficiency virus (HIV). Rarely, conjunctivitis is seen during systemic infection with
influenza virus, Epstein-Barr virus, paramyxovirus (measles, mumps, Newcastle), and rubella.
Viral conjunctivitis, although usually benign and self-limited, tends to follow a longer course than acute bacterial conjunctivitis,
lasting for approximately 2-4 weeks. Viral infection is characterized commonly by an acute follicular conjunctival reaction and
preauricular adenopathy.
Pathophysiology
Adenoviral conjunctivitis is the most common cause of viral conjunctivitis. Particular subtypes of adenoviral conjunctivitis include
epidemic keratoconjunctivitis (pink eye) and pharyngoconjunctival fever. Transmission occurs through contact with infected upper
respiratory droplets, fomites, and contaminated swimming pools.[1 ]
Primary ocular herpes simplex infection is common in children and usually is associated with a follicular conjunctivitis. Infection
usually is caused by HSV type I, although HSV type II may be a cause, especially in neonates. Recurrent infection, typically seen
in adults, usually is associated with corneal involvement.
VZV can affect the conjunctiva during primary infection (chickenpox) or secondary infection (zoster). Infection can be caused by
direct contact with VZV or zoster skin lesions or by inhalation of infectious respiratory secretions.
Picornaviruses cause an acute hemorrhagic conjunctivitis that is clinically similar to adenoviral conjunctivitis but is more severe and
hemorrhagic. Infection is highly contagious and occurs in epidemics.
Molluscum contagiosum may produce a chronic follicular conjunctivitis that occurs secondary to shedding of viral particles into the
conjunctival sac from an irritative eyelid lesion.
Vaccinia virus has become a rare cause of conjunctivitis because with the elimination of smallpox, the vaccination rarely is
administered. Infection occurs through accidental inoculation of viral particles from the patient's hands.
HIV is the etiologic agent of acquired immunodeficiency syndrome (AIDS). Ocular abnormalities in patients with AIDS primarily
affect the posterior segment, but anterior segment findings have been reported. When conjunctivitis occurs in a patient with AIDS,
it tends to follow a more severe and prolonged course than in patients without AIDS. In general, patients with AIDS may develop a
transient nonspecific conjunctivitis, characterized by irritation, hyperemia, and tearing, that requires no specific treatment.
Microsporidia has been isolated from the cornea and conjunctiva of several patients with AIDS and keratoconjunctivitis. In these
patients, symptoms included foreign body sensation, blurred vision, and photophobia; most cases resolved without antimicrobial
therapy.
Frequency
United States
Viral conjunctivitis is a common ocular disease both in the United States and worldwide. Because it is so common, and many
cases are not brought to medical attention, accurate statistics on the frequency of disease are unavailable. Viral infection frequently
occurs in epidemics within families, schools, offices, and military organizations.
International
Same as in the United States.
Mortality/Morbidity
Most cases of viral conjunctivitis are self-limited and mild, although chronic infections have been reported. Long-term ocular
sequelae are uncommon.
Sex
Viral conjunctivitis can occur equally in men and women.
Age
Viral conjunctivitis can affect all age groups, depending on the specific viral etiology. Usually, adenovirus affects patients aged 20-
40 years. HSV and primary VZV infection usually affect young children and infants. Herpes zoster ophthalmicus results from
reactivation of latent VZV infection and may present in any age group. Typically, the picornaviruses affect children and young
adults in the lower socioeconomic classes.[2 ]
Clinical
History
While the manifestations of various types of bacterial conjunctivitis are fairly homogenous, those of viral conjunctivitis can vary from
one disease process to another. History should focus on eliciting information that will aid in differentiating the various etiologic
agents of viral infection.
Inquire about timing, onset, and duration of systemic and ocular symptoms; severity and frequency of symptoms; appropriate risk
factors; and personal and environmental exposures.
Patients with adenoviral conjunctivitis may give a history of recent exposure to an individual with red eye at home, school, or work,
or they may have a history of recent symptoms of an upper respiratory tract infection. The eye infection may be unilateral or
bilateral.
Patients may complain of ocular itching, foreign body sensation, tearing, redness, and photophobia (with corneal involvement as in
epidemic keratoconjunctivitis).
Systemic manifestations are rare, except in cases of pharyngoconjunctival fever.
Primary ocular HSV infection predominantly affects young children and infants, but it may occur in individuals of all ages. Patients
usually present with a red, irritated, watery eye. Often, concomitant eyelid skin involvement with multiple vesicular lesions is
present.
VZV is characterized by a generalized vesicular eruption, fever, and constitutional symptoms. Ocular infection usually is unilateral
and presents as small papular lesions that erupt along the lid margin or at the limbus and may be accompanied by a mild follicular
conjunctivitis.
Herpes zoster ophthalmicus represents reactivation of latent VZV infection of the trigeminal ganglion. It is characterized by a
prodrome of fever, malaise, nausea, vomiting, and severe pain and skin lesions along the ophthalmic division of the trigeminal
nerve. Conjunctival involvement includes hyperemia, follicular or papillary conjunctivitis, and a serous or mucopurulent discharge.
Acute hemorrhagic conjunctivitis has been reported in epidemics in association with 2 major picornaviruses, enterovirus 70 and
Coxsackie A24. It mostly affects children and young adults in the lower socioeconomic classes. Patients experience a rapid onset
of watery discharge, foreign body sensation, burning, and photophobia within 24 hours of exposure.
Molluscum contagiosum can produce a chronic follicular conjunctivitis in association with an irritative eyelid lesion. The lesion
usually is a small, elevated, pearly, umbilicated nodule near the lid margin. Multiple lesions may be present, especially in patients
who are HIV positive.
Other viruses are less frequent causes of conjunctivitis. In these cases, conjunctivitis usually occurs in association with a systemic
illness and includes infections caused by influenza virus, Epstein-Barr virus, paramyxovirus (measles, mumps, Newcastle), rubella,
and HIV.
Physical
Typical signs of adenoviral conjunctivitis include preauricular adenopathy, epiphora, hyperemia, chemosis, subconjunctival
hemorrhage, follicular conjunctival reaction, and occasionally a pseudomembranous or cicatricial conjunctival reaction. The cornea
often demonstrates a punctate epitheliopathy. The eyelids often are edematous and ecchymotic. In severe cases, there can be a
corneal epithelial defect. It typically begins in one eye and progresses to the fellow eye over a few days. The second eye is usually
less significantly involved.
With HSV infection, vesicles may be present on the eyelid or face, the eyelids may be swollen, and an ulcerative blepharitis may be
present.
Corneal involvement in HSV manifests as a dendritic keratitis with typical features of linear branching and dendritic figures.
Small papular lesions that erupt along the lid margin or at the limbus are present with varicella conjunctivitis. These lesions may
resolve without sequelae, or they may become pustular and form painful reactive conjunctival ulcers.
In herpes zoster ophthalmicus, look for skin involvement with the appearance of a dermatomal pattern of vesicles. These vesicles
may become necrotic, resulting in pitted scarring of the skin. Conjunctival involvement includes hyperemia, follicular or papillary
conjunctivitis, and a serous or mucopurulent discharge. Preauricular adenopathy is common. Very early in the process, there may
be multiple fine dendritic corneal lesions, which disappear over a few days without treatment.
Acute hemorrhagic conjunctivitis starts unilaterally but rapidly involves the fellow eye within 1 or 2 days. Signs on examination
include a swollen, edematous eyelid, and pronounced hemorrhage beneath the bulbar conjunctiva.
Causes
A variety of viruses can be responsible for conjunctival infection. Adenovirus is the most common cause, and HSV is the most
problematic. Less common causes include VZV, picornavirus (enterovirus 70, Coxsackie A24), poxvirus (molluscum contagiosum,
vaccinia), and HIV.
Differential Diagnoses
Conjunctivitis, Acute Hemorrhagic Keratoconjunctivitis, Epidemic

Conjunctivitis, Allergic Keratoconjunctivitis, Sicca

Conjunctivitis, Bacterial Nasolacrimal Duct, Obstruction

Conjunctivitis, Giant Papillary Pharyngoconjunctival Fever

Conjunctivitis, Neonatal Red Eye Evaluation

Contact Lens Complications Uveitis, Anterior, Nongranulomatous

Keratitis, Herpes Simplex

Keratoconjunctivitis, Atopic

Other Problems to Be Considered

HSV keratoconjunctivitis
VZV keratoconjunctivitis
Ocular chlamydial infections
Vernal keratoconjunctivitis
Blepharoconjunctivitis
Contact lens keratoconjunctivitis
Foreign body
Epithelial keratitis
Workup
Laboratory Studies
Generally, a diagnosis of viral conjunctivitis is made on the clinical features alone. Such findings include the classic corneal
dendrites of HSV infection and follicular conjunctivitis, and preauricular adenopathy associated with adenoviral infection.
Conventional laboratory identification can be expensive and time-consuming but may be helpful in certain circumstances.[3,4,5,6 ]
Specimens should be obtained for culture and smear if inflammation is severe, in chronic or recurrent infections, with atypical
conjunctival reactions, and with failure to respond to treatment.

Giemsa staining of conjunctival scrapings may aid in characterizing the inflammatory response. Polymorphonuclear cells are
prevalent in bacterial infections, whereas mononuclear cells and lymphocytes are seen with viruses.

Viral isolation methods may be helpful in the diagnosis of acute follicular conjunctivitis, but they are not indicated in chronic
conjunctivitis.

Direct immunofluorescence monoclonal antibody staining and enzyme-linked immunosorbent assay (ELISA) are rapid and widely
available detection techniques.

Alternative methods include immunoperoxidase, electron microscopy, and polymerase chain reaction (PCR).
Serologic tests are available but generally require 2 serum samples at least 2 weeks apart, which can delay treatment.
Treatment
Medical Care
Treatment of adenoviral conjunctivitis is supportive. No evidence exists that demonstrates efficacy of antiviral agents.
Patients should be instructed to use cold compresses and lubricants, such as artificial tears, for comfort.
Topical vasoconstrictors and antihistamines may be used for severe itching but generally are not indicated because they are
minimally helpful and may cause rebounding of symptoms, as well as local toxicity and hypersensitivity.
For patients who may be susceptible, a topical astringent or antibiotic may be used to prevent bacterial superinfection.
Topical steroids may be used for pseudomembranes or when subepithelial infiltrates impair vision, although subepithelial infiltrates
may recur after discontinuing the steroids. Extreme caution should be taken when using corticosteroids, as they may worsen an
underlying HSV infection.
An in vitro study using adenovirus 8 and A549 human epithelial cell cultures demonstrated that povidone-iodine at a concentration
of 1:10 (0.8%) is highly effective against free adenovirus, less effective against intracellular adenoviral particles in already infected
cells, and not significantly cytotoxic for healthy cells. Thus, povidone-iodine 0.8% may represent a potential option to reduce
contagiousness in cases of adenoviral infections.
Patients with conjunctivitis caused by HSV usually are treated with topical antiviral agents, including idoxuridine solution and
ointment, vidarabine ointment, and trifluridine solution. An ophthalmologist should see any patient with ocular HSV infection.
Treatment of HSV keratitis is discussed in Keratitis, Herpes Simplex.
Treatment of VZV eye disease includes oral acyclovir, 600-800 mg, 5 times daily for 7-10 days, to terminate viral replication.
Topical corticosteroids usually are not indicated for conjunctivitis or keratitis.
Treatment of acute hemorrhagic conjunctivitis is supportive as in adenoviral infection and includes bed rest, cold compresses, and
analgesics. Antibiotics have no useful role unless bacterial superinfection is present.
For conjunctivitis associated with molluscum contagiosum, disease will persist until the skin lesion is treated. Removal of the
central core of the lesion or inducement of bleeding within the lesion usually is enough to cure the infection. Occasionally, surgical
excision is required.
Other viral causes of conjunctivitis generally are self-limited and treated supportively with compresses for comfort and topical
antibiotics as necessary to prevent bacterial superinfection.
Consultations
An important aspect of treatment is to know the proper time to refer the patient to a specialist.
Patients with hyperacute conjunctivitis or those with corneal involvement, such as ulceration, herpetic keratitis, or suspected orbital
cellulitis, should be referred to an ophthalmologist.
An ophthalmologist also should evaluate patients who fail to respond to appropriate therapy.
Medication
Medications used in the treatment of viral conjunctivitis include the following: topical artificial tears, 4-8 times per day, for 1-3
weeks; topical vasoconstrictor/antihistamine, 4 times per day, for severe itching; topical steroids for pseudomembranes and
subepithelial infiltrates; topical antibiotic to prevent bacterial superinfection; topical antiviral agents for HSV infection; and oral
acyclovir for VZV infection.[7 ]
Ocular Lubricants
These agents are used for symptomatic relief.

Artificial tears (Refresh, Celluvisc, Murine)

Act to stabilize and thicken precorneal tear film and prolong tear film breakup time, which occurs with dry eye states.
Dosing
Adult
1-2 gtt 4-8 times/d; may use more frequently if preservative free
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hyperemia, photophobia, stickiness of eyelashes, and ocular discomfort or irritation may occur
Antihistamines
These agents are used to treat severe itching.

Levocabastine (Livostin)
Potent histamine H1-receptor antagonist; for ophthalmic use.
Dosing
Adult
1 gtt in each affected eye qid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Shake well prior to use; not for internal (systemic) use; avoid use of contact lenses while on medication
Corticosteroids
These agents are used for pseudomembranes and decreased vision and/or glare due to subepithelial infiltrates. They have anti-
inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune
response to diverse stimuli.

Prednisolone ophthalmic (AK-Pred, Pred Forte)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Less potent (eg, prednisolone 0.125%, fluorometholone 0.1%) are usually sufficient to treat subepithelial infiltrates. The steroid
must be tapered very slowly, over months.
Dosing
Adult
1 gtt q1-6h, depending on severity of infection; taper slowly over several d to wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; HSV keratitis; acute viral keratitis; VZV; suspected fungal keratitis; mycobacterial infection; glaucoma
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with glaucoma; corticosteroids are associated with increased intraocular pressure and cataract in some
patients; they may worsen certain infections, such as from herpes simplex, bacteria, and fungi
Antivirals
These agents are used for the treatment of HSV infection.

Trifluridine (Viroptic)
Pyrimidine (thymidine) analogue DOC in the United States for topical antiviral therapy for HSV infection. Inhibits viral replication by
incorporating into viral DNA in place of thymidine. If no response in 7-14 d, consider other treatments.
Dosing
Adult
1 gtt into affected eye q2h while awake; not to exceed 9 gtt/d for 10 d, not to exceed 21 d; taper thereafter
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
All topical antiviral medications currently available for clinical use in the United States are toxic; adverse reactions include
discomfort upon instillation and palpebral edema, irritation, and superficial punctate or epithelial keratopathy

Acyclovir (Zovirax)
Prodrug activated by phosphorylation by virus-specific thymidine kinase that inhibits viral replication.
Dosing
Adult
Herpes zoster ophthalmicus: 800 mg PO 5 times/d for 7-10 d
Recurrent episodes: 400-800 mg PO bid for 7-10 d; initiate treatment immediately upon onset of symptoms of recurrent episodes
Prevention of herpes simplex infections: 400 mg PO bid, can be used to prevent recurrent herpes simplex infections and
inflammations
Pediatric
20 mg/kg/dose PO q6h up to a maximum of 800 mg
Interactions
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir
Contraindications
Documented hypersensitivity; caution in renal disease
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using nephrotoxic drugs
Follow-up
Further Outpatient Care
Patients with conjunctivitis, especially those treated with medications, require follow-up care. Patients should return in 1-3 weeks or
sooner if the condition significantly worsens.
Patients with conjunctivitis who wear contact lenses should be instructed to discontinue lens wear until signs and symptoms have
resolved.
Deterrence/Prevention
Prevention of transmission, especially in health care facilities, is extremely important. Careful hand washing before seeing every
patient, proper cleansing of instruments, and frequent changing of multiuse ophthalmic drops are vital. Using a single infective
examination room, as well as educating the staff and the patient, is important.
Patients should be instructed to take contagion and isolation precautions for at least 2 weeks or as long as the eyes are red and
weeping.
Complications
Complications include the following: punctate keratitis with subepithelial infiltrates, bacterial superinfection, corneal ulceration with
keratoconjunctivitis, and chronic infection.
Epithelial keratitis may accompany viral conjunctivitis. Punctate epithelial erosions that stain with fluorescein characterize viral
keratitis. Rarely, these changes are sufficiently distinctive morphologically to allow identification of a specific type of virus as the
etiologic agent. If the conjunctivitis persists or is severe, disturbances in the anterior stroma beneath the epithelial abnormalities
may occur. In general, the stromal or subepithelial abnormalities are transient and resolve despite persistence of epithelial keratitis.
However, in cases of adenoviral infection, the stromal abnormalities may persist for months to years, long after the epithelial
changes have resolved. In such cases, these subepithelial infiltrates are considered to be immunologic in origin, the result of
antigen-antibody reaction. If they are in the pupillary axis, they may cause decreased vision and/or glare.
Prognosis
Most cases of viral conjunctivitis are acute, benign, and self-limited. The infection usually resolves spontaneously within 2-4 weeks.
Subepithelial infiltrates may last for several months, and, if in the visual axis, they may cause decreased vision or glare.
Patient Education
To allay patient anxiety, it is helpful to inform patients that their symptoms may worsen during the first 4-7 days after onset before
they begin to improve and may not resolve for 2-4 weeks. The contagiousness of the infection also should be emphasized. Proper
isolation from work or school is advisable to prevent epidemics in the office and at school.
For excellent patient education resources, visit eMedicine's Eye and Vision Center and Skin, Hair, and Nails Center. Also, see
eMedicine's patient education articles Pinkeye, How to Instill Your Eyedrops, and Molluscum Contagiosum.
Miscellaneous
Medicolegal Pitfalls
Physicians have been sued by patients who believe they acquired viral conjunctivitis in the doctor's office. Every attempt to prevent
transmission from patient to patient (not to mention doctor) should be made. Suggestions include not having patients with a red eye
wait in the general waiting room, having a special examination room for patients with red eye, disinfecting the examination room
after seeing any patient with a red eye, not shaking hands with patients with red eye (after explaining the reason to them), touching
their eyelids with cotton-tipped applicators and not your fingers, washing the hands immediately after examining the patient (even
before writing in the chart), and not giving the chart to the patient to bring to the receptionist.
Special Concerns
Viral conjunctivitis is an occupational hazard of eye care physicians. Take all precautions possible not to become a victim.
Conjunctivitis, Bacterial
David S Marlin, MD, Consulting Staff, Department of Ophthalmology, Kaiser Foundation Hospital, Los Angeles Medical Center
Updated: Jun 1, 2009
Introduction
Background
Bacterial conjunctivitis is a microbial infection involving the mucous membrane of the surface of the eye. This condition, which is
usually a benign self-limited illness, sometimes can be serious or signify a severe underlying systemic disease. Occasionally,
significant ocular and systemic morbidity may result.[1 ]
The purpose of this article is to help the practitioner recognize the character and significance of the condition, to avoid pitfalls in
diagnosis, and to convey appropriate treatment modalities.
Pathophysiology
The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as streptococci, staphylococci,
and Corynebacterium strains. Alterations in the host defense or in the species of bacteria can lead to clinical infection. An alteration
in the flora can occur by external contamination, by spread from adjacent sites, or via a blood-borne pathway.
The primary defense against infection is the epithelial layer covering the conjunctiva. Disruption of this barrier can lead to infection.
Secondary defenses include hematologic immune mechanisms carried by the conjunctival vasculature; tear film immunoglobulins
and lysozyme; and the rinsing action of lacrimation and blinking.
Frequency
United States
Bacterial conjunctivitis is a common condition in all areas of the United States. It is likely that most people will experience an
episode. Most of the benign cases probably are treated by primary physicians or resolve spontaneously.
International
Bacterial conjunctivitis is common worldwide. Community sequelae can be devastating in areas affected by blinding infections of
newborns as well as in areas heavily affected by Chlamydia trachomatis.[2 ]
Mortality/Morbidity
Mortality in the setting of bacterial conjunctivitis is related to the failure to recognize and treat the underlying disease. Sepsis and
meningitis caused by Neisseria gonorrhoeae can be life threatening.[3 ]Chlamydial infection in the newborn can lead to pneumonia
and/or otitis media.[4 ]Morbidity in terms of discomfort, ocular discharge, and redness are common in benign cases and often lead to
absence from work and school. Morbidity can be associated with misdiagnosis. Since many eye diseases cause the eye to be red,
it is beneficial to have a solid approach to diagnosis.
Race
 Bacterial conjunctivitis occurs in all races.
 Differences in frequencies among races are likely to reflect geographical variations in the prevalence of pathogens.
Sex
 Probably, both sexes have an equal natural resistance to bacterial conjunctivitis.
 Differences in rates of infection probably reflect behavioral patterns, such as the exposure of female elementary school
teachers to children affected by the condition.
Age
 Age is a relevant factor in the significance of bacterial conjunctivitis.
 The practitioner must be vigilant in considering sexually transmitted diseases caused by N gonorrhoeae and Chlamydia in
sexually active age groups and in newborns who may have been exposed during birth. Tactful and confidential history
taking are a necessary skill. It is important not to violate HIPPA Regulations during history taking and treatment. If a
practitioner is mired in an ethical or medicolegal situation, it is a good idea to seek advice from administration and/or
colleagues.
Clinical
History
Eliciting a clinical history from the patient is influenced by such factors as age and social habits and may occasionally focus on
sensitive issues that can be embarrassing to discuss.
 Most cases of bacterial conjunctivitis occur in otherwise healthy individuals. In these cases, the history should take the
following factors into consideration:
o Age is a consideration in determining whether the case may be related to defective host resistance of the elderly
patient. If this is a consideration, it is appropriate to inquire about concomitant or recent increased susceptibility
to other types of infections, for example, urinary tract or respiratory tract infections, which may hold clues as to
the bacterial source.
o Patients at a sexually active age should be considered for venereal diseases.
  If the conjunctivitis is associated with copious purulence, severe injection, and chemosis, then a
discussion of possible exposure to N gonorrhoeae must take place. Bacterial cultures, including Thayer-
Martin and chocolate agar, and a Gram stain must be taken.
 A history of sexual partners must be obtained if the cultures/stain verify this condition so that they also
can be treated.
 The practitioner must be aware that laws require reporting incidences of this disease to the appropriate
Board of Health.
 A similar history must be obtained when chlamydial conjunctivitis is suspected.
 Clinical suspicion may be present at first presentation or upon treatment failure of an unsuspected case.
 It is probably desirable to have the nurse or other office-related personnel take the sexual history to
avoid a sense of inappropriateness.
 It is better to ask the patient if friends or family members should leave the room for this aspect of the
evaluation.
o Duration of the disease and previous attempts at therapy should be documented.
o It is usual for symptoms to be present for several days or weeks at the time of presentation. An uncommonly long
duration or a frequent recurrence suggests that other factors or conditions may be present.
o For instance, a molluscum lesion at the lid margin may be shedding virus into the eye. Chlamydial infection or
viral keratoconjunctivitis may be present. A history of resistance to therapy may prompt the practitioner to obtain
a culture.
o History of recent exposure to other cases is helpful. An exposure to a case that healed uneventfully would be
comforting, whereas exposure to someone with known epidemic keratoconjunctivitis or herpes simplex would
raise concern.
o A brief history to assess possible occupational exposure may be appropriate.
o A brief history of systemic illness should be obtained to determine if a recent viral upper respiratory tract infection
has occurred or if there are any major known systemic illnesses, such as AIDS or diabetes.
o A medication history is important to document what already has been tried and to rule out medicamentosa or
other drug causes for the condition.
o Ocular redness and irritation may occur due to an antibacterial eye drop solution or the preservatives in the
solution.
o Systemic chemotherapeutic agents can cause an irritative conjunctivitis.
o A history of allergies to medications should be established for avoidance purposes and recorded in the medical
record prominently since this is often the only medical encounter with an otherwise healthy individual.
o Patients with typical bacterial conjunctivitis do not complain of photophobia. Sensitivity to light is a symptom of
intraocular inflammation as in iritis or corneal lesions, such as those found in viral keratitis.
o A history of contact lens wear opens up an array of possibilities in the setting of a red eye. Corneal ulcers, which
are infections within the stroma of the cornea, may occur with contact lens wear. Improper contact lens care
and/or contaminated solutions can lead to corneal infections with bacteria, Acanthamoeba, or fungi. In early
2006, an outbreak of fungal infections with Fusarium species occurred due to a contact lens solution. In these
cases, the infection involves the cornea and may be associated with a red eye.
Physical
The physical examination should evaluate the following signs:
 Conjunctival injection may be present segmentally or diffusely. The palpebral conjunctival pattern may hold clues as to the
etiology.
 Using slit lamp biomicroscopy, the inflammation of the conjunctiva can be characterized as being follicular or papillary.
o A follicular pattern has blood vessels circumferentially around the base of the tiny elevated lesions. This pattern
is characteristic of a viral or chlamydial conjunctivitis.
o A papillary pattern has vessels coming up the center of the tiny elevated lesion and is characteristic of bacterial
or allergic conjunctivitis.
 The discharge in bacterial conjunctivitis is typically more purulent than the watery discharge of viral conjunctivitis. Thus,
there is more "mattering" of the lid margins and associated difficulty in prying the lids open following sleep.
  In uncomplicated bacterial conjunctivitis, slit lamp examination reveals a quiet anterior chamber that is devoid of visible
cells. The vitreous is also unaffected.
 A preauricular lymph node is unusual in bacterial conjunctivitis but is found in severe conjunctivitis caused by N
gonorrhoeae. It is associated with viral ocular syndromes, typically herpes simplex keratitis and epidemic
keratoconjunctivitis.
 Eyelid edema is often present, but it is mild in most cases of bacterial conjunctivitis. Severe lid edema in the presence of
copious purulent discharge raises the suspicion N gonorrhoeae infection.
 Visual acuity is preserved in bacterial conjunctivitis, except for the expected mild blur secondary to the discharge and
debris in the tear film.
 The pupil reacts normally in bacterial conjunctivitis. A fixed pupil in the setting of a red eye should raise the suspicion for
angle-closure glaucoma or iritis with posterior synechiae.
 Dilation and tortuosity of the major vessel injection suggests a cavernous sinus-carotid artery fistula rather than
conjunctivitis.
Causes
 Bacterial conjunctivitis occurs in otherwise healthy individuals.
 Risk factors include frequent exposure to infected individuals, sinusitis, immunodeficiency states, and exposure to agents
of sexually transmitted disease at birth.
Differential Diagnoses
Blepharitis, Adult Gonococcus

Cellulitis, Preseptal Herpes Simplex

Chlamydia Herpes Zoster

Conjunctivitis, Acute Hemorrhagic Hordeolum

Conjunctivitis, Allergic Horner Syndrome

Conjunctivitis, Giant Papillary Keratitis, Bacterial

Conjunctivitis, Neonatal Keratitis, Fungal

Conjunctivitis, Viral Keratitis, Herpes Simplex

Contact Lens Complications Keratoconjunctivitis, Epidemic

Corneal Foreign Body Keratoconjunctivitis, Superior Limbic

Corneal Graft Rejection Molluscum Contagiosum

Dacryocystitis Ocular Rosacea

Endophthalmitis, Bacterial Pharyngoconjunctival Fever

Endophthalmitis, Fungal Scleritis

Endophthalmitis, Postoperative Squamous Cell Carcinoma, Conjunctival

Episcleritis Subconjunctival Hemorrhage

Filtering Bleb Complications Thyroid Ophthalmopathy

Fistula, Carotid Cavernous Trachoma

Glaucoma, Angle Closure, Acute Trichiasis

Glaucoma, Malignant Uveitis, Anterior, Granulomatous

Glaucoma, Neovascular

Glaucoma, Uveitic
Other Problems to Be Considered
Nongranulomatous iritis
Workup
Laboratory Studies
 Conjunctival scrapings and cultures most often are used in laboratory studies.
o Cultures can be completed for viral, chlamydial, and bacterial agents.
o If testing for N gonorrhoeae, specific procedures should be followed to optimize the yield.
o Fungal culture would be unusual, except in the setting of a corneal ulcer or in the case of known contamination of
a contact lens solution such as occurred in early 2006.
o Conjunctival scrapings can be performed with topical anesthetic and gentle use of a platinum spatula or similar
blunt metallic object.
o Gram stain is useful to identify bacterial characteristics.
o Giemsa stain is helpful to screen for intracellular inclusion bodies of Chlamydia.
o Additionally, the nature of the inflammatory reaction is reflected in the cellular response. Lymphocytes
predominate in viral infections, neutrophils in bacterial infections, and eosinophils in allergic reactions.
Imaging Studies
 Imaging studies do not play a significant role in the workup of bacterial conjunctivitis unless an underlying condition, such
as sinusitis, is suspected.
o MRA, CT scan, and orbital color Doppler may play a role in a suspected cavernous sinus fistula.
o Orbital CT scan may be indicated to rule out an orbital abscess or pansinusitis, when the conjunctivitis is part of
an orbital cellulitis.
Procedures
 Certain procedures may address a known or suspected underlying cause for conjunctivitis or conditions that mimic it.
o Removal of offending lashes with epilation forceps or by electrolysis may be indicated for trichiasis.
o Nasolacrimal duct irrigation may be attempted to see if an obstruction that predisposes to infection is present. An
obstruction should be suspected in chronic and intermittent purulent conjunctivitis.
o Eversion of the eyelid at the slit lamp is indicated when a foreign body is suspected.
Histologic Findings
Gram and Giemsa stains in the presence of bacteria demonstrate the expected inflammatory cell response in the stroma. However,
this consideration is only academic because the condition is not an indication for biopsy. Cultures and scrapings are usually
diagnostic.
Treatment
Medical Care
 The mainstay of medical treatment of bacterial conjunctivitis is topical antibiotic therapy.
 Systemic antibiotics are indicated for N gonorrhoeae and chlamydial infections.
 Practice patterns for prescribing topical antibiotics vary. Most practitioners prescribe a broad-spectrum agent on an
empirical basis without culture for a routine, mild-to-moderate case of bacterial conjunctivitis. Always be aware of the
differential diagnosis, and instruct patients to seek follow-up care if the expected improvement does not occur or if vision
becomes affected.
o Sodium sulfacetamide, gentamicin, tobramycin, neomycin, trimethoprim and polymyxin B combination,
ciprofloxacin, ofloxacin, gatifloxacin, and erythromycin are representatives of commonly used first-line agents.
o Eye drops have the advantage of not interfering with vision. Ointments have the advantage of prolonged contact
with the ocular surface and an accompanying soothing effect.
 Chlamydial infection of the newborn requires systemic treatment of the neonate, the mother, and at-risk contacts.
o The neonate may be treated with erythromycin orally in liquid form 50 mg/kg/day in 4 divided doses for 2 weeks.
o The mother and at-risk contacts may be treated with doxycycline 100 mg orally twice daily for 7 days.
  N gonorrhoeae infection of the newborn also requires systemic treatment of the neonate, the mother, and at-risk contacts.
o The neonate may be treated with intravenous aqueous penicillin G 100 units per kg per day in 4 divided doses
for 1 week.
o The mother and at-risk contacts may be treated with a single dose of intramuscular ceftriaxone 125 mg followed
by oral doxycycline 100 mg twice daily for 7 days.
 Prophylaxis against ophthalmia neonatorum is a major force in the worldwide effort to prevent blindness.[5 ]Common
regimens are the instillation of 1% silver nitrate solution, 1% tetracycline ointment, or 0.5% erythromycin ointment.
Surgical Care
 Surgical intervention is not required in the setting of bacterial conjunctivitis, except when indicated for the treatment of
causative conditions, such as hordeolum, nasolacrimal duct obstruction, and sinusitis.
Consultations
 Consultations with infectious disease specialists and/or pediatricians may be indicated in suspected or proven chlamydial
or N gonorrhoeae infections.
 An experienced ophthalmic pathologist can be an excellent resource in determining the cause of a resistant conjunctivitis
by interpreting conjunctival scrapings.
Diet
 Dietary factors do not play a role in bacterial conjunctivitis, except in situations where a severe deficiency leads to an
immunocompromised state.
Activity
 Activity precautions pertain to limiting the spread of the infection.
o It is customary to advise the infected individual to avoid sharing towels and linens.
o A patient with bacterial conjunctivitis should wash hands often and avoid contaminating public swimming pools.
o Workers and students often are excused during the first several days of treatment to decrease the possibility of
spread.
Medication
Many antibiotic eye preparations can be used as first-line therapy in bacterial conjunctivitis. The justification for treating this
condition empirically with a broad-spectrum topical agent is that relatively high levels of the drug are delivered directly to the site of
infection. This level of drug concentration exceeds what is normally achieved in body tissues by oral or parenteral routes.
Therefore, the antibiotic spectrum of the individual drug is enhanced.
This list of medicines is limited to a few common choices. Many other agents are available. Combination antibiotic-steroid
medications are not discussed in this article, as these medicines play a role in postoperative care and only are used with extreme
care in the setting of bacterial conjunctivitis.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Most cases of routine bacterial
conjunctivitis respond to the commercially available combination of antibiotics.
Although the aminoglycosides are used in other fields of medicine primarily to treat gram-negative bacteria, the spectrum of
efficacy expands to include gram-positive bacteria when used topically for conjunctivitis.
Fluoroquinolones have gained popularity in ocular therapy due to their efficacy in the treatment of bacterial corneal ulcers.
Fluoroquinolones have been used mostly as second-line agents in routine bacterial conjunctivitis.
Neonatal chlamydial infection is treated with oral erythromycin.
Doxycycline is used to treat the mother of a neonate with chlamydial infection as well as her at-risk contacts.
Intravenous penicillin G is used for neonatal gonorrhea infections.
Third-generation cephalosporins are used in the treatment of adult gonorrhea infections.

Sulfacetamide ophthalmic (Bleph-10, Cetamide, AK-Sulf)

Effective in most cases of bacterial conjunctivitis including those caused by Streptococcus pneumoniae, Haemophilus influenzae,
and group A Streptococcus pyogenes. It may have some local activity againstChlamydia. Available as a solution and ointment
preparation.
Dosing
Adult
Solution (10%): Instill 1-3 gtt q2-3h in affected eye, while awake, for 1 wk with less frequent administration at night
Ointment: Apply 0.5-ribbon into conjunctival sac qid for 1 wk
Pediatric
Administer as in adults; sometimes 5% preparation used
Interactions
Effects decreased when used concurrently with gentamicin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Practitioners should be aware of the toxicity of systemically administered sulfonamides including the rare hematologic effects of
agranulocytosis and hemolytic anemia; therefore, it is advisable to treat only if clinically indicated; caution in severely dried eye;
ointment may retard corneal epithelial healing

Gentamicin (Genoptic, Ocumycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Most cases of bacterial conjunctivitis will respond to this
agent including pseudomonads, Staphylococcus aureus, group A streptococci, S pneumoniae, and H influenzae. Commercially
available in solution or ointment form.
Dosing
Adult
Ointment: Apply 0.5-inch (1/25 cm) ribbon to affected eye(s) qid for 1 wk
Solution: Instill 1-2 gtt qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; steroid combinations after uncomplicated
removal of a foreign body from cornea also should avoid using this product
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or
fungal overgrowth of nonsusceptible organisms and may lead to a secondary infections

Erythromycin topical (E-Mycin)

Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Effective in most cases of bacterial conjunctivitis including those caused by S aureus, group A streptococci, S pneumoniae, and H
influenzae.
Dosing
Adult
Apply 0.5-inch (1.25 cm) ribbon qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, mycobacterial, fungal infections of eye; patients using steroid combinations after uncomplicated
removal of a foreign body from cornea also should avoid using this product
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may
result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate
measures if superinfection occurs); may not cover pseudomonads in the setting of immunocompromised patients

Azithromycin ophthalmic (AzaSite)

Ophthalmic macrolide antibiotic. Indicated for bacterial conjunctivitis caused by CDC coryneform group G bacteria, Haemophilus
influenzae, Staphylococcus aureus, Streptococcus mitis group, and Streptococcus pneumoniae.
Dosing
Adult
Instill 1 gtt in affected eye(s) bid (administer doses 8-12 h apart) for 2 d, then 1 gtt qd for next 5 d
Pediatric
<1 year: Not established
≥ 1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Thoroughly wash hands before using; for topical ophthalmic use only; prolonged use may result in resistant organisms; do not wear
contact lenses until infection resolves; may cause eye irritation; less common adverse effects include burning, stinging, and/or
irritation when instilled; other less common adverse effects include contact dermatitis, corneal erosion, dry eyes, dysgeusia, nasal
congestion, ocular discharge, punctate keratitis, and sinusitis

Bacitracin ophthalmic (AK-Tracin, Baciguent)

Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth. Most cases of routine bacterial conjunctivitis
will respond to bacitracin including those caused by group A streptococci, S aureus, S pneumoniae, and H influenzae.
Dosing
Adult
Apply 0.25- to 0.5-inch ribbon bid/qid into conjunctival sac(s) for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; vaccinia, varicella, epithelial herpes simplex keratitis, mycobacterial infections, fungal diseases of the
eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Ophthalmic ointments may delay healing of corneal epithelia; in deep-seated infections of the eye, supplement with systemic
medications; prolonged use may result in overgrowth of nonsusceptible organisms

Ciprofloxacin ophthalmic (Ciloxan)

Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by
strains of microorganisms susceptible to ciprofloxacin. They are effective in most cases of routine conjunctivitis including those
caused by S aureus, group A streptococci, H influenzae, and Pseudomonas aeruginosa. They may not cover all cases of S
pneumoniae. Newer classes of fluoroquinolones (eg, gatifloxacin, moxifloxacin) are available and are sometimes used for
conjunctivitis or a red eye, particularly in the perioperative period for eye surgery.
Dosing
Adult
1-2 gtt in the eye(s) qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, mycobacterial, and fungal eye infections; avoid coadministration with steroid combinations after
uncomplicated removal of a foreign body from cornea
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Practitioners should be aware that the fluoroquinolones are not as effective against Pneumococcus as they are against other
bacteria; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated
antibiotic therapy

Trimethoprim and polymyxin B (Polytrim)

For ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic.
Available as a solution and ointment. This combination of drugs is effective against the common causes of bacterial conjunctivitis
including group A streptococci, S aureus, H influenzae, S pneumoniae, and pseudomonads.
Dosing
Adult
Solution: 1-2 gtt qid for 1 wk
Ointment: 0.5-ribbon into conjunctival sac qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, fungal, and mycobacterial infections of the eye
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use in deep ocular infections or in those likely to become systemic; prolonged use of antibiotics, or repeated therapy, may
result in bacterial or fungal overgrowth of nonsusceptible organism

Erythromycin (EES, Ery-Tab, Erythrocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein
synthesis to arrest. Effective in the treatment of chlamydial infections.
Dosing
Adult
Adults are treated with doxycycline
Pediatric
50 mg/kg/d PO divided qid for 2 wk
Interactions
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant
effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Contraindications
Documented hypersensitivity; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc);
discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Doxycycline (Bio-Tab, Vibramycin, Doryx)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Doxycycline is a tetracycline class of antibiotic that is effective in the treatment of adult chlamydial infections.
Dosing
Adult
100 mg PO bid for 7-21 d
Pediatric
Not prescribed for pediatric patients
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can
increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing
breakthrough bleeding and increased risk of pregnancy
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider
drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy
through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible
microorganisms. Used in the hospital setting for neonatal gonorrheal infections.
Dosing
Adult
Adults use ceftriaxone/doxycycline regimen
Pediatric
100 U/kg/d IV divided qid for 1 wk
Interactions
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function and in the setting of seizure disorders

Ceftriaxone (Rocephin)
Third-generation cephalosporin that is an adjunct in the treatment of adult gonorrhea infections. Arrests bacterial growth by binding
to one or more penicillin-binding proteins.
Dosing
Adult
125 mg IM single dose, followed by a 1-wk course of doxycycline 100 PO bid for 7-21 d
Pediatric
Not for use in pediatric population
Interactions
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase
nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible
organisms may occur with prolonged use or repeated therapy; caution in breastfeeding women and in the setting of renal disease
or seizure disorders

Tobramycin ophthalmic (Tobrex)

Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell
membrane. Available as a solution, ointment, and lotion.
Dosing
Adult
Solution: 1-2 gtt qid for 1 wk
Ointment: Apply 0.5-inch ribbon in conjunctival sac bid/tid qid for 1 wk
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Interactions
Effects decrease when used concurrently with gentamicin
Contraindications
Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; steroid combinations after uncomplicated
removal of a foreign body from cornea also should avoid using this product
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics may result in
bacterial or fungal overgrowth of nonsusceptible organisms

Neomycin (Mycifradin)
Used in the treatment of minor infections. Inhibits bacterial protein synthesis and growth.
Dosing
Adult
Apply 0.5-inch (1/25 cm) ribbon to affected eye(s) qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Absorption of neomycin is possible and may cause nephrotoxicity and ototoxicity; prolonged use may result in overgrowth of
nonsusceptible organisms; may irritate ocular surface, resulting in mild injection of the conjunctiva and punctate staining of the
cornea

Ofloxacin ophthalmic (Ocuflox)

Pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. Inhibits bacterial growth by inhibiting DNA gyrase.
Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to ofloxacin.
Dosing
Adult
1-2 gtt in affected eye(s) qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Failure to respond after treating for 2-3 d may indicate presence of resistant organism or another causative agent; do not use in
ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy

Levofloxacin ophthalmic (Quixin)

S (-) enantiomer of ofloxacin. Inhibits DNA gyrase in susceptible organisms, thereby inhibiting relaxation of supercoiled DNA and
promoting breakage of DNA strands.
Dosing
Adult
1-2 gtt in affected eye(s) qid for 1 wk
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Failure to respond after treating for 2-3 d may indicate presence of resistant organism or another causative agent; do not use in
ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy

Gatifloxacin ophthalmic solution 0.3% (Zymar)

Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. Elicits a dual mechanism of action by
possessing an 8-methoxy group, thereby inhibiting the enzymes DNA gyrase and topoisomerase IV. DNA gyrase is involved in
bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial
cell division. Indicated for bacterial conjunctivitis due to Corynebacterium propinquum, S aureus, Staphylococcus epidermidis,
Streptococcus mitis, S pneumoniae, or H influenzae.
Dosing
Adult
Days 1-2: Instill 1 gtt into affected eye(s) q2h while awake; not to exceed 8 administrations/d
Days 3-7: Instill 1 gtt into affected eye(s) up to 4 times/d while awake
Pediatric
<1 year: Not established
>1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For ophthalmic use only; commonly causes conjunctival irritation, increased lacrimation, corneal inflammation, and papillary
conjunctivitis; less common adverse effects include conjunctival hemorrhage, dry eye, eye discharge, eye irritation, eye pain, eyelid
swelling, headache, red eye, reduced visual acuity, and taste disturbance

Besifloxacin ophthalmic (Besivance)

Quinolone antimicrobial ophthalmic susp indicated for bacterial conjunctivitis. Susceptible bacteria include CDC coryneform group
G (Corynebacterium pseudodiphtheriticum, Corynebacterium stratum), Haemophilus influenza, Moraxella lacunata,
Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Streptococcus mitis,
Streptococcus oralis, Streptococcus pneumoniae,and Streptococcus salivarius. Available as a 0.6% ophthalmic suspension.
Dosing
Adult
Instill 1 gtt in affected eye(s) tid (4-12 h between doses) for 7 d
Pediatric
<1 year: Not established
≥ 1 year: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In clinical trials, adverse effects occurred in <3% of patients and included redness of eyes, blurred vision, eye pain, eye irritation,
eye itching, and headache; do not use with contact lens (remove and do not wear contacts during course of therapy and with
symptoms of bacterial conjunctivitis); for topical ophthalmic use only; prolonged use may lead to bacterial resistance
Follow-up
Further Inpatient Care
 Inpatient care for bacterial conjunctivitis would be provided only in the setting of hospitalization for other reasons. It is
important to realize that, in the inpatient setting, the differential diagnosis must be carefully considered since the patients
tend to be ill. Therefore, it is more common to see a red eye due to endogenous endophthalmitis or an infected corneal
ulcer in this population.
 Serious consideration should be given to admitting patients with hyperacute bacterial conjunctivitis if the entire cornea
cannot be visualized, as there may be an early corneal ulceration, especially in Neisseriainfections.[3 ]Topical antibiotic,
proper hygiene, and isolation are considerations for these patients.
Deterrence/Prevention
 Hygiene and avoidance of close contact accomplish deterrence of bacterial conjunctivitis with infected individuals.
Complications
 Bacterial conjunctivitis seldom leads to complications. General concerns include membrane formation and subsequent
scarring of the punctum; corneal ulcer when the epithelium is not intact; and symblepharon from severe inflammation.
 In eyes with previous intraocular surgery, particularly with filtering blebs, endophthalmitis could result.
Prognosis
 The prognosis for complete recovery without sequelae is excellent in bacterial conjunctivitis.
 Only cases with extremely pathogenic bacteria, such as Chlamydia trachomatis or N gonorrhoeae, are expected to
develop complications.
Patient Education
 Patients and household members should be educated to pay attention to hygiene and the avoidance of close contact with
the infected individual.
Miscellaneous
Medicolegal Pitfalls
 Medicolegal concerns do arise in connection with bacterial conjunctivitis. As with all medical practice, careful discussion
and documentation is paramount. A few general guidelines are helpful.
o Know the differential diagnosis.
o Perform an eye examination and, in particular, document that iritis and acute glaucoma have been ruled out.
o The physician should be aware of more unusual conditions, such as carotid-cavernous fistula.
o Always consider Chlamydia or N gonorrhoeae in the differential diagnosis. Be sure to treat systemically and ask
for advice from other specialists when needed.
o Instruct patients to report to the clinic if they do not recover completely in a timely manner, so that therapy can be
reassessed.
o Consider culture and conjunctival scrapings for resistant cases.
o Be aware of drug alerts, such as the one in early 2006 related to a contaminated commercial contact lens
solution.
Special Concerns
 Of special concern is the care of ophthalmia neonatorum. The practitioner should make sure that appropriate prophylaxis
is administered and that suspected cases are managed properly. 
  Also of special concern is trachoma, a devastating disease. See Trachoma.

What is VISION 2020?

VISION 2020 is the global initiative for the elimination of avoidable blindness, a joint programme of the World Health Organization
(WHO) and the International Agency for the Prevention of Blindness (IAPB) with an international membership of NGOs,
professional associations, eye care institutions and corporations.

Up to 80% of the world's blindess is avoidable.

Avoidable blindness is defined as blindness which could be either treated or prevented by known, cost-effective means. Although
there are many other causes of vision impairment, VISION 2020 seeks to address the main causes of avoidable blindness, in order
to have the greatest possible impact on vision loss worldwide.

Target disease areas for VISION 2020 are:

Cataract

Refractive Error

Trachoma

Childhood Blindness

Low Vision

Onchocerciasis/River Blindness

Glaucoma

Diabetic Retinopathy

Age Related macular degeneration

Trachoma
A specific communicable keratoconjunctivitis usually of chronic evolution caused by the chlamydia trachomatis, primarily affecting
the superficial epithelium, characterized by formation of follicles, papillary hyperplasia and pannus, the natural reolution of which is
by cicatrization involving potentially considerable visual disability. (Duke-Elder)
It means rough (Greek)
Epidemiology
Worldwide
 500 million affected
 2 million are blind
 15.5 % of global blindness
Nepal
 6.5 % (1 million) of population affected
 2.4 % of blindness
 commonest in western and far western terai (Bheri & Seti zone) Chettry, Magar & Tharu
Disease Characteristics
 Poverty, dirt, flies, poor sanitation, etc.
  F>M
 Transmission by direct inoculation by finger, flies and fomites.
 Prevalence a fly population in a region
 Incubation period is 5 – 12 days
 Age commonest in childhood
 Reservoir of infection children with active disease
Clamydia trachomatis
 A, B, Ba & C ® Trachoma (commonest is C)
 D – K ® Inclusion conjunctivitis
 L1, L2 & L3 ® Lymphogranuloma venereum
 Elementary body (300 nm, don’t divide, infectious) ® Reticulate body (1000 nm, divide, non-infectious) ®
intracytoplasmic inclusion body (Halberstaedter – von Prowazek)
 
Pathology
 Primary epithelial lesion of conjunctiva and cornea
 Chronic inflammation characterized by papillary hypertrophy of epithelium and lymphoid infiltration of
subepithelial tissue.
Follicle
 Mass of mononuclear cells surrounded by phagocytes, giant phagocytes (Leber’s cells), polymorphs, mast cells
and eosinophils.
 May be large (upto 5 mm)
 Central necrosis ® mature (Sago grain) ® cicatrization
 Many follicles may coalesce ® Folliculoma of Pascheff
Papillae
 Epithelium undergoes hypertrophy and is thrown in folds to form papillae.
 Between adjacent papillae pseudoglands may form ® retention cysts and concretions
Pannus
 Subepithelial infiltration and vascularization of peripheral cornea contiguous with the limbus first between
epithelium and the Bowman’s membrane followed by destruction of the latter.
Other changes
 Increased Goblet cells
 Cellular infiltration of tarsus ® thickening ® degeneration ® softening
 Lacrimal gland infiltration
 Infiltration of lacrimal sac and dacryolith formation
 Decrease Tear lysozyme
 Increase C3 & Factor B in tears and corresponding  decrease in serum.
Clinical Features
Conjunctiva
 Congestion, irritation, watering, discharge & photophobia
 Follicles gray white nodule with surrounding blood vessels
uppper trasal conjunctiva
Upper fornix
less commonly in the lower fornix, plica & bubar conjunctiva
 Papillary Hyperplasia of epithelium each with a central twig of vessel
give rise to a velvety appearance of conjunctiva
formation of concretions
  Scarring 
Stellate
Mosaic pattern
Arlt’s line
 
Cornea
 Follicles at limbus (Herbert’s follicles)
surrounded by vessels (Herbert;s rossettes)
 Pannus 
Progressive: infiltration extends beyond vascularisation
Regressive: vascularisation extends beyond infiltration
Types of Trachomatous Pannus
1. Pannus tenuis: recent and thin
2. Pannus vasculosus: highly vascular
3. Pannus crassus: thick & fleshy
4. Pannus ciccus: cicatricial
Other types of Pannus
1. Pannus trachomaous
2. Pannus leprosus (leprosy)
3. Pannus scrofulous (phlyctenular conjunctivitis)
4. Pannus degenerativus (atrophic bulbi, glaucoma, etc.)
 Superficial keratitis & punctate epithelial defects
 Herbert’s pits: scarring of limbal folicales initially gives rise to a depressed scar which later fills up and gets
pigmented
 Opacification of cornea
Classification of Trachoma
McCallan (1908)
Stage I Incipient Trachoma (Infiltration)
 Immature follicles on upper tarsus
 Minimal papillary hypertrophy
 Faint subepithelial opacities with diffuse punctate keratitis
 Early pannus
Stage II Established Trachoma (Florid infiltration)
IIa Follicular Hypertrophy Predominant
 Mature well defined sago grain follicles
 Advanced keratitis
 Limbal follicles
 Advanced pannus with subepithelial infiltration and corneal haze
IIb Papillary Hypertrophy Predominant
 Papillary hypertrophy obliterating the follicles
 Intense cellular infiltration
 Pannus & infiltration of upper limbus
 Necrosis of follicles at limbus and tarsus
Stage III Cicatrising Trachoma (Scarring)
 Follicular necrosis & scarring with island of follicles & papillae inbetween
  Beginning of entropion and trichiasis
 Gross pannus
 Usually denotes re-infection
Stage IV Healed Trachoma (Sequelae)
 Tarsal conjunctiva completely scarred but pattern smooth, mosaic or Arlt’s line
 Cornea free of infiltrates anmd staining
 Sequelae
WHO Classification (1987)
Meant to be used by field workers
TF Trachomatous Inflammation Follicular
> 5 folicles (> 0.5 mm diameter) on upper tarsal conjunctiva
TI Trachomatous Inflammation Intense
inflammation & papillary hypertrophy obscurring > ½ of tarsal vessels
TT Trachomatous Trichiasis
at least 1 trichiatic cilia rubbing on theglobe or evidence of its recent removal
TS Trachomatous Scarring
obvious trachomatous scarring of upper tarsal conjunctiva
CO Corneal Opacity
Trachomatous corneal opacity at least a part of which extends over the pupil
Diagnostic Criteria
At least 2 of following:
1. Follicles on upper tarsal conjunctiva
2. Limbal follicles or Herbert’s pits
3. Typical conjunctival scarring
4. Vascular pannus most marked in the superior limbus
Sequelae
1. Distortion of lids
2. Entropion
3. Trichiasis
4. Ectropion (hypertrophy of conjunctiva)
5. Herbert’s pits
6. Ptosis (tylosis & infiltration of LPS)
7. Madarosis
8. Posterior symblepharon
9. Parenchymatous xerosis
10. Defective lid closure, lid deformity & deficient tear film ® corneal damage.
11. Cicatrization involving lacrimal drainage & dacryolith formation ® epiphora
12. Glaucoma (perilimbal fibrosis & infiltration of the outflow channels)
 
Secondary Infection
H. aegyptius (commonest)
Complications
1. Corneal ulcer
 2. Iritis
Differential Diagnosis
1. Folliculosis
2. Toxic follicular conjunctivitis: Molluscum contagiosum, Topical drugs,Eye cosmetics
3. Bacterial e.g. Moraxella
4. Axenfeld’s Follicular Conjunctivitis
5. Chronic follicular Conjunctivitis
6. Perinaud’s Oculoglandular Syndrome
7. Vernal Conjunctivitis
Laboratory Diagnosis
Detection of HP bodies on smear
1. Iodine stain
2. Giemsa stain
3. Immunoflourescent stain
4. Cytology
Isolation of Chlamydia
1. Yolk sac culture
2. Tissue culture on irradiated McCoy Type II cells
Serology
1. Complement fixation test
2. Immunodiffusion Assay
3. Radioisotope Assay
4. Microimmunoflourescence
5. ELISA
6. Serial Radial Hemolysis
Cutaneous Hypersensitivity
 
Treatment
Historical
1. Copper Sulphate
2. Silver Nitrate
3. Gonoccocal pus
4. Scarification
5. Lid Excision
Current
Topical
 Oint. Tetracycline 1 % 2-4 times/day for 6 weeks
 Oint. Erythromycin 1 % 2-4 times/day for 6 weeks
 G. Sulphacetamide 20 % QID for 6 weeks
Systemic
 Tetracycline 250 mg QID PO for 3-4 weeks
 Erythromycin 250 mg QID PO for 3-4 weeks
 Doxycycline 250 mg BD PO for 3-4 weeks
  Azithromycin 20 mg / kg body weight single dose
Surgical Treatment
 Concretions are removed with hypodermic needle
 Trichiasis is dealt with by epilation, electrolysis or cryotherapy
 Entropion by appropriate operation
Mild to Moderate: Wedge resection of tarsus (Fox’s modification of Streatfield – Snellen’s Operation)
Moderate to Severe: Tarsal Fracture (Ballen’s modification of Burrow’s operation)
Prophylaxsis
Mass or Blanket Therapy
Criteria
 Prevalence > 5 % in children < 10 years of moderate to severe trachoma
Schedule
 Ointment Tetracycline OD for 10 days or BD for 5 days, every month for 6 months.
Public health Measures
 Water supply to promote general hygiene
 Better sanitation
 Controlling fly population
 Health & hygiene education of school children
Vaccine
 Major Outer Membrane Protein (MOMP) Vaccine (under investigation)