Patient information: Eye infections (conjunctivitis)

CONJUNCTIVITIS OVERVIEW

Conjunctivitis, also called "pink eye", is defined as an inflammation of the conjunctiva. The conjunctiva is the thin membrane that lines the inner surface of the eyelids and the whites of the eyes (called the sclera, (figure 1). Conjunctivitis can affect children and adults. The most common symptoms of conjunctivitis include a red eye and discharge.

There are many potential causes of conjunctivitis, including bacterial or viral infections, allergies, or a non-specific condition (eg, a foreign body in the eye). All types of conjunctivitis cause a red eye, although not everyone with a red eye has conjunctivitis.

This topic review discusses the signs and symptoms, evaluation, and treatment of the various types of conjunctivitis.

TYPES OF CONJUNCTIVITIS

There are four main types of conjunctivitis: bacterial, viral, allergic, and non-specific. Most cases of infectious conjunctivitis are viral in adults and children, however, bacterial conjunctivitis is more common in children than in adults.

Viral conjunctivitis — Viral conjunctivitis is typically caused by a virus that can also cause the common cold. A person may have symptoms of conjunctivitis alone, or as part of a general cold syndrome, with swollen lymph nodes (glands), fever, a sore throat, and runny nose. (See "Patient information: The common cold in adults" and "Patient information: The common cold in children".)

Viral conjunctivitis is highly contagious. It is spread by contact, usually with objects which have come into contact with the infected person's eye secretions. As examples, the virus can be transmitted when an infected person touches their eye and then touches another surface (eg, door handle) or shares an object that has touched their eye (eg, a towel or pillow case).

The most common symptoms of viral conjunctivitis include redness, watery or mucus discharge, and a burning, sandy, or gritty feeling in one eye. Some people have morning crusting followed by watery discharge, perhaps with some scant mucus discharge throughout the day. The second eye usually becomes infected within 24 to 48 hours.

There is no cure for viral conjunctivitis. (See 'Viral conjunctivitis treatment' below.) Recovery can begin within days, although the symptoms frequently get worse for the first three to five days, with gradual improvement over the following one to two weeks for a total course of two to three weeks. Some people experience morning crusting that continues for up to two weeks after the initial symptoms, although the daytime redness, irritation, and tearing should be much improved.

Bacterial conjunctivitis — Bacterial conjunctivitis is commonly caused by one of four bacteria. The infection is highly contagious, often affecting multiple family members or children within a classroom. Bacterial conjunctivitis is spread by contact, usually with objects which have come into contact with the infected person's eye secretions. As examples, the virus can be transmitted when an infected person touches their eye and then touches another surface (eg, door handle) or shares an object that has touched their eye (eg, a towel or pillow case).

The most common symptoms of bacterial conjunctivitis include redness and thick discharge from one eye, although both eyes can become infected. The discharge may be yellow, white, or green, and it usually continues to drain throughout the day. The affected eye often is "stuck shut" in the morning.

Most types of bacterial conjunctivitis resolve quickly and cause no permanent damage when treated with antibiotic eye drops or ointment. (See 'Bacterial conjunctivitis treatment' below.)

Non-specific conjunctivitis — It is possible to develop a red eye and discharge that is not caused by an infection or allergy. The most common causes include one of the following.

• People with a dry eye may have chronic or intermittent redness or discharge.
• A person whose eyes are irrigated after a chemical splash may have redness and discharge.
• A person with a foreign body (eg, dust, eyelash) in the eye may have redness and discharge for 12 to 24 hours after the object is removed.

All of these problems generally improve spontaneously within 24 hours.

Allergic conjunctivitis — Allergic conjunctivitis (eye symptoms caused by allergies) is discussed in a separate topic. (See "Patient information: Allergic conjunctivitis".)

CONJUNCTIVITIS DIAGNOSIS

The diagnosis of conjunctivitis most often requires an examination by a healthcare provider or eye care specialist because many conditions can cause eye redness.

The healthcare provider may ask the following questions:

• When did the eye problem begin? Has anyone else in the house had a similar problem?
• Is there discharge from the eye continuously? Is the discharge watery, thin and mucus-like, or thick and sticky?
• Are there any non-eye symptoms (eg, coughing, fever, sore throat, nasal congestion, sneezing)?

Referral to eye care specialist — People with the following signs and symptoms may have a more serious problem and should be evaluated immediately by an eye specialist (ophthalmologist or optometrist).

• Eye tenderness
• Difficulty seeing clearly
• Difficulty keeping the eye open or sensitivity to light
• Severe headaches with nausea
• Recent trauma to the eye
• Use of contact lenses

CONJUNCTIVITIS TREATMENT

The treatment of conjunctivitis depends upon the cause. For this reason, it is important to have the correct diagnosis before treatment begins.

Viral conjunctivitis treatment — A topical antihistamine/decongestant eye drop may help to relieve the itching and irritation of viral conjunctivitis. These drops are available without a prescription in most pharmacies (table 1). However, particular care must be taken to avoid spreading viral infections from one eye to the other — apply drops only to affected eye and wash hands thoroughly after application. Similar to cold medicines, this treatment may reduce the symptoms but does not shorten the course of the infection. Another option is to use warm or cool compresses, as needed.

The irritation and discharge may get worse for three to five days before getting better, and symptoms can persist for two to three weeks.

Bacterial conjunctivitis treatment — Bacterial conjunctivitis is usually treated with an antibiotic eye drop or ointment. When started early, treatment helps to shorten the duration of symptoms, although most cases do resolve spontaneously if no treatment is used.

Adults — Adults are usually treated with an antibiotic eye drop or ointment for five to seven days. Redness, irritation, and eye discharge should begin to improve within 24 to 48 hours. If there is no improvement or if the condition worsens within this time, the person should be evaluated by an ophthalmologist.

Contact lens wearers — People who wear contact lenses should be evaluated by a healthcare provider before treatment begins; this is to confirm the diagnosis of conjunctivitis and to be sure that another, more serious condition related to contact lens use (an infection of the cornea), is not present.

People who wear contact lenses should avoid wearing the lenses during the first 24 hours of treatment, or until the eye is no longer red. The contact case should be thrown away and the contacts disinfected overnight or replaced (if disposable).

Children — Children with bacterial conjunctivitis may be treated with antibiotic eye drops or ointment. Ointment is generally preferred for young children and those who have difficulty applying eye drops. Ointment should be applied inside the lower eyelid. Even if the ointment is not applied directly inside the eyelid, it is usually effective because it sticks to the lid and is spread with blinking. Vision may be blurred for up to 20 minutes after use of ointment.

Return to work/school — The safest approach to avoid spreading viral and bacterial conjunctivitis to others is to stay home until there is no longer any discharge from the eye(s). However, this is not practical for most students and for those who work outside the home. Most daycare centers and schools require that students receive 24 hours of eye drops or ointment before returning to school. This treatment helps to prevent the spread of bacterial conjunctivitis, but is not necessary or helpful for children with viral conjunctivitis.

Viral conjunctivitis is similar to a cold because it spreads easily between people. Younger children, who may not remember to wash their hands or avoid touching their eyes, should probably not attend school until the discharge has resolved. Older students or adults may choose to attend school/work, although they should limit close contact with others.

In addition, adults who have contact with the very old, the very young, and people with a weakened immune system should limit contact with these susceptible individuals.

Non-specific conjunctivitis treatment — The conjunctiva heals quickly after it is injured, and non-specific conjunctivitis usually resolves within a few days without any treatment. However, the eye may feel better faster when it is treated with a lubricant, such as drops or ointments (table 2). These products are available without a prescription in most pharmacies. Preservative-free preparations are more expensive and are necessary only for people with a severe case of dry eye and those who are allergic to preservatives.

Lubricant drops can be used as often as hourly with no side effects. The ointment provides longer lasting relief but blurs vision temporarily. For this reason, some people use ointment only at bedtime. It may be worthwhile to switch brands if one brand of drop or ointment is irritating, since each preparation contains different active and inactive ingredients and preservatives.

Antibiotic or steroid eye drops/ointments are not recommended unless there is a specific reason they are needed (eg, a bacterial infection or inflammatory condition). Using these treatments when they are not needed can lead to serious complications. If the symptoms of conjunctivitis do not improve within two weeks, an examination with an ophthalmologist may be recommended.

CONJUNCTIVITIS PREVENTION

Bacterial and viral conjunctivitis are both highly contagious and spread by direct contact with secretions or contact with contaminated objects. Simple hygiene measures can help minimize transmission to others.

• Adults or children with bacterial or viral conjunctivitis should not share handkerchiefs, tissues, towels, cosmetics, or bed sheets/pillows with uninfected family or friends.
• Hand washing is an essential and highly effective way to prevent the spread of infection. Hands should be wet with water and plain soap, and rubbed together for 15 to 30 seconds. It is not necessary to use antibacterial hand soap. Teach children to wash their hands before and after eating and after touching the eyes, coughing, or sneezing.
• Alcohol-based hand rubs are a good alternative for disinfecting hands if a sink is not available. Hand rubs should be spread over the entire surface of hands, fingers, and wrists until dry, and may be used several times. These rubs can be used repeatedly without skin irritation or loss of effectiveness.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: The common cold in adults
Patient information: The common cold in children
Patient information: Allergic conjunctivitis

Professional Level Information:
Allergic conjunctivitis
Conjunctivitis
Evaluation of the red eye

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Allergy, Asthma, and Immunology

      (www.aaaai.org)

[1-3]