• Dilated conjunctival capillaries with leukocytic infiltration and edema of conjunctiva and substantial propria
• In children with competent lymphocyte function (>3 months of age), visible conjunctival lymphoid follicles may develop.

• Viral conjunctivitis is extremely common, and highly contagious. Adenovirus is the common cause.
• Contagious conjunctivitis may also be caused by bacteria (staphylococci, streptococci, and Haemophilus). Serious complications are rare.
• Ophthalmia neonatorum (neonatal conjunctivitis) remains a significant cause of blindness worldwide.
• Chlamydia, herpes simplex, and chemicals such as silver nitrate are other causes.

• Extremely rare for common bacterial, viral, or allergic conjunctivitis
• Blindness may result from untreated neonatal conjunctivitis.

• Chemical conjunctivitis
  • Noninfectious, mild, self-limited
  • Result of silver nitrate administration (Credé prophylaxis)
• Birth trauma
  • Unilateral, often with associated eyelid contusion
  • History of forceps use or difficult delivery
• Congenital glaucoma
  • Mild conjunctival redness, minimal discharge
  • Look for enlarged eye, cloudy cornea, tearing, and photophobia
• Nasolacrimal duct obstruction
  • Unilateral or bilateral discharge
  • May be clear to mucopurulent with reflux from nasolacrimal sac
  • Usually, conjunctiva is white and uninflamed

• Preseptal cellulitis
  • Early eyelid edema/erythema
  • Looks like conjunctivitis, especially in young children, who are difficult to examine
  • Motility deficit, proptosis, decreased vision, afferent pupillary defect—orbital cellulitis
• Keratitis
  • Keratitis signifies corneal infection and may have associated conjunctivitis.
  • Primary herpes keratitis is associated with vesicular eyelid rash and pain.
  • Consult an ophthalmologist for specific treatment. Bacterial keratitis may be caused by staphylococci, streptococci, and Pseudomonas; Lyme spirochete; or vitamin A deficiency.
• Iritis
  • Usually unilateral, with or without a history of trauma
  • Photophobia, decreased vision, and constant pain (except associated with juvenile rheumatoid arthritis)
  • A contagious history is rare.
  • Consult an ophthalmologist for full examination, including pupillary dilation.

• Type I ophthalmia neonatorum (<40–60 days of age)
  • Acute perinatal conjunctivitis with purulent discharge
• Type 2 ophthalmia neonatorum
  • “Pink eye”
  • Red, watery eyes with acute onset, with or without upper respiratory tract infection
  • Often, history of similar infection in siblings or contacts
  • Usually viral, occasionally bacterial, commonly self-limited

• Discharge ranges from clear, watery (often viral) to mucopurulent (often bacterial).
• Conjunctiva are inflamed and edematous.
• May have eyelid swelling or submandibular and preauricular lymphadenopathy
• Cornea clear
• Vision, pupils, and motility are normal.
• Refer to an ophthalmologist if vesicular rash is present on eyelids and corneal changes are present (possible herpes simplex).

• Gram stain of discharge (always in ophthalmia neonatorum):
  • Gonococcus (GC): gram-negative intracellular diplococcus
  • Polymorphonuclear leukocytes without bacteria likely chemical (neonatal) or viral conjunctivitis
  • Intracytoplasmic, paranuclear inclusion bodies on Gram stain: Chlamydia
• Culture
  • Thayer-Martin test for GC
  • Viral cultures for herpesvirus and adenovirus are not clinically useful.
  • Chlamydia culture techniques are not widely available.
• Immunofluorescence staining
  • May be useful in identifying Chlamydia infection

• GC: Aqueous penicillin G, 100,000/kg/d IV q.i.d for 7 days or ceftriaxone, 28 to 50 mg/kg/d IV q8 to 12h and ocular irrigation followed by topical 0.5% erythromycin or 1.0% tetracycline ophthalmic ointments q.i.d for 14 days.
• Chlamydia: Oral erythromycin syrup, 12.5 mg/kg/d in four doses for 14 days. Topical 0.5% erythromycin or 1.0% tetracycline ophthalmic ointment q.i.d both eyes for 14 days. Recurrence or intolerance is treated with trimethoprim-sulfamethoxazole, 0.5 mL/kg/d in two divided doses for 14 days and topical ointments as above.
• Herpes simplex: Topical trifluorothymidine (viroptic solution), nine times a day for at least 14 days with or without systemic acyclovir (IV solution)
• Chemical
  • Close observation only
  • Self-limited
• Viral or epidemic keratoconjunctivitis
  • Cool compresses
  • May use empiric antibiotic treatment if bacterial infection is suspected, including erythromycin 0.5%, tetracycline 1% ointment, or polymyxin B solution four times a day.
  • No specific antiadenovirus treatment is available.

• Daily follow-up is necessary for GC, Chlamydia, and herpes simplex virus.
• For epidemic viral conjunctivitis, frequency is dictated by severity (daily to weekly).

• GC conjunctivitis is benign if recognized early, and devastating if misdiagnosed or delayed.
• Chlamydia chronic infection leads to scarring and corneal opacity; chlamydial pneumonia develops in 20% of these patients.
• Viral: usually benign course, but may rarely lead to conjunctival scarring
• HSV may lead to significant visual loss from recurrence and corneal scarring, even with proper therapy.

• Failure to diagnose GC conjunctivitis may lead to corneal perforation (ocular disaster).
• Recommending no follow-up routinely
  • Follow atypical conjunctivitis closely until a more serious disease can be excluded.
  • A nonresponsive or worsening condition needs ophthalmic consultation.
• Treating any red eye with steroids
  • Activates or accelerates unrecognized HSV infection
  • Chronic administration may raise intraocular pressure or cause cataracts.
• Chronic use of empiric broad-spectrum antibiotics for self-limited conjunctivitis promotes bacterial resistance.
• It is critical to rule out GC infection because of the destructive nature of eye disease and associated systemic infection.

Q: Is conjunctivitis contagious?
A: All infectious conjunctivitis is contagious, but to varying degrees. Viral or epidemic keratoconjunctivitis (EKC) is the most contagious. Careful handling of secretions, tissues, towels, bed linens, and strict hand washing usually prevent spread. Wipe surfaces with isopropyl alcohol or dilute bleach to prevent recontamination. GC, Chlamydia, and HSV can be transmitted through infected discharge or secretions, but this is less common. The most common source is the infected birth canal.

Q: Should the patient with “pink eye” (non-GC, non-Chlamydia, non-HSV conjunctivitis) be treated with empiric antibiotics?
A: Empiric treatment with topical antibiotics does little harm except for sulfa-containing compounds. Antibiotic toxicity, including Stevens-Johnson reactions, can occur from sulfa antibiotics, and use of antibiotics long term promotes selection of resistant strains of bacteria.

Bell TA, Grayston JT, Krohn MA, Krommal RA, Eye Prophylaxis Study Group. Randomized trial of silver nitrate, erythromycin and no prophylaxis for the presence of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 1993;92:755–760.

Brown ZA, Vontrer LA, Bonchetti J, et al. Effects on infants of a first episode of genital herpes during pregnancy. N Engl J Med 1977;317:1246–1251.

Crede CSF. Reports from the obstetrical clinic in Leipzig: prevention of eye inflammation in the newborn. Am J Dis Child 1971;121:3–4.

Isenberg SJ, Apt L, Yoshimori R, et al. The source of the conjunctival flora at birth and implications for ophthalmia neonatorum prophylaxis. Am J Ophthalmol 1988;106:458–462.

Chen JY. Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin and no prophylaxis. Pediatr Infect Dis J 1992;11(12):1026–1030.