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Emergency And Acute Medicine – Conjunctivitis
Description
Conjunctivitis is inflammation of the conjunctiva caused by a wide range of infectious and noninfectious etiologies. It is commonly referred to as “pink eye” and is a frequent reason for emergency and primary care visits.
Etiology
Bacterial causes include Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. Gonococcal conjunctivitis is an ophthalmic emergency because of rapid corneal invasion and risk of blindness. Chlamydial conjunctivitis occurs through autoinoculation from genital secretions and is common in newborns. Viral conjunctivitis is most often due to adenovirus, including epidemic keratoconjunctivitis, and is frequently associated with upper respiratory infections. Herpes simplex virus may cause recurrent ocular disease, and corticosteroids are contraindicated. Allergic conjunctivitis is associated with atopy and nasal symptoms. Contact-related conjunctivitis may result from chemical irritation or hypersensitivity, with Pseudomonas species commonly implicated in contact lens users.
Clinical Features
Patients typically present with red eye, burning or gritty sensation, foreign body sensation, discharge, eyelid sticking on awakening, chemosis, eyelid edema, tearing, and itching. Bacterial conjunctivitis produces mucopurulent discharge. Gonococcal infection causes hyperacute, copious purulent discharge within 12 hours, severe chemosis, and eyelid swelling. Chlamydial conjunctivitis presents with lacrimation, mucopurulent discharge, photophobia, and frequent concomitant genital infection. Viral conjunctivitis often causes watery discharge, preauricular lymphadenopathy, and spreads to the other eye within 24–48 hours. Epidemic keratoconjunctivitis may reduce vision due to corneal infiltrates. Allergic conjunctivitis is marked by intense itching and watery discharge. Contact-related disease may present acutely with corneal ulceration but normal visual acuity and intraocular pressure.
Essential Evaluation
History should assess onset, exposures, sick contacts, sexual history, medication or cosmetic use, and systemic disease. A careful eye examination including slit-lamp evaluation and fluorescein staining is essential.
Diagnostic Tests And Interpretation
Routine cultures are not required in uncomplicated cases. Indications for bacteriologic studies include ophthalmia neonatorum, suspected gonococcal infection, immunocompromised patients, systemic illness, or lack of improvement within 48–72 hours. Identification of gram-negative intracellular diplococci on Gram stain is sufficient to initiate gonococcal therapy. Serologic testing such as rapid plasma reagin may be indicated when sexually transmitted infection is suspected.
Differential Diagnosis
Conditions to exclude include acute angle-closure glaucoma, anterior uveitis, keratitis, corneal abrasion, foreign body, dry eye, scleritis, episcleritis, nasolacrimal obstruction, and subconjunctival hemorrhage.
Initial Management
Empiric treatment with broad-spectrum topical antibiotics is appropriate for most suspected bacterial cases. Systemic therapy is mandatory for gonococcal, chlamydial, meningococcal infections, ophthalmia neonatorum, and severe disease. Herpetic infections require ophthalmology consultation.
Emergency Department Management
Discharge should be gently cleaned from the eye, and contact lens wearers must discontinue lens use and discard contaminated lenses. Emphasize hand hygiene and avoidance of shared towels or cosmetics. Warm soaks help remove debris. Bacterial conjunctivitis is treated with topical antibiotics continued for 48 hours after symptom resolution. Failure to improve within 48–72 hours warrants culture and reevaluation. Viral conjunctivitis requires supportive care only. Allergic conjunctivitis is treated with antihistamine or mast cell stabilizer drops, artificial tears, and avoidance of triggers. Noninfectious irritation is managed with lubricating drops or ointments.
Medications
All contact lens wearers require antipseudomonal coverage. Common topical agents include ciprofloxacin, gentamicin, tobramycin, erythromycin, and sulfacetamide. Chlamydial infection requires systemic therapy with doxycycline or erythromycin. Gonococcal conjunctivitis requires parenteral ceftriaxone plus topical antibiotics. Viral conjunctivitis is managed with artificial tears and topical antihistamines. Herpetic disease is treated with antiviral ophthalmic agents. Allergic conjunctivitis responds to antihistamine, mast cell stabilizer, or NSAID drops.
Pediatric Considerations
In neonates, conjunctivitis often reflects systemic infection acquired during birth. Chemical conjunctivitis occurs within the first 36 hours of life. Ophthalmia neonatorum occurs within the first four weeks and is commonly caused by gonococcal, chlamydial, or herpetic infection. Ointments are preferred over drops in infants.
Disposition And Follow-Up
Hospital admission is required for known or suspected gonococcal infection at any age. Most patients can be discharged with close follow-up.
Follow-Up Recommendations
Ophthalmology follow-up is recommended for all bacterial conjunctivitis cases and is mandatory for epidemic keratoconjunctivitis or severe disease.
Key Clinical Insights And Common Errors
Conjunctivitis is highly contagious, particularly viral forms and epidemic keratoconjunctivitis, which may remain transmissible for up to two weeks. Strict hand hygiene and meticulous disinfection of examination equipment are essential to prevent spread. Corticosteroids should be used with extreme caution, as they can exacerbate unrecognized herpes simplex infection and worsen outcomes.
Description
Conjunctivitis is inflammation of the conjunctiva caused by a wide range of infectious and noninfectious etiologies. It is commonly referred to as “pink eye” and is a frequent reason for emergency and primary care visits.
Etiology
Bacterial causes include Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. Gonococcal conjunctivitis is an ophthalmic emergency because of rapid corneal invasion and risk of blindness. Chlamydial conjunctivitis occurs through autoinoculation from genital secretions and is common in newborns. Viral conjunctivitis is most often due to adenovirus, including epidemic keratoconjunctivitis, and is frequently associated with upper respiratory infections. Herpes simplex virus may cause recurrent ocular disease, and corticosteroids are contraindicated. Allergic conjunctivitis is associated with atopy and nasal symptoms. Contact-related conjunctivitis may result from chemical irritation or hypersensitivity, with Pseudomonas species commonly implicated in contact lens users.
Clinical Features
Patients typically present with red eye, burning or gritty sensation, foreign body sensation, discharge, eyelid sticking on awakening, chemosis, eyelid edema, tearing, and itching. Bacterial conjunctivitis produces mucopurulent discharge. Gonococcal infection causes hyperacute, copious purulent discharge within 12 hours, severe chemosis, and eyelid swelling. Chlamydial conjunctivitis presents with lacrimation, mucopurulent discharge, photophobia, and frequent concomitant genital infection. Viral conjunctivitis often causes watery discharge, preauricular lymphadenopathy, and spreads to the other eye within 24–48 hours. Epidemic keratoconjunctivitis may reduce vision due to corneal infiltrates. Allergic conjunctivitis is marked by intense itching and watery discharge. Contact-related disease may present acutely with corneal ulceration but normal visual acuity and intraocular pressure.
Essential Evaluation
History should assess onset, exposures, sick contacts, sexual history, medication or cosmetic use, and systemic disease. A careful eye examination including slit-lamp evaluation and fluorescein staining is essential.
Diagnostic Tests And Interpretation
Routine cultures are not required in uncomplicated cases. Indications for bacteriologic studies include ophthalmia neonatorum, suspected gonococcal infection, immunocompromised patients, systemic illness, or lack of improvement within 48–72 hours. Identification of gram-negative intracellular diplococci on Gram stain is sufficient to initiate gonococcal therapy. Serologic testing such as rapid plasma reagin may be indicated when sexually transmitted infection is suspected.
Differential Diagnosis
Conditions to exclude include acute angle-closure glaucoma, anterior uveitis, keratitis, corneal abrasion, foreign body, dry eye, scleritis, episcleritis, nasolacrimal obstruction, and subconjunctival hemorrhage.
Initial Management
Empiric treatment with broad-spectrum topical antibiotics is appropriate for most suspected bacterial cases. Systemic therapy is mandatory for gonococcal, chlamydial, meningococcal infections, ophthalmia neonatorum, and severe disease. Herpetic infections require ophthalmology consultation.
Emergency Department Management
Discharge should be gently cleaned from the eye, and contact lens wearers must discontinue lens use and discard contaminated lenses. Emphasize hand hygiene and avoidance of shared towels or cosmetics. Warm soaks help remove debris. Bacterial conjunctivitis is treated with topical antibiotics continued for 48 hours after symptom resolution. Failure to improve within 48–72 hours warrants culture and reevaluation. Viral conjunctivitis requires supportive care only. Allergic conjunctivitis is treated with antihistamine or mast cell stabilizer drops, artificial tears, and avoidance of triggers. Noninfectious irritation is managed with lubricating drops or ointments.
Medications
All contact lens wearers require antipseudomonal coverage. Common topical agents include ciprofloxacin, gentamicin, tobramycin, erythromycin, and sulfacetamide. Chlamydial infection requires systemic therapy with doxycycline or erythromycin. Gonococcal conjunctivitis requires parenteral ceftriaxone plus topical antibiotics. Viral conjunctivitis is managed with artificial tears and topical antihistamines. Herpetic disease is treated with antiviral ophthalmic agents. Allergic conjunctivitis responds to antihistamine, mast cell stabilizer, or NSAID drops.
Pediatric Considerations
In neonates, conjunctivitis often reflects systemic infection acquired during birth. Chemical conjunctivitis occurs within the first 36 hours of life. Ophthalmia neonatorum occurs within the first four weeks and is commonly caused by gonococcal, chlamydial, or herpetic infection. Ointments are preferred over drops in infants.
Disposition And Follow-Up
Hospital admission is required for known or suspected gonococcal infection at any age. Most patients can be discharged with close follow-up.
Follow-Up Recommendations
Ophthalmology follow-up is recommended for all bacterial conjunctivitis cases and is mandatory for epidemic keratoconjunctivitis or severe disease.
Key Clinical Insights And Common Errors
Conjunctivitis is highly contagious, particularly viral forms and epidemic keratoconjunctivitis, which may remain transmissible for up to two weeks. Strict hand hygiene and meticulous disinfection of examination equipment are essential to prevent spread. Corticosteroids should be used with extreme caution, as they can exacerbate unrecognized herpes simplex infection and worsen outcomes.
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