Connecticut Children’s ophthalmologist Caroline DeBenedictis, MD shares answers to common questions about conjunctivitis.

What is conjunctivitis?

Conjunctivitis is inflammation or infection of the conjunctiva, which is the clear layer of tissue covering the sclera (white portion of the eye). Dilation of the conjunctival vessels occurs, resulting in hyperemia of the conjunctiva. This red or pink coloration of the conjunctiva is the hallmark of conjunctivitis. Causes include but are not limited to infectious (bacterial, viral), inflammatory (allergic, immune-mediated), and chemical (medication). Conjunctivitis signs and symptoms include hyperemia of the conjunctiva, tearing, discharge, foreign body sensation, itching, and chemosis (conjunctival edema). There can be overlap in signs and symptoms. History is key in differentiation between the types of conjunctivitis.

What is “pink eye”?

“Pink eye” is a descriptive term used to describe a hyperemic eye. When most parents or patients talk about “pink eye”, they usually mean a viral conjunctivitis. However, not all “pink eye” or conjunctivitis is viral or infectious in etiology.

Viral conjunctivitis

When caused by a viral infection, patients often have a history of a recent upper respiratory infection or close contact with sick individuals. The pre-auricular nodes can be enlarged. Conjunctivitis symptoms often start in one eye, involving the fellow eye a few days later and are associated with watery discharge. Adenovirus is the most common cause. Viral conjunctivitis is self-limited although symptoms can worsen for the first 4-7 days after onset before improving. Time until resolution varies from 1 to 3 weeks depending on serotype. As viral conjunctivitis is highly contagious, patients should avoid touching their eyes and close contact with others (shaking hands, sharing towels/pillows). Frequent handwashing is imperative. Antibiotic drops are not effective in treating viral conjunctivitis although artificial tears and cool compresses can help soothe the eye if irritated. Topical antihistamine drops may be used for itching as needed. Work and school restrictions are recommended to decrease spread of infection. The patient is contagious as long as the eye is red which can range from 5 days up to three weeks.

Commonly, parents request antibiotic drops due to school policies. Unfortunately these policies do not account for the different types of infectious conjunctivitis. A child with viral conjunctivitis is contagious while the eye is red. Antibiotic drops are not proven efficacious in treating viral conjunctivitis. Therefore, it is up to the primary care physician to decide how to best treat the patient and counsel the family in this situation.

Special considerations for viral conjunctivitis include Epidemic Keratoconjunctivitis (EKC) and Herpes Simplex Virus Conjunctivitis (HSV). EKC is caused by subgroup D adenovirus serotypes 8, 19, and 37. This is a severe form of viral conjunctivitis often mistaken for pre-septal or orbital cellulitis. Patients with EKC have a significant amount of eyelid edema and chemosis. They also get blurry vision and photophobia. Patients with EKC are highly contagious as long as the eye is red or up to 21 days. Patients with HSV conjunctivitis likely have a history of fever blisters, cold sores, or recurring unilateral conjunctivitis.

Red flags for patients with viral conjunctivitis include significant pain or photophobia, worsening vision, worsening symptoms after the first few days from onset, or no signs of improvement after 1 week. These patients should be considered for referral to an eye specialist to confirm diagnosis and tailor the treatment regimen.

Bacterial conjunctivitis

Bacterial conjunctivitis is caused by direct exposure from infected individuals, proliferation of native skin flora, or spread from the patient’s own nasal and sinus mucosa. Newborns can be exposed during labor and delivery. Common causes include Staphylococcus aureus, Staphylococcus epidermis, Haemophilus influenza, Streptococcus pneumonia, and Moraxella catarrhalis. Patients have foreign body sensation and purulent or mucopurulent discharge. Itching is less frequently associated with bacterial conjunctivitis. There can be matting of the eyelids. Frequent handwashing and decreased close contact with others are recommended. Although non-virulent cases of bacterial conjunctivitis are self-limited within 1-2 weeks, most recommended treatment regimens include topical antibiotics to shorten the course and contagious period. This includes antibiotic drops or ointment 4 times per day for 5-7 days. Antibiotic choice depends on patient allergy, resistance patterns, suspected pathogen, availability, and cost. Broad spectrum options include polytrim, bacitracin, aminoglycosides, and fluorquinolones. It is reasonable to treat with polytrim or bacitracin unless there are concerns regarding bacterial resistance or allergies. Mode of delivery, drop or ointment, should be discussed with the parent as they may feel one option is easier to apply at home than the other.

Allergic conjunctivitis

Itching is the predominant symptom in allergic conjunctivitis along with redness and watery discharge. There can also be associated lid edema and chemosis. Allergic conjunctivitis is usually bilateral and patients often have a history of allergies or atopic conditions. Treatment begins with eliminating the offending agent if possible. Cool compresses and topical antihistamine drops can control the symptoms.

Vernal conjunctivitis is a more severe form of allergic conjunctivitis that can cause white raised dots around the limbus (where sclera meets cornea) called Horner-Trantas dots. These patients should be referred to an eye care specialist for help in management.

Ophthalmia neonatorum

Ophthalmia neonatorum or neonatal conjunctivitis is a conjunctivitis occurring within the first 4 weeks of life. Etiologies include chemical, bacterial, or viral. Chlamydial, gonococcal, and HSV infections should be considered in this age group. Birth through caesarian section does not exclude the possibility of these infections if there is prolonged or premature rupture of membranes. Neonatal conjunctivitis can cause significant morbidity and mortality without early detection. Treatment depends on suspected organism and results of gram stain, Giemsa stain, and culture. A combination of topical and systemic medication is used to decrease the chance of permanent scarring, blindness, and mortality.

Red flags in conjunctivitis

Signs and symptoms that should prompt reconsideration of diagnosis or referral to an eye care specialist include pain or photophobia, worsening symptoms, no improvement within appropriate time frame, trauma, decreased vision, or no response to treatment. Contact lens wearers with a red eye associated with pain should be referred to an eye care specialist

Should I use steroids?

No, steroids should not be prescribed for the eye by anyone other than an eye care specialist. Some conditions worsen with steroids. In addition, an eye doctor monitors for side effects, including glaucoma and cataract.