Conjunctivitis

📚Definitions 

Conjunctiva: Mucous membrane that lines the inside surface of the lids and covers the surface of the globe up to the limbus (the junction of the sclera and the cornea). The portion covering the globe is the "bulbar conjunctiva," and the portion lining the lids is the "tarsal conjunctiva."

Conjunctivitis:  A condition of the eye characterized by redness, itching, or mild pain inside of the eye, often associated with discharge. This should be differentiated from redness and swelling of the eyelid or significant eye pain.

🗺️ Overview

Pink eye/conjunctivitis is a common patient complaint. It can be unilateral or bilateral. The vast majority of cases can be treated by the primary or urgent care physician, although some patients need urgent referral to an ophthalmologist. Acute conjunctivitis is usually benign and self-limited or easily treated. Viruses, bacteria, environmental allergens, and mechanical or chemical irritants comprise the major causative agents.

🚨 Important History

• Seasonal allergy history and active “hay fever” symptoms, including rhinorrhea and especially itchy eyes.
• Concurrent URI symptoms.

• Eye pain, itch, or facial/scalp pain.

• Visual changes/loss.

• Fever.
• Discharge.

• Foreign body sensation.

• Contact lens wearer.

• Glaucoma history.

• Trauma history.

• Concurrent urethritis.

• Recent eye surgery, especially cataract surgery.

• History of rosacea or facial rash.

📹 Video Examination 

• Have the patient lean into the camera for a close look at the eye and have them pull down on the lower eyelid with their finger and look up, down, left, and right.
• Uploaded pictures are helpful with the zoom effect to identify crusting in the eyelashes, eyelid swelling, or surrounding erythema.
• Pupil symmetry (reactivity is difficult to assess on video).

• Extraocular movements.

• Injected conjunctiva (bulbar or tarsal).

• Clarity and smoothness of the cornea.

• Active discharge—purulent, watery, or persistent tearing.

• Patient ill or toxic appearing.

• Lid abnormality (redness or swelling).

• Evidence of pain with blinking and/or sensitivity to light.

• Subconjunctival hemorrhage.
• Facial rash.

🎯 Diagnosis 

Conjunctivitis is a clinical diagnosis of exclusion, made on the basis of history and physical examination. Patients often call all cases of red eye "conjunctivitis" and presume that all cases are bacterial and require antibiotics. When a patient reports "conjunctivitis" or "pink eye," clinicians should not accept that as a diagnosis but should rather review the history, symptoms, and signs prior to treating.

🔀 Differential Diagnosis

• Infectious—viral or bacterial, fungal (contact lens wearer, uncontrolled diabetics, immunosuppressed).
• Allergic.

• Blepharitis.

• Chemical—solvents, skin or hair products, other chemicals.

• Mechanical—trauma.

• (Empyema) Endophthalmitis, post cataract surgery.

• Hemorrhage (e.g., subconjunctival—history of sneezing, straining, coughing, etc., usually not painful).
• Glaucoma/internal derangement.

• Autoimmune rheumatologic: uveitis, iritis (uncommon causes of pink eye)

📩 Referral Indicators 

• Urgent:
  • Impaired vision—inability to read ordinary print with the affected eye.
  • Severe eye pain—routine pink eye is usually uncomfortable but not severely painful.
  • Sensation of a foreign body, which interferes with the patient’s ability to open the eye or keep the eye open. This could indicate an active corneal process. It is to be differentiated from sensations of grittiness or scratchiness or “sand in my eyes,” which is common in routine pink eye conditions.

• Significant photophobia.

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  • Trauma—an injury prior to the pink or red eye.
  • Contact lens wear increases the risk that pink eye is due to keratitis.
  • Concern regarding preseptal or postseptal (periorbital) cellulitis.
  • Floaters or flashing lights.
  • Chemical eye injury.
  • Glaucoma history—the risk of angle-closure glaucoma increases with age; it is typically accompanied by unilateral red eye, headache—often unilateral (specific eye pain is unusual), malaise, nausea, and general distress. Visual acuity decreases as the closure progresses. This uncommon condition is an ocular emergency.

  • Painful facial blisters near eye or on the tip of the nose suggestive of Herpes Zoster.

     

• Non-urgent:
  • Contact lens wearer.
  • Recent trauma with relatively mild symptoms.
  • Possible foreign body.
  • Associated fever or sinus symptoms.
  • Allergy management.

💆 Treatment 

There is no role for corticosteroid use in telemedicine treatment of conjunctivitis. Ophthalmic corticosteroids (either alone or in combination steroid/antibiotic drops) are not indicated in the first-line management of acute conjunctivitis by primary care clinicians. Corticosteroids can cause sight-threatening complications (e.g., corneal scarring, melting, and perforation) when used inappropriately. Chronic ophthalmic corticosteroid treatments can also cause cataract and glaucoma. Ophthalmologists may prescribe topical corticosteroids in certain cases of ocular allergy, viral keratitis, and chronic blepharitis. Use in these conditions should be supervised by an ophthalmologist.

Viral, allergic, mechanical, and chemical conjunctivitis are all self-limited. Non-specific treatment may increase comfort:

• Refresh lubricant drops, 1-2 QID as needed.

• Refresh lubricant ointment, 1/2-inch QHS (may blur vision).

• Warm compress.

Allergic Conjunctivitis:

• Avoid rubbing the eyes, which can degranulate mast cells.

• Lubricant drops to enhance drainage of allergens from the eyes.

• Cool compresses.

• Topical antihistamines: Olopatadine (Patanol) (age 2 and up) or Ketotifen (Zaditrol, Alaway) 1 drop twice daily (age 3 and up).
• Decrease or avoid contact lenses, to which allergens adhere.

• Oral antihistamines as indicated.

• Topical NSAIDs are associated with corneal adverse effects in susceptible patients and should NOT be used to treat allergic conjunctivitis (e.g., Ketorolac).

   

Bacterial Conjunctivitis:

Ointment is preferred over drops for infants. Ointment stays on the lids and can have therapeutic effect even if it is not clear that any of the dose was applied directly to the conjunctiva. Because ointments blur vision for 20 minutes after the dose is administered, drops are preferable for most people who need to read, drive, and perform other tasks that require clear vision immediately after dosing.

Patients should respond to treatment within one to two days by showing a decrease in discharge, redness, and irritation. At this point, it is reasonable to reduce the dose from four times daily to twice daily. Patients who do not respond should be referred to an ophthalmologist.

Adults:

• Polymyxin/trimethoprim drops, 1-2 QID for 5-7 days (> 2 months).
• Ofloxacin 0.3% ophthalmic drops (preferred agent in contact lens wearers) 1-2 drops QID for 5-7 days (> 1 year).
• Ciprofloxacin 0.3% ophthalmic drops (preferred agent in contact lens wearers) 1-2 drops QID for 5-7 days (> 1 year).
• Azithromycin ophthalmic solution is available with less frequent dosing but is more expensive. Availability and emerging resistance are concerns.
• Sulfa drops and sodium sulamyd are not first-line agents.

• Avoid contact lenses until discharge stops, discard lenses, thoroughly wash lens cases, and avoid eye makeup until symptoms have resolved.

   

Contagion

• Both viral and bacterial conjunctivitis are highly contagious. Careful hygiene is recommended, especially if discharge is present.
• If bacterial conjunctivitis is suspected, the patient is considered contagious until they have completed 24 hours of antibiotic treatment.

📘 Coding

ICD-10 Codes

• H10.31 Acute conjunctivitis unspecified right.

• H10.32 Acute conjunctivitis unspecified left.

If you have any questions or would like more information, please reach out to the Delegating Physician.