Author: Section Editor: Deputy Editor

8/23/2021 Conjunctivitis - UpToDate
Author: Deborah S Jacobs, MD

Section Editor: Matthew F Gardiner, MD
Deputy Editor: Jane Givens, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2021. | This topic last updated: Oct 02, 2020.
INTRODUCTION
Conjunctivitis is a common diagnosis in patients who complain of a red eye. It is usually a

benign or self-limited condition, or one that is easily treated. Other causes of red eye are
discussed elsewhere. (See "The red eye: Evaluation and management".)
This topic will review the clinical manifestations, diagnosis, and treatment of conjunctivitis.
Other conditions which may be confused with conjunctivitis include acute angle-closure
glaucoma, iritis, uveitis, and infectious keratitis. In contrast to acute conjunctivitis, these
conditions are sight-threatening and must be managed by an ophthalmologist. They are
discussed elsewhere:
● (See "Angle-closure glaucoma".)

● (See "Uveitis: Etiology, clinical manifestations, and diagnosis" and "Uveitis: Treatment".)
● (See "Herpes simplex keratitis".)
● (See "Complications of contact lenses", section on 'Infectious keratitis'.)
Infectious conjunctivitis in the neonate is discussed separately. (See "Chlamydia

trachomatis infections in the newborn" and "Gonococcal infection in the newborn".)
DEFINITIONS AND ANATOMY
Conjunctivitis literally means "inflammation of the conjunctiva." The conjunctiva is the

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" (
figure 1).
The conjunctiva is comprised of an epithelium and a substantia propria. The epithelium is a

non-keratinized squamous epithelium that also contains goblet cells. The substantia
propria is highly vascularized and is the site of considerable immunologic activity.
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The conjunctiva is generally transparent. When it is inflamed, as in conjunctivitis, it appears

pink or red on general inspection. Up close, the examiner can discern fine blood vessels,
termed "injection," in contrast to extravasated blood, which is seen in subconjunctival
hemorrhage. All conjunctivitis is characterized by a red eye, but not all red eyes are
conjunctivitis. (See "The red eye: Evaluation and management".)
CLASSIFICATION AND EPIDEMIOLOGY
Acute conjunctivitis can be classified as infectious (bacterial or viral) or noninfectious

(allergic, toxic, or nonspecific). The prevalence of each type is different in pediatric and
adult populations [1-3]. Bacterial conjunctivitis is more common in children than in adults.
However, for both adults and children, the majority of infectious cases are viral [4].
CAUSES AND CLINICAL MANIFESTATIONS
Bacterial conjunctivitis
Common presentations — Patients with bacterial conjunctivitis typically complain of

redness and discharge in one eye, although it can also be bilateral. Similar to viral and
allergic conjunctivitis, the affected eye is often "stuck shut" in the morning [5]. The purulent
discharge continues throughout the day and is thick and globular; it may be yellow, white,
or green. The discharge differs from that of viral or allergic conjunctivitis, which is mostly
watery during the day, with a scant, stringy component that is mucus rather than pus. On
examination, patients with bacterial conjunctivitis typically have purulent discharge at the
lid margins and in the corners of the eye which reappears within minutes of wiping the lids.
This contrasts with patients with viral or allergic conjunctivitis, in whom the eyes appear
watery and where there may be mucus present on close inspection of the tear film or if one
pulls down the lower lid, but pus does not appear spontaneously and continuously at the
lid margin and in the corners of the eye.
Bacterial conjunctivitis is commonly caused by Staphylococcus aureus, Streptococcus

pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. S. aureus infection is more
common in adults; the other pathogens are more common in children [6].
Bacterial conjunctivitis is highly contagious and is spread by direct contact with the patient
and their secretions or with contaminated objects and surfaces. Outbreaks due to S.
pneumoniae have been described on college campuses and among military trainees [7,8].
Hyperacute bacterial conjunctivitis — Neisseria species, particularly N. gonorrhoeae,

can cause a hyperacute bacterial conjunctivitis that is severe and sight-threatening,
requiring immediate ophthalmologic referral ( picture 1) [9]. The organism is usually
transmitted from the genitalia to the hands and then to the eyes. Concurrent urethritis is
typically present.
The eye infection is characterized by a profuse purulent discharge present within 12 hours
of inoculation [10]; the amount of discharge is striking. Other symptoms are rapidly
progressive and include redness, irritation, and tenderness to palpation. There is typically
marked chemosis (conjunctival edema), lid swelling, and tender preauricular adenopathy.
Conjunctival scrapings should be sent for immediate Gram stain to identify gram-negative
diplococci. Polymerase chain reaction (PCR) can also be used for diagnosis of gonococcal
conjunctivitis [11].
Chronic chlamydial infections
● Trachoma – Conjunctivitis is the major clinical manifestation of active trachoma, a

chronic keratoconjunctivitis caused by recurrent infection with Chlamydia trachomatis.
This disorder that is largely limited to endemic areas in less developed regions and is
discussed separately. Active trachoma, which is most common in children and is
typically asymptomatic, includes redness, discomfort, light sensitivity, and
mucopurulent discharge. (See "Trachoma".)
● Adult inclusion conjunctivitis – Adult inclusion conjunctivitis is not strictly an acute

conjunctivitis but rather a chronic, indolent conjunctivitis. It is a sexually transmitted
infection (STI) caused by certain serotypes of C. trachomatis. Concurrent asymptomatic
urogenital infection is typically present.
The eye infection presents as a unilateral, or sometimes bilateral, follicular

conjunctivitis of weeks’ to months’ duration that has not responded to topical antibiotic
therapy. There can be an associated keratitis. This diagnosis should be considered in
chronic cases among populations at risk for STI.
Diagnosis is confirmed with Giemsa or direct fluorescent antibody (DFA) staining of

conjunctival smears or by culture of swabbed specimens.
Viral conjunctivitis
Common presentations — Viral conjunctivitis is typically caused by adenovirus, with

many serotypes implicated [12]. The conjunctivitis may be part of a viral prodrome followed
by adenopathy, fever, pharyngitis, and upper respiratory tract infection, or the eye infection
may be the only manifestation of the disease. Viral conjunctivitis is highly contagious; it is
spread by direct contact with the patient and their secretions or with contaminated objects
and surfaces [13]. Conjunctivitis can also be part of the prodrome or presentation of other
viral upper respiratory tract infections.

Viral conjunctivitis typically presents as conjunctival injection with watery or mucoserous

discharge ( picture 2) and a burning, sandy, or gritty feeling in one eye. Patients may
report "pus" in the eye, but on further questioning they have morning crusting followed by
watery discharge, perhaps with some scant mucus throughout the day.
The second eye usually becomes involved within 24 to 48 hours, although unilateral signs
and symptoms do not rule out a viral process. Patients often believe that they have a
bacterial conjunctivitis that has spread to the fellow eye; they do not appreciate that this is
the ocular manifestation of a systemic illness, even if they are experiencing viral symptoms
at the same time.
On examination there is typically only mucoid discharge if one pulls down the lower lid or
looks very closely in the corner of the eye. Usually there is profuse tearing rather than
discharge. The tarsal conjunctiva may have a follicular or "bumpy" appearance ( picture 3
). There may be an enlarged and tender preauricular node.
Viral conjunctivitis is a self-limited process. The clinical course parallels that of the common
cold. While recovery can begin within days, the symptoms frequently get worse for the first
three to five days, with very gradual resolution over the following one to two weeks for a
total course of two to three weeks. Just as a patient with a cold can have morning coughing
and nasal congestion or discharge two weeks after symptoms first arise, patients with viral
conjunctivitis may have morning crusting two weeks after the initial symptoms, although
the daytime redness, irritation, and tearing should be much improved.
Conjunctivitis might accompany herpes simplex virus (HSV) keratitis, acute varicella zoster
(chickenpox), or herpes zoster ophthalmicus (V1 shingles), but the conjunctival process is
self-limited, requiring no treatment beyond what would be undertaken for the herpes
keratitis, for acute management of herpes zoster, or for management of chronic sequelae
of herpes zoster ophthalmicus.
Epidemic keratoconjunctivitis — One form of viral conjunctivitis, epidemic

keratoconjunctivitis (EKC), is particularly fulminant and causes a keratitis (inflammation of
the cornea) that typically appears a few days after the initial conjunctivitis. It is typically
caused by adenovirus types 8, 19, and 37 [14]. However, there is clinical variation; the same
viral strain that causes EKC in one patient may cause ordinary viral conjunctivitis in another,
probably due to differences in host immune factors. The corneal and conjunctival
epithelium are both involved. In addition to the typical symptoms of viral conjunctivitis, the
patient develops a foreign body sensation and multiple corneal infiltrates sometimes visible
with a penlight (though easily seen at the slit lamp). The foreign body sensation is severe
enough to preclude opening the eyes spontaneously, and the infiltrates typically degrade
acuity by two or three lines to the 20/40 range.

Keratitis is potentially vision-threatening, and patients should be referred to an

ophthalmologist to confirm the diagnosis and to decide whether a course of ophthalmic
corticosteroids is warranted.
Allergic conjunctivitis — Allergic conjunctivitis is caused by airborne allergens contacting

the eye that trigger a classic type I immunoglobulin E (IgE)-mediated hypersensitivity
response specific to that allergen, causing local mast cell degranulation and the release of
chemical mediators including histamine, eosinophil chemotactic factors, and platelet-
activating factor, among others.
It typically presents as bilateral redness, watery discharge, and itching ( picture 4).
Itching is the cardinal symptom of allergy, distinguishing it from a viral etiology, which is
more typically described as grittiness, burning, or irritation. Eye rubbing can worsen
symptoms. Patients with allergic conjunctivitis often have a history of atopy, seasonal
allergy, or specific allergy (eg, to cats), and other allergic symptoms (eg, nasal congestion,
sneezing, wheezing) may be present.
The clinical findings are the same as those seen in viral conjunctivitis. Both cause diffuse
injection with a bumpy or follicular appearance to the tarsal conjunctiva ( picture 3).
Some allergic conjunctivitis may present with larger papillary rather than follicular reaction.
There is profuse watery or mucoserous, stringy discharge, and both may have morning
crusting. It is the complaint of itching and the history of allergy or hay fever as well as a
recent exposure that distinguishes allergic conjunctivitis.
In some cases of allergic conjunctivitis, there is marked chemosis (conjunctival edema); in

extreme instances, there can be bullous chemosis, in which the bulging, edematous
conjunctiva extends forward beyond the lid margins. Bullous chemosis is most commonly
seen in patients with extreme hypersensitivity to cats. A detailed discussion of allergic
disease is presented separately. (See "Allergic conjunctivitis: Clinical manifestations and
diagnosis".)
Toxic conjunctivitis — Toxic conjunctivitis (also called toxic keratoconjunctivitis) is a

chronic inflammation of the surface of the eye due to an offending agent, usually a
preservative or medication. Toxic conjunctivitis is discussed in a separate topic. (See "Toxic
conjunctivitis".)
Noninfectious, noninflammatory conjunctivitis — Patients can develop a red eye and

discharge that is not related to either an infectious or inflammatory process. The discharge
is more likely mucus than pus. Usually the cause is a transient mechanical or chemical
insult. All of these generally improve spontaneously within 24 hours.
● Patients with dry eye may report chronic or intermittent redness or discharge and may
interpret these symptoms as being related to an infectious cause.
● Patients whose eyes are irrigated after a chemical splash may have redness and
discharge; this is often related to the mechanical irritation of irrigation rather than
superinfection.
● A patient with an ocular foreign body that was spontaneously expelled may have
redness and discharge for 12 to 24 hours.
EVALUATION AND DIAGNOSIS
Distinguishing between types of conjunctivitis — The clinical manifestations of the

different etiologies of acute conjunctivitis are described in detail below. Key distinguishing
features (including examination findings) between bacterial, viral and allergic conjunctivitis
are also presented in the table ( table 1). Patients may report discomfort which is highly
subjective, varies among patients, and could be described as grittiness, burning, foreign
body sensation, or pain. Typically, patients with conjunctivitis of any etiology can open the
eye or eyes spontaneously, which is not the case for keratitis (see "The red eye: Evaluation
and management"). There can be varying degrees of lid swelling and conjunctival chemosis
that is not helpful in discerning etiology.
General approach — 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 calls to report
"conjunctivitis" or "pink eye," clinicians should not accept that as a diagnosis but should
rather review the history, symptoms, and signs prior to treating. A detailed description of
how to take a history and examine a patient with a red eye is discussed elsewhere. (See
"The red eye: Evaluation and management".)
● History – Typical features of conjunctivitis include a history of morning crusting and

daytime redness and discharge. A history of itching is highly suggestive of allergic
conjunctivitis.
It is worthwhile to elicit the character of the ocular discharge, as patients may refer to
all discharge as “pus.” In bacterial conjunctivitis the complaint of discharge
predominates, while in viral and allergic conjunctivitis patients report a burning and
gritty feeling or itching.
A recent history of trauma should prompt investigation for etiologies other than
conjunctivitis.
A history of contact lens use should prompt specific evaluation for keratitis. (See
'Contact lens wearers' below.)

Warning signs for sight-threatening conditions should be excluded. (See 'Reasons for
urgent ophthalmologic referral' below.)
Certain features on history raise concern for more serious diagnoses and should
prompt ophthalmologic referral. These include photophobia, severe headache with
nausea, and severe foreign body sensation. (See 'Reasons for urgent ophthalmologic
referral' below.)
● Examination – On examination, the redness or injection in conjunctivitis should be

diffuse, involving the bulbar (globe) conjunctiva for 360 degrees as well as the
palpebral (tarsal) conjunctiva (the mucus membrane on the inner surface of the lids).
• If the conjunctival injection is localized rather than diffuse, another diagnosis such
as foreign body, pterygium, or episcleritis should be considered. (See "Pterygium"
and "Episcleritis".)
• If the tarsal conjunctiva is spared, suspicion should be raised for keratitis, iritis, and
angle-closure glaucoma. These serious conditions cause a red eye with 360 degree
involvement of the bulbar conjunctiva, often in a ciliary flush pattern, but without
tarsal conjunctival involvement. (See 'Reasons for urgent ophthalmologic referral'
below.)
The diagnosis of conjunctivitis can be made in a red eye if there is discharge, vision is
normal, and there is no evidence of keratitis, iritis, or angle-closure glaucoma (see "The red
eye: Evaluation and management"). In addition, on examination there should be no focal
pathology in the lids such as hordeolum (stye), nodular ulceration or mass suspicious for
neoplasia, or blepharitis (diffuse eyelid margin thickening and hyperemia with lash crusts) (
picture 5). In these other disorders, conjunctival hyperemia, if present, is reactive rather
than primary.
Certain features on examination raise concern for more serious diagnoses and should
prompt ophthalmologic referral. (See 'Reasons for urgent ophthalmologic referral' below.)
Limited role for testing — Cultures or stains are not necessary for the initial diagnosis
and therapy of conjunctivitis, and ophthalmologists typically do not generally perform
cultures even when they are referred cases that have not responded to initial therapy. The
exception is patients with signs and symptoms of hyperacute conjunctivitis in whom
Giemsa and Gram stains may be helpful to identify N. gonorrhoeae. (See 'Hyperacute
bacterial conjunctivitis' above.)
A rapid (10-minute) test for adenoviral conjunctivitis is available, however, lack of

reimbursement limits its wide adoption. This test has reasonable sensitivity and specificity
under study conditions [15] and might aid clinicians in determining a viral as opposed to
bacterial etiology, thereby avoiding empiric antibiotic therapy. Elimination of empiric

antibiotic therapy has theoretical benefits including prescription drug savings, avoidance of
side effects, and reduction of antibiotic resistance, and a modelled cost-effectiveness
analysis suggests a potential for significant cost savings with point of care (POC) testing
[16].
Swabbing for culture, stains, and direct antibody or polymerase chain reaction (PCR) testing
is typically reserved only for atypical or chronic cases that fail to improve or respond to
therapy.
Contact lens wearers — The diagnosis of conjunctivitis should be made carefully in

contact lens wearers, who are subject to myriad secondary chronic conjunctivitides that
require a change in contact lens fit, lens type, or lens hygiene and may require suppression
of hypersensitivity. Soft contact lens wearers have a high risk of pseudomonal keratitis,
especially with use of extended-wear lenses [17,18]. This causes an acute red eye and
discharge in association with an ulcerative keratitis. The ulcerative keratitis can lead to
ocular perforation within 24 hours if it is not recognized and treated appropriately. Thus,
the presence of keratitis should be ruled out prior to presuming and treating conjunctivitis.
Keratitis causes objective foreign body sensation, and the patient is usually unable to
spontaneously open the eye or keep it open; there is typically a corneal opacity visible with
a penlight. (See "The red eye: Evaluation and management" and "Complications of contact
lenses".)
Reasons for urgent ophthalmologic referral — The following warning signs should

prompt urgent referral to an ophthalmologist:
● Reduction of visual acuity (concerns about infectious keratitis, iritis, angle-closure

glaucoma).
● Ciliary flush – A pattern of injection in which the redness is most pronounced in a ring
at the limbus, (the transition zone between the cornea and the sclera). This is
concerning for infectious keratitis, iritis, and angle-closure glaucoma.
● Photophobia (concerns about infectious keratitis, iritis).
● Severe foreign body sensation that prevents the patient from keeping the eye open
(concerns about infectious keratitis).
● Corneal opacity (concerns about infectious keratitis).
● Fixed pupil (concerns about angle-closure glaucoma).
● Severe headache with nausea (concerns about angle-closure glaucoma).

● Suspicion for hyperacute bacterial conjunctivitis or epidemic keratoconjunctivitis (EKC).

(See 'Hyperacute bacterial conjunctivitis' above and 'Epidemic keratoconjunctivitis'
above.)
Note that photophobia and severe foreign body sensation are also characteristic of corneal
abrasion, a condition that can be initially treated in the primary care or emergency care
setting, with referral to ophthalmology if symptoms persist. Corneal abrasion is
accompanied by tearing, but typically there is no discharge. (See "Corneal abrasions and
corneal foreign bodies: Management" and "Corneal abrasions and corneal foreign bodies:
Clinical manifestations and diagnosis".)
THERAPY
General considerations
Preventing contagion — Bacterial and viral conjunctivitis are both highly contagious

and spread by direct contact with secretions or contact with contaminated objects. Infected
individuals should not share handkerchiefs, tissues, towels, cosmetics, linens, or eating
utensils.
Need for examination prior to therapy — Providers are often pressured to prescribe

antibiotics for conjunctivitis, even when there is nothing to suggest a bacterial process. This
can be a particular issue for parents or other caretakers because most daycare centers and
schools require that students with conjunctivitis receive 24 hours of topical therapy before
returning to school. Patients may sometimes request to be treated without being
examined. (See 'Returning to work, school, or sports' below.)
We believe that no patient should be treated for conjunctivitis without an examination. In

principle, only those diagnosed with bacterial conjunctivitis should receive antibiotics. If the
decision is made to prescribe antibiotics without an examination, we use an inexpensive
nontoxic antibiotic such as erythromycin ophthalmic ointment or trimethoprim polymyxin
B ophthalmic drops, except in the case of contact lens wearers (see 'Common conjuctivitis
in contact lens wearers' below). Ointment is preferred over drops for children. Dosing for
antibiotics is provided in the table ( table 2).
No role for corticosteroid use — Ophthalmic corticosteroids (either alone or in

combination steroid/antibiotic drops) are not effective and have no role in the
management of acute conjunctivitis by primary care clinicians [19]. Corticosteroids can
cause sight-threatening complications (eg, corneal scarring, melting, and perforation) when
used inappropriately. Chronic ophthalmic corticosteroid treatments can also cause cataract
and glaucoma [20,21].

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 as discussed in separate topic reviews. (See "Allergic conjunctivitis:
Management", section on 'Glucocorticoids' and "Atopic keratoconjunctivitis", section on
'Topical corticosteroids' and "Vernal keratoconjunctivitis", section on 'Topical
corticosteroids' and "Blepharitis", section on 'Topical glucocorticoids'.)
Specific therapy — Therapy should be directed at the likely etiology of conjunctivitis

suggested by the history and physical examination ( table 1).
Bacterial
Common conjunctivitis — Bacterial conjunctivitis is self-limited in most cases,

although topical antibiotics may shorten the clinical course if given before day 6 [4,22,23].
In most cases, the choice of whether to use antibiotics for the treatment of acute bacterial
conjunctivitis is driven by values and preferences (for example, in back to work or school
situations). However, antibiotic treatment is required for acute conjunctivitis in contact lens
wearers as well as for cases of adult inclusion conjunctivitis or hyperacute bacterial
conjunctivitis. (See 'Common conjuctivitis in contact lens wearers' below and 'Adult
inclusion conjunctivitis treatment' below and 'Hyperacute bacterial conjunctivitis treatment'
below.)
Treatment options for acute bacterial conjunctivitis are presented in the table ( table 2).
Preferred choices include erythromycin ophthalmic ointment or trimethoprim-polymyxin B
drops. The dosing is 0.5 inch (1.25 cm) of erythromycin ointment deposited inside the lower
lid, or one to two drops of trimethoprim polymyxin B, four times daily for five to seven days
to the affected eye. These agents are preferred as they are inexpensive, widely available,
and non-toxic, and they have low rates of hypersensitivity. Common alternative therapies
include bacitracin ointment (limited by cost) and bacitracin-polymyxin B ointment (limited
by cost and patient sensitivity).
Ointment is preferred over drops for children, those with poor compliance, or those in
whom it is difficult to administer eye medications. 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 adults 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.
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Some alternative treatment options have specific limitations:
● Azithromycin is approved in the United States as an ophthalmic solution for bacterial

conjunctivitis in patients one year of age and older. It is dosed less frequently than
other ophthalmic solutions (one drop twice daily for two days, then one drop daily for
five days) but is considerably more expensive than erythromycin or sulfacetamide, and
its availability raises a concern about promoting the emergence of organisms resistant
to azithromycin, which could limit its use for other infections [24].
● Sulfacetamide ophthalmic drops are also available but are not a first-line option
because of the potential for rare but serious allergic events.
● Aminoglycoside drops and ointments are poor choices since they are toxic to the
corneal epithelium and can cause a reactive keratoconjunctivitis after several days of
use.
● Chloramphenicol drops are a generally inexpensive and well-tolerated option used

widely around the world for the treatment of bacterial conjunctivitis. However, topical
use of chloramphenicol has been associated with the very rare but catastrophic
complications of bone marrow hypoplasia, aplastic anemia, and death and is not
marketed or used in the United States for the treatment of ocular infections [25].
● Fluoroquinolones are not first-line therapy for routine cases of bacterial conjunctivitis
because of concerns regarding emerging resistance and cost. The exception is
conjunctivitis in a contact lens wearer due to the high incidence of Pseudomonas
infection.
Common conjuctivitis in contact lens wearers — For all contact lens wearers with
bacterial conjunctivitis, we suggest antibiotic treatment due to the increased risk of
keratitis and/or infection with gram-negative organisms. Fluoroquinolones are the
preferred agent to treat bacterial conjunctivitis in contact lens wearers due to the high
incidence of Pseudomonas infection. Patients should stop wearing contact lenses. If there is
any corneal opacity or suspicion of keratitis, the patient should be evaluated by an
ophthalmologist. Microbial keratitis is more likely if there is foreign body sensation or
reduced vision (see "Complications of contact lenses", section on 'Infectious keratitis')
Chronic conjunctivitis in a contact lens wearer is best addressed by a knowledgeable
optometrist or ophthalmologist.
If the diagnosis is bacterial conjunctivitis, contact lens wear can resume when the eye is
white and has no discharge for 24 hours after the completion of antibiotic therapy, or, in
the case of viral conjunctivitis, when the eye is white with no discharge. The lens case
should be discarded and the lenses subjected to overnight disinfection or replaced if
disposable.
Adult inclusion conjunctivitis treatment — Antibiotic treatment for adult inclusion

conjunctivitis requires systemic therapy (typically with doxycycline, tetracycline,
erythromycin, or azithromycin) to eradicate the C. trachomatis infection. (See "Trachoma",
section on 'Treatment'.)
Hyperacute bacterial conjunctivitis treatment — Hyperacute bacterial

conjunctivitis due to Neisseria typically requires systemic therapy and is discussed
elsewhere. (See "Treatment of uncomplicated Neisseria gonorrhoeae infections", section on
'Conjunctivitis'.)
Viral — There is no specific topical or systemic antiviral agents for the treatment of viral
conjunctivitis. Systemic antibiotic and antiviral therapies play no role.
Symptomatic relief may be achieved with:
● Topical antihistamine/decongestants, which are available over the counter

(naphazoline-pheniramine, ketotifen, olopatadine and others). Some patients find relief
in switching from one to another, although there is little evidence that one is superior
for symptoms.
● Warm or cool compresses.
● Nonantibiotic lubricating agents such as those used for noninfectious conjunctivitis.

There are a wide variety of products on the market with various formulations, none
proven superior for symptomatic relief ( table 2). (See 'Noninfectious,
noninflammatory conjunctivitis' above.)
Patients must be told that the eye irritation and discharge may get worse for three to five
days before getting better, that symptoms can persist for two to three weeks, and that use
of any topical agent (antibiotics or antihistamine/decongestant) for that duration might
result in irritation and toxicity, which can itself cause redness and discharge. Clinicians must
be wary of trying one agent after another in patients with viral conjunctivitis who are
expecting drugs to "cure" their symptoms. Patient education is often more effective than
prolonged or additional therapies for patients who experience improvement but
incomplete resolution of symptoms after a few days.
Allergic — There are numerous therapy options available for allergic conjunctivitis,

including naphazoline-pheniramine, ketotifen, olopatadine, and others ( table 2) [26,27].
This is discussed elsewhere (see "Allergic conjunctivitis: Management"). Ketorolac drops
should not be used for viral or allergic conjunctivitis. Although these are labelled for relief
of itching due to seasonal allergic conjunctivitis, ketorolac is a nonsteroidal
antiinflammatory drug (NSAID), and post-market experience reveals that topical NSAIDs are

associated with corneal adverse effect in some susceptible patients, which may become
sight-threatening. (See "Allergic conjunctivitis: Clinical manifestations and diagnosis".)
Toxic — The primary approach to toxic conjunctivitis is recognition and removal of the

offending agent. Stopping as many topical agents as feasible is a good first step. However,
glaucoma drops should not be stopped except by the prescribing clinician, as pressure rise
may cause irreversible vision loss. Recovery may take weeks rather than days. With some
agents, there is paradoxical rebound redness when agents are stopped, making adherence
to medical advice difficult for patients. Patients in whom a glaucoma medication is thought
to be the culprit, or those with severe symptoms or problematic rebound redness, should
be referred to an ophthalmologist for management. (See "Toxic conjunctivitis".)
Noninfectious noninflammatory — The conjunctival surface regenerates rapidly from

insults that precipitate noninfectious conjunctivitis, leading to spontaneous resolution of
symptoms. Nevertheless, these patients may have symptom relief with the use of topical
lubricants, which can be purchased over the counter as drops and ointments ( table 2).
Preservative-free preparations are more expensive and are necessary only in severe cases
of dry eye or in highly allergic patients when frequency of use greater than six times daily is
required.
Lubricant drops can be used as often as hourly for one to two days with no side effects. The
ointment provides longer-lasting relief but blurs vision; thus, many patients use the
ointment only at bedtime. It may be worthwhile to switch brands if a patient finds one
brand of drop or ointment irritating since each preparation contains different active
ingredients, vehicles, and preservatives.
Persistent symptoms — Patients with acute bacterial conjunctivitis usually respond to

treatment within one to two days by showing a decrease in discharge, redness, and
irritation. Patients who do not respond should be referred to an ophthalmologist. Patients
with other forms of acute conjunctivitis (eg, viral or allergic) usually improve within two
weeks, and those who do not should also be referred to an ophthalmologist.
Diagnoses to consider in patients with persistent symptoms include dry eye (see "Dry eye
disease"), medicamentosa (drug toxicity) (see "Toxic conjunctivitis"), pterygium (see
"Pterygium"), blepharoconjunctivitis (see "Blepharitis"), and adult inclusion conjunctivitis.
(See 'Chronic chlamydial infections' above.)
RETURNING TO WORK, SCHOOL, OR SPORTS
● Work/school – Clinicians are often asked to advise patients and families or caregivers
as to when it is safe to return to work or school. Bacterial and viral conjunctivitis are

both highly contagious and spread by direct contact with secretions or contact with
contaminated objects. Infected individuals should not share handkerchiefs, tissues,
towels, cosmetics, linens, or eating utensils. The safest approach to prevent spread to
others is to stay home until there is no longer any discharge, but this is not feasible for
most students and for those who work outside the home. Most daycare centers and
schools require that students receive 24 hours of topical therapy before returning to
school. Such therapy will probably reduce the transmission of conjunctivitis due to
bacterial infection but will do nothing to reduce the spread of viral infections.
We suggest advising patients to consider that their problem is like a cold, and their
decision to return to work or school should be similar to the one they would make in
that situation. Those who have contact with the very old, the very young, and immune-
compromised individuals should take care to avoid spread of infection from their eye
secretions to these susceptible people.
● Sports – For bacterial conjunctivitis, patients should not return to playing sports until
they have used an antibiotic for a minimum of 24 hours and had resolution of eye
drainage. Clearance to return to play for viral conjunctivitis depends on the sport.
Athletes who participate in sports that are individual and/or noncontact and which do
not involve shared equipment (eg, cross-country running) can return when they feel
able and can see clearly. If these athletes return before symptoms have resolved, they
should be advised not to touch their eyes and to wash their hands frequently. Athletes
who participate in contact sports, sports with shared equipment (eg, gymnastics), or
water-based sports may return to play once daytime discharge has abated, typically
after about five days.
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, “The Basics” and “Beyond the
Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces
are longer, more sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

● Basics topic (see "Patient education: Conjunctivitis (pink eye) (The Basics)")
● Beyond the Basics topics (see "Patient education: Conjunctivitis (pink eye) (Beyond the
Basics)" and "Patient education: Allergic conjunctivitis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Conjunctivitis may be infectious (bacterial or viral) or noninfectious (allergic, toxic,

dryness, and others). Most infectious conjunctivitis is probably viral; bacterial
conjunctivitis is more common in children than in adults. (See 'Classification and
epidemiology' above.)
● The diagnosis of conjunctivitis is made in a patient with a red eye and discharge only if
the vision is normal and there is no evidence of keratitis, iritis, or angle-closure
glaucoma. Warning signs for alternative conditions that should prompt evaluation by
an ophthalmologist are discussed above. (See 'Reasons for urgent ophthalmologic
referral' above and 'Evaluation and diagnosis' above.)
● Distinguishing between bacterial, viral and allergic conjunctivitis can be achieved on

the basis of history and physical examination. All etiologies can cause symptoms of the
eyes being stuck closed in the morning. Helpful distinguishing characteristics are
presented in the table ( table 1). (See 'Causes and clinical manifestations' above.)
• Bacterial conjunctivitis should only be diagnosed in patients with thick purulent

discharge that continues throughout the day and should be confirmed by a
clinician examination. The discharge can generally be seen at the lid margins and
at the corner of the eye. Bacterial conjunctivitis is usually unilateral but can be
bilateral. (See 'Bacterial conjunctivitis' above.)
Hyperacute bacterial conjunctivitis may be due to Neisseria infection; this can be

severe and sight-threatening. Such patients require urgent ophthalmology referral
( picture 1). (See 'Hyperacute bacterial conjunctivitis' above.)
• Viral conjunctivitis typically presents as injection, mucoid or serous discharge, and

a burning or gritty feeling in one eye. It may be an isolated manifestation or part of
a systemic viral illness. The second eye usually becomes involved within 24 to 48
hours; unilateral viral infection may occur. Usually there is profuse tearing rather
than discharge; the latter may be present on close examination. The symptoms
generally worsen for three to five days and resolve over one to two weeks. (See
'Viral conjunctivitis' above.)

• Allergic conjunctivitis typically presents as bilateral redness, watery discharge, and

itching. Itching is the cardinal symptom of allergy, distinguishing it from a viral
etiology. Patients with allergic conjunctivitis often have a history of atopy, seasonal
allergy, or specific allergy. (See 'Allergic conjunctivitis' above.)
● With some exceptions, antibiotic treatment of bacterial conjunctivitis is NOT required

because the course is usually self-limited. However, because topical antibiotics may
shorten the clinical course, the choice of whether to use antibiotics for the treatment of
acute bacterial conjunctivitis is driven by patient preferences (for example in back to
work or school situations).
For patients who select antibiotic treatment for bacterial conjunctivitis, we suggest
treatment with either erythromycin ophthalmic ointment (0.5 inch applied to the lower
lid) or trimethoprim-polymyxin drops (one to two drops) over alternative agents (Grade
2C). Either agent is administered four times daily for five to seven days. Ointment is
preferred over drops for children, those with poor compliance, and those in whom it is
difficult to administer eye medications. (See 'Bacterial' above.)
Important exceptions include the following patients who should be evaluated by

ophthalmologist:
• For all contact lens wearers with bacterial conjunctivitis, we suggest antibiotic
treatment (Grade 2C). Fluoroquinolones are the preferred agent to treat bacterial
conjunctivitis in contact lens wearers due to the high incidence of Pseudomonas
infection. Patients should stop wearing contact lens. If there is any corneal opacity
or suspicion of keratitis, the patient should be evaluated by an ophthalmologist.
(See 'Common conjuctivitis in contact lens wearers' above.)
• Hyperacute bacterial conjunctivitis due to Neisseria typically require systemic

therapy. This is discussed separately. (See "Treatment of uncomplicated Neisseria
gonorrhoeae infections", section on 'Conjunctivitis'.)
• Patients with chlamydial infection (typically a chronic infection) require systemic

antibiotic therapy. This is discussed separately. (See "Trachoma", section on
'Treatment'.)
Patients who do not respond to antibiotic treatment within a few days should also be
referred to an ophthalmologist. (See 'Bacterial' above.)
● Symptomatic treatment is appropriate for patients with viral or noninfectious

conjunctivitis.

• Topical antihistamine/decongestants and/or lubricating agents may provide

symptom relief for patients with viral conjunctivitis ( table 2). (See 'Viral' above.)
• The management of allergic conjunctivitis is discussed separately. (See "Allergic

conjunctivitis: Management".)
• For patients with noninfectious conjunctivitis, topical lubricants may provide

symptom relief and can be used as often as six times daily ( table 2). (See
'Noninfectious noninflammatory' above.)
● Infectious conjunctivitis is highly contagious. Contact limitation is advised. For bacterial

conjunctivitis, 24 hours of treatment and resolution of drainage is advised before
returning to school or work. Patients with viral conjunctivitis may remain infectious
beyond that period; advice regarding return to school or work should be individualized.
(See 'Preventing contagion' above and 'Returning to work, school, or sports' above.)
● Ophthalmic corticosteroids have no role in the management of acute conjunctivitis

and should not be prescribed by primary care clinicians for this indication. (See 'No role
for corticosteroid use' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Weiss A, Brinser JH, Nazar-Stewart V. Acute conjunctivitis in childhood. J Pediatr 1993;
122:10.
2. Fitch CP, Rapoza PA, Owens S, et al. Epidemiology and diagnosis of acute conjunctivitis
at an inner-city hospital. Ophthalmology 1989; 96:1215.
3. Gigliotti F, Williams WT, Hayden FG, et al. Etiology of acute conjunctivitis in children. J
Pediatr 1981; 98:531.
4. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment.
JAMA 2013; 310:1721.
5. Rietveld RP, ter Riet G, Bindels PJ, et al. Predicting bacterial cause in infectious
conjunctivitis: cohort study on informativeness of combinations of signs and
symptoms. BMJ 2004; 329:206.
6. Friedlaender MH. A review of the causes and treatment of bacterial and allergic
conjunctivitis. Clin Ther 1995; 17:800.

7. Martin M, Turco JH, Zegans ME, et al. An outbreak of conjunctivitis due to atypical
Streptococcus pneumoniae. N Engl J Med 2003; 348:1112.
8. Crum NF, Barrozo CP, Chapman FA, et al. An outbreak of conjunctivitis due to a novel
unencapsulated Streptococcus pneumoniae among military trainees. Clin Infect Dis
2004; 39:1148.
9. Ullman S, Roussel TJ, Culbertson WW, et al. Neisseria gonorrhoeae

keratoconjunctivitis. Ophthalmology 1987; 94:525.
10. Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult
gonococcal conjunctivitis. Am J Ophthalmol 1986; 102:575.
11. McAnena L, Knowles SJ, Curry A, Cassidy L. Prevalence of gonococcal conjunctivitis in

adults and neonates. Eye (Lond) 2015; 29:875.
12. Roba LA, Kowalski RP, Gordon AT, et al. Adenoviral ocular isolates demonstrate
serotype-dependent differences in in vitro infectivity titers and clinical course. Cornea
1995; 14:388.
13. Azar MJ, Dhaliwal DK, Bower KS, et al. Possible consequences of shaking hands with
your patients with epidemic keratoconjunctivitis. Am J Ophthalmol 1996; 121:711.
14. Jernigan JA, Lowry BS, Hayden FG, et al. Adenovirus type 8 epidemic
keratoconjunctivitis in an eye clinic: risk factors and control. J Infect Dis 1993;
167:1307.
15. Sambursky R, Tauber S, Schirra F, et al. The RPS adeno detector for diagnosing
adenoviral conjunctivitis. Ophthalmology 2006; 113:1758.
16. Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for
adenoviral conjunctivitis. Am J Med Sci 2008; 336:254.
17. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact-lens-associated
microbial keratitis and its related morbidity. Lancet 1999; 354:181.
18. Tabbara KF, El-Sheikh HF, Aabed B. Extended wear contact lens related bacterial
keratitis. Br J Ophthalmol 2000; 84:327.
19. Wilkins MR, Khan S, Bunce C, et al. A randomised placebo-controlled trial of topical
steroid in presumed viral conjunctivitis. Br J Ophthalmol 2011; 95:1299.
20. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/017011s047lbl.pdf (Acce

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10:505.
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infective conjunctivitis in children in primary care: a randomised double-blind placebo-
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8/23/2021 Conjunctivitis - UpToDate

Author: Deborah S Jacobs, MD

Conjunctivitis is a common diagnosis in patients who complain of a red eye. It is usually a

● (See "Angle-closure glaucoma".)

Infectious conjunctivitis in the neonate is discussed separately. (See "Chlamydia

DEFINITIONS AND ANATOMY

Conjunctivitis literally means "inflammation of the conjunctiva." The conjunctiva is the

The conjunctiva is comprised of an epithelium and a substantia propria. The epithelium is a

The conjunctiva is generally transparent. When it is inflamed, as in conjunctivitis, it appears

CLASSIFICATION AND EPIDEMIOLOGY

Acute conjunctivitis can be classified as infectious (bacterial or viral) or noninfectious

CAUSES AND CLINICAL MANIFESTATIONS

Common presentations — Patients with bacterial conjunctivitis typically complain of

Bacterial conjunctivitis is commonly caused by Staphylococcus aureus, Streptococcus

Hyperacute bacterial conjunctivitis — Neisseria species, particularly N. gonorrhoeae,

Chronic chlamydial infections

● Trachoma – Conjunctivitis is the major clinical manifestation of active trachoma, a

● Adult inclusion conjunctivitis – Adult inclusion conjunctivitis is not strictly an acute

The eye infection presents as a unilateral, or sometimes bilateral, follicular

Diagnosis is confirmed with Giemsa or direct fluorescent antibody (DFA) staining of

Common presentations — Viral conjunctivitis is typically caused by adenovirus, with

https://www.uptodate.com/contents/conjunctivitis?search=gonorrhea conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&display… 3/20

Viral conjunctivitis typically presents as conjunctival injection with watery or mucoserous

Epidemic keratoconjunctivitis — One form of viral conjunctivitis, epidemic

https://www.uptodate.com/contents/conjunctivitis?search=gonorrhea conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&display… 4/20

Keratitis is potentially vision-threatening, and patients should be referred to an

Allergic conjunctivitis — Allergic conjunctivitis is caused by airborne allergens contacting

In some cases of allergic conjunctivitis, there is marked chemosis (conjunctival edema); in

Toxic conjunctivitis — Toxic conjunctivitis (also called toxic keratoconjunctivitis) is a

Noninfectious, noninflammatory conjunctivitis — Patients can develop a red eye and

EVALUATION AND DIAGNOSIS

Distinguishing between types of conjunctivitis — The clinical manifestations of the

General approach — Conjunctivitis is a clinical diagnosis of exclusion, made on the basis of

● History – Typical features of conjunctivitis include a history of morning crusting and

https://www.uptodate.com/contents/conjunctivitis?search=gonorrhea conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&display… 6/20

● Examination – On examination, the redness or injection in conjunctivitis should be

A rapid (10-minute) test for adenoviral conjunctivitis is available, however, lack of

bacterial etiology, thereby avoiding empiric antibiotic therapy. Elimination of empiric

Contact lens wearers — The diagnosis of conjunctivitis should be made carefully in

Reasons for urgent ophthalmologic referral — The following warning signs should

● Reduction of visual acuity (concerns about infectious keratitis, iritis, angle-closure

● Photophobia (concerns about infectious keratitis, iritis).

● Corneal opacity (concerns about infectious keratitis).

● Fixed pupil (concerns about angle-closure glaucoma).

● Severe headache with nausea (concerns about angle-closure glaucoma).

https://www.uptodate.com/contents/conjunctivitis?search=gonorrhea conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&display… 8/20

● Suspicion for hyperacute bacterial conjunctivitis or epidemic keratoconjunctivitis (EKC).

Preventing contagion — Bacterial and viral conjunctivitis are both highly contagious

Need for examination prior to therapy — Providers are often pressured to prescribe

We believe that no patient should be treated for conjunctivitis without an examination. In

No role for corticosteroid use — Ophthalmic corticosteroids (either alone or in

https://www.uptodate.com/contents/conjunctivitis?search=gonorrhea conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&display… 9/20

Ophthalmologists may prescribe topical corticosteroids in certain cases of ocular allergy,

Specific therapy — Therapy should be directed at the likely etiology of conjunctivitis

Common conjunctivitis — Bacterial conjunctivitis is self-limited in most cases,

https://www.uptodate.com/contents/conjunctivitis?search=gonorrhea conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=default&displa… 10/20

Some alternative treatment options have specific limitations:

● Azithromycin is approved in the United States as an ophthalmic solution for bacterial

● Chloramphenicol drops are a generally inexpensive and well-tolerated option used

Adult inclusion conjunctivitis treatment — Antibiotic treatment for adult inclusion

Hyperacute bacterial conjunctivitis treatment — Hyperacute bacterial

Symptomatic relief may be achieved with:

● Topical antihistamine/decongestants, which are available over the counter