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Conjuntivitis
AUTOR: Deborah S Jacobs, MD
EDITOR DE SECCIÓN: Matthew F Gardiner, MD
EDITOR ADJUNTO: Jane Givens, MD, MSCE
Todos los temas se actualizan a medida que hay nueva evidencia disponible y nuestro proceso de revisión por pares se
completa.
Revisión de la literatura vigente hasta: marzo de 2024.

Este tema se actualizó por última vez: 30 de octubre de 2023.
INTRODUCCIÓN
La conjuntivitis es un diagnóstico común en pacientes que se quejan de ojos rojos. Por lo

general, es una afección benigna o autolimitada, o que se trata fácilmente. Otras causas de ojos
rojos se analizan en otra parte. (Ver "Los ojos rojos: Evaluación y manejo" .)
Este tema revisará las manifestaciones clínicas, el diagnóstico y el tratamiento de la

conjuntivitis. Otras afecciones que pueden confundirse con conjuntivitis incluyen glaucoma
agudo de ángulo cerrado, iritis, uveítis y queratitis infecciosa. A diferencia de la conjuntivitis
aguda, estas afecciones ponen en peligro la vista y deben ser tratadas por un oftalmólogo. Se
discuten en otra parte:
● (Ver "Glaucoma de ángulo cerrado" .)

● (Ver "Uveítis: etiología, manifestaciones clínicas y diagnóstico" y "Uveítis: tratamiento" .)
● (Ver "Queratitis por herpes simple" .)
● (Consulte "Complicaciones de las lentes de contacto", sección sobre "Queratitis infecciosa"
.)
La conjuntivitis infecciosa en el recién nacido se analiza por separado. (Ver "Infecciones por
Chlamydia trachomatis en el recién nacido" e "Infección gonocócica en el recién nacido" .)
La conjuntivitis leñosa se analiza por separado. (Consulte "Deficiencia de plasminógeno",

sección sobre "Conjuntivitis leñosa" .)
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DEFINICIONES Y ANATOMÍA
Conjuntivitis significa literalmente "inflamación de la conjuntiva". La conjuntiva es la membrana

mucosa que recubre la superficie interior de los párpados y cubre la superficie del globo hasta
el limbo (la unión de la esclerótica y la córnea). La porción que cubre el globo es la "conjuntiva
bulbar" y la porción que recubre los párpados es la "conjuntiva tarsal" ( figura 1 ).
La conjuntiva está compuesta por un epitelio y una sustancia propia. El epitelio es un epitelio
escamoso no queratinizado que también contiene células caliciformes. La sustancia propia está
muy vascularizada y es el sitio de considerable actividad inmunológica.
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, while viral is more common in adults
[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
( picture 1). 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 ( figure 2).
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 2) [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 3) 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 ( figure 2).
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 4). 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 5). Itching is
the cardinal symptom of allergy, distinguishing it from a viral etiology, which is more typically
described as grittiness, burning, or irritation ( figure 2). 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 ( figure 2). Both cause
diffuse injection with a bumpy or follicular appearance to the tarsal conjunctiva ( picture 4).
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 — Key distinguishing features (including

examination findings) between bacterial, viral and allergic conjunctivitis are also presented in
the table and graphic ( table 1 and figure 2). 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 ( figure 2).
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 (or
unchanged), 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 6). 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 ( picture 7). (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 conjunctivitis in
contact lens wearers' below). Ointment is preferred over drops for children. Dosing for
antibiotics is provided in the table ( table 2).
There are emerging data on the value of online treatment of conjunctivitis. In a study
comparing asynchronous online text-based e-visits (without photo or video), phone calls, and in-
person encounters among pediatric patients with conjunctivitis, antibiotic prescribing was
greater with phone call encounters (41.6 percent) than with e-visits (25.7 percent) or face-to-face
encounters (19.8 percent) [19].
No role for corticosteroid use — Ophthalmic corticosteroids (either alone or in combination

steroid/antibiotic drops) have no role in the management of acute conjunctivitis by primary
care clinicians [20]. 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 [21,22].
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 'Corticosteroids' 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
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Common conjunctivitis — Bacterial conjunctivitis is self-limited in most cases, although

topical antibiotics may shorten the clinical course if given before day 6 [4,23,24]. 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
conjunctivitis 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 for noncontact lens wearers 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.
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 [25].
● 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 [26].
● 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 conjunctivitis 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 gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents",
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 and table 3) [27,28].
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
● Causes – 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.)
● Diagnosis – The diagnosis of conjunctivitis is made in a patient with a red eye and
discharge only if the vision is normal (or unchanged) 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 types – 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 and graphic ( table 1 and
figure 2). (See 'Causes and clinical manifestations' above.)
• Bacterial – 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 ( picture 1). 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 2). (See 'Hyperacute bacterial conjunctivitis' above.)
• Viral – 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 – 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.)
● Treatment of bacterial conjunctivitis - The use of antibiotics for bacterial conjunctivitis is

individualized. Most patients do not require antibiotics:
• Noncontact lens wearers - most cases are self-limited and do not require antibiotics.
However, topical antibiotics may shorten the clinical course and allow for quicker return
to work or school. For noncontact lens wearers who select antibiotic treatment, we
suggest either erythromycin ophthalmic ointment or trimethoprim-polymyxin drops
over alternative agents ( table 2) (Grade 2C). Either agent is administered four times
daily for five to seven days. Ointment may be preferred in those with difficulty
administering eye drops (eg, children) but may blur the vision. (See 'Bacterial' above.)
• Limited role for antibiotics – For the following patients with bacterial conjunctivitis,
antibiotic treatment is warranted:
- Contact lens wearers – For all contact lens wearers with bacterial conjunctivitis,
we suggest antibiotic treatment. (Grade 2C) A topical fluoroquinolone is preferred
due to the high incidence of Pseudomonas infection. Patients should discontinue
contact lens use until there is no discharge for 24 hours after completion of
therapy; used lenses and lens case should be discarded. If there is any corneal
opacity or suspicion of keratitis, the patient should be evaluated by an
ophthalmologist. (See 'Common conjunctivitis in contact lens wearers' above.)
- Hyperacute bacterial conjunctivitis due to Neisseria – This requires systemic

therapy and management by an ophthalmologist. (See "Treatment of
uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and
adolescents", section on 'Conjunctivitis'.)
- Chlamydial infection (typically a chronic infection) – This requires systemic

antibiotic therapy and management by an ophthalmologist. (See "Trachoma",
section on 'Treatment'.)
• Referral for persistent symptoms – Patients with presumed bacterial conjunctivitis

who do not respond to topical antibiotic treatment within a few days should be referred
to an ophthalmologist. (See 'Persistent symptoms' above.)
● Treatment of viral, allergic, or noninfectious conjunctivitis
• Viral - Topical antihistamine/decongestants and/or lubricating agents may provide

symptom relief ( table 2). Contact lens wearers should temporarily discontinue lens
use and may resume when symptoms resolve. Used lenses and lens case should be
discarded. (See 'Viral' above.)
• Allergic - Minimize exposure to the allergen. Use of topical lubricants, cool compresses,
and topical or systemic antihistamines may provide symptom relief ( table 3) (See
"Allergic conjunctivitis: Management".)
• Noninfectious – 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.)
● Treatments to avoid – Avoid topical corticosteroids and topical NSAIDS – Ophthalmic

corticosteroids (alone or in combination preparations) should not be prescribed by primary
care clinicians for acute conjunctivitis; they can cause sight-threatening complications
when used inappropriately. Ketorolac should not be used to treat allergic conjunctivitis.
Topical NSAIDS (nonsteroidal anti-inflammatory drugs) are associated with corneal
adverse effect in susceptible patients. (See 'No role for corticosteroid use' above and
'Allergic' above.)
● Infection control – Infection control and return to work or school – Bacterial and viral
conjunctivitis are highly contagious. Advise patients to limit spread by avoiding direct
contact with secretions or contaminated objects (eg, makeup, contact lenses). (See
'Preventing contagion' above and 'Returning to work, school, or sports' above.)
• For bacterial conjunctivitis, postpone return to school or work until 24 hours of

treatment and resolution of discharge.
• Patients with viral conjunctivitis may remain infectious for a variable period related to
the underlying viral syndrome; return to activities is individualized.
Use of UpToDate is subject to the Terms of Use.
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. Penza KS, Murray MA, Myers JF, et al. Treating pediatric conjunctivitis without an exam: An
evaluation of outcomes and antibiotic usage. J Telemed Telecare 2020; 26:73.
20. 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.
21. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/017011s047lbl.pdf (Accessed
on May 06, 2020).
22. Renfro L, Snow JS. Ocular effects of topical and systemic steroids. Dermatol Clin 1992;
10:505.
23. Rose PW, Harnden A, Brueggemann AB, et al. Chloramphenicol treatment for acute
infective conjunctivitis in children in primary care: a randomised double-blind placebo-
controlled trial. Lancet 2005; 366:37.
24. Chen YY, Liu SH, Nurmatov U, et al. Antibiotics versus placebo for acute bacterial
conjunctivitis. Cochrane Database Syst Rev 2023; 3:CD001211.
25. Ophthalmic azithromycin (AzaSite). Med Lett Drugs Ther 2008; 50:11.
26. Fraunfelder FW, Fraunfelder FT. Restricting topical ocular chloramphenicol eye drop use in
the United States. Did we overreact? Am J Ophthalmol 2013; 156:420.
27. Friedlaender MH. The current and future therapy of allergic conjunctivitis. Curr Opin
Ophthalmol 1998; 9:54.
28. Ciprandi G, Buscaglia S, Cerqueti PM, Canonica GW. Drug treatment of allergic
conjunctivitis. A review of the evidence. Drugs 1992; 43:154.
Topic 6907 Version 65.0
GRAPHICS
Anatomy of the conjunctiva
The conjunctiva is a thin, transparent tissue that covers the outer surface of the eye. It consists of two
continuous parts, one on the inner surface of the eyelid (the tarsal conjunctiva) and the other over the
sclera (the bulbar conjunctiva). These are outlined in the drawing as a thin, pink line.
Graphic 54272 Version 5.0
Bacterial conjunctivitis
Courtesy of Deborah Jacobs, MD.
Distinguishing bacterial, viral, and allergic conjunctivitis
Hyperacute bacterial conjunctivitis
The discharge from hyperacute bacterial conjunctivitis is thick and globular; it may be yellow, white, or
green.
Reproduced with permission from: Trobe, JD. The Eyes Have It: An interactive teaching and assessment program on vision care. WK
Kellog Eye Center, University of Michigan. Copyright © Jonathan D Trobe, MD.
Viral conjunctivitis
Viral conjunctivitis typically presents as injection, watery or mucoserous discharge, and a burning, sandy,
or gritty feeling in one eye.
Reproduced with permission from: Trobe JD. The Eyes Have It: An interactive teaching and assessment program on vision care. WK
Follicular conjunctivitis
Note reflections of illuminating light by follicles (foci of lymphoid tissue) in the lower lid conjunctiva.
Courtesy of Deborah Jacobs, MD.
Allergic conjunctivitis
Allergic conjunctivitis typically presents as bilateral redness, watery discharge, and itching.
Distinguishing types of acute conjunctivitis
Bacterial Viral Allergic
Systemic symptoms. Usually none. May be part of a viral Nasal congestion,

prodrome followed by sneezing, wheezing.
adenopathy, fever,
pharyngitis, and upper
respiratory tract
infection. There may be
an enlarged and tender
preauricular node.
Itching. Limited to none. Limited to none. Primary complaint. May

Primary complaint is also report grittiness,
grittiness, burning or burning, or irritation.
irritation.
Ocular discharge. Purulent, may be yellow, Watery with strands of Watery.

white, or green. Recurs mucus.
at lid margins and
corners of the eye within
minutes of wiping lids.
Conjunctival Pink or red. Pink or red. Very rarely Pink. Bulbar conjunctiva
appearance. hemorrhagic. Tarsal may be chemotic (puffy)
conjunctiva may have a Tarsal conjunctiva may
follicular or "bumpy" have a follicular or
appearance. "bumpy" appearance.
Blepharitis
Lids demonstrate findings of blepharitis: diffuse eyelid margin thickening and hyperemia with lash crusts.
Kellogg Eye Center, University of Michigan. Copyright © Jonathan D Trobe, MD.
Bacterial keratitis
The white corneal opacity suggests purulence necrosis.
Reproduced with permission from: Trobe JD. The Physician's Guide to Eye Care, American Academy of Ophthalmology 1993.
Copyright © 1993.
Therapy of conjunctivitis
Dose (each affected eye)
Empiric approach
Erythromycin 5 mg/gram ophthalmic ointment 0.5 inch (1.25 cm) 4 times daily for 5 to 7 days
(preferred in noncontact lens wearers)
or
Trimethoprim-polymyxin B 0.1%-10,000 units/mL 1 to 2 drops 4 times daily for 5 to 7 days

ophthalmic drops (preferred in noncontact lens
wearers)
or
Ofloxacin 0.3% ophthalmic drops (preferred 1 to 2 drops 4 times daily for 5 to 7 days
agent in contact lens wearer) *
or
Ciprofloxacin 0.3% ophthalmic drops (preferred 1 to 2 drops 4 times daily for 5 to 7 days
agent in contact lens wearer) *
or
Ciprofloxacin 0.3% ophthalmic ointment 0.5 inch (1.25 cm) 2 or 3 times daily for 5 to 7 days
(preferred agent in contact lens wearers) *
or
Fusidic acid 1% ophthalmic suspension 1 drop 2 times daily for 7 days

(alternative for noncontact lens wearers;
available in many areas other than United States)
Specific approach
Bacterial conjunctivitis ¶
Erythromycin 5 mg/gram ophthalmic 0.5 inch (1.25 cm) 4 times daily for 5 to 7 days
ointment (preferred in noncontact lens
wearers)
or
Trimethoprim-polymyxin B 0.1%-10,000 1 to 2 drops 4 times daily for 5 to 7 days

units/mL ophthalmic drops (preferred in
noncontact lens wearers)
or
Bacitracin-polymyxin B 500 units-10,000 0.5 inch (1.25 cm) 4 to 6 times daily for 5 to 7 days
units/gram ophthalmic ointment (alternative
in noncontact lens wearers)
or
Bacitracin 500 units/gram ophthalmic 0.5 inch (1.25 cm) 4 to 6 times daily for 5 to 7 days
ointment (alternative in noncontact lens
wearers)
or
Ofloxacin 0.3% (preferred agent in contact 1 to 2 drops 4 times daily for 5 to 7 days
lens wearers) *
or
Ciprofloxacin 0.3% ophthalmic drops 1 to 2 drops 4 times daily for 5 to 7 days

(preferred agent in contact lens wearer) *
or
Ciprofloxacin 0.3% ophthalmic ointment 0.5 inch (1.25 cm) 2 or 3 times daily for 5 to 7 days
(preferred agent in contact lens wearers) *
or
Azithromycin 1% ophthalmic drops 1 drop 2 times daily for 2 days; then 1 drop daily for
(alternative for noncontact lens wearers) 5 days
or
Fusidic acid 1% ophthalmic suspension 1 drop 2 times daily for 7 days

(alternative for noncontact lens wearers;
available in many areas other than United
States)
Viral conjunctivitis Δ
Antihistamine/decongestant drops (OTC) ◊ 1 to 2 drops 4 times daily as needed for no more

than 3 weeks
Allergic conjunctivitis Δ
Antihistamine/decongestant drops (OTC) ◊ 1 to 2 drops 4 times daily as needed for no more

than 2 weeks
or
Antihistamine/mast cell stabilizer drops ◊ Generally, 1 to 2 drops 1 to 3 times daily (regimens

vary by medication)
Non-specific conjunctivitis
Eye lubricant drops (OTC) ◊ 1 to 2 drops up to 6 times daily as needed
and/or
Eye lubricant ointment (OTC) ◊ 0.5 inch (1.25 cm) at bedtime or 4 times daily as
needed
This table is intended for use in conjunction with UpToDate content on conjunctivitis. Some clinical
presentations warrant prompt urgent referral to an ophthalmologist; warning signs may include
decreased visual acuity, photophobia, severe pain, worsening symptoms after 1 day, or no response
within a few days (except viral conjunctivitis which may worsen for 3 to 5 days); refer to topic.
Dosage regimens listed may differ from manufacturer's recommendations.
OTC: over-the-counter (available without a prescription in the United States).
* Patients should discontinue contact lens use until there is no discharge for 24 hours after completion of
therapy; used lenses and lens case should be discarded. If there is any corneal opacity or suspicion of
keratitis, the patient should be evaluated by an ophthalmologist. Other available ophthalmic
fluoroquinolones include levofloxacin 1.5% and moxifloxacin 0.5% solutions.
¶ In some countries, topical chloramphenicol is an option.
Δ Eye lubricant drops and/or ointment may be beneficial for mild symptoms.
◊ OTC available ophthalmic solutions include:

Antihistamine/decongestant: Naphazoline-pheniramine
Antihistamine/mast cell stabilizer: Alcaftadine, ketotifen, olopatadine
Eye lubricants: Polyethylene glycol, propylene glycol, glycerin, others; a preservative-free
formulation is preferred
Courtesy of Deborah S. Jacobs, MD with additional data from: The Wills Eye Manual, Chapter 5, "Conjunctiva/Sclera/Iris/External
Disease," 8th ed, Gervasio K, Peck T eds, Philadelphia, PA: Lippincott Williams & Wilkins, 2022.
Ophthalmic medications for the treatment of allergic conjunctivitis
Pharmacologic class Usual adult dosing Pediatric dosing
Antihistamines with mast cell-stabilizing properties: Decreased itching should be evident

within 24 to 72 hours; may result in dry eye sensation or burning
Olopatadine 0.1% and 0.2% One drop per eye twice daily ≥2 years: One drop per eye twice
(OTC Pataday, generics), 0.7% (0.1%); one drop per eye once daily (0.1%); one drop per eye
(OTC Pataday) daily (0.2% and 0.7%) once daily (0.2% and 0.7%)
Alcaftadine 0.25% (OTC One drop per eye once daily ≥2 years: One drop per eye once
Lastacaft) daily
Bepotastine 1.5% (Bepreve, One drop per eye twice daily ≥2 years: One drop per eye twice
generics) daily
Cetirizine 0.24% (Zerviate) One drop per eye twice daily ≥2 years: One drop per eye twice
daily
Epinastine 0.05% (generics) One drop per eye twice daily ≥2 years: One drop per eye twice
daily
Ketotifen 0.025% (multiple One drop per eye twice daily ≥3 years: One drop per eye twice
OTC products) daily
Azelastine 0.05% (generics) One drop per eye twice daily ≥3 years: One drop per eye twice
daily
Emedastine 0.05% (not One drop per eye up to 4 times ≥3 years: One drop per eye up to
available in US but may be daily 4 times daily
available in other countries)
Vasoconstrictor/antihistamine combination: Increased redness can occur temporarily when

medication is stopped
Naphazoline 0.25% and One to two drops per eye up to 4 ≥6 years: One to two drops per
pheniramine 0.3% (OTC times daily eye up to 4 times daily
Naphcon-A, OTC Visine, OTC
Visine-A)
Naphazoline 0.27% and

pheniramine 0.315% (OTC
Opcon-A, generics)
Mast cell stabilizers: Decreased itching may be evident within a few days or may take up to
four weeks
Cromolyn sodium 4% One to two drops per eye up to 6 ≥4 years: One to two drops per
(generics) times daily eye up to 6 times daily
Nedocromil 2% (Alocril) One to two drops per eye twice ≥3 years: One to two drops per
daily eye twice daily
Lodoxamide 0.1% (Alomide) Una o dos gotas por ojo 4 veces >2 años: una o dos gotas en el
al día durante hasta 3 meses ojo 4 veces al día durante un
máximo de 3 meses
Pemirolast 0,1% (no disponible Una o dos gotas por ojo hasta 4 ≥3 años: una o dos gotas por ojo
en EE. UU., pero puede estar veces al día durante hasta 4 hasta 4 veces al día durante hasta
disponible en otros países) semanas 4 semanas
Los nombres comerciales de Estados Unidos se muestran entre paréntesis después del nombre genérico.
OTC: sin receta (disponible sin receta).
Gráfico 91098 Versión 15.0
Divulgaciones del colaborador

Deborah S Jacobs, MD Consultores/Consejos asesores: Cloudbreak [Oftalmología/pterigión]; Dompé
[Oftalmología/queratitis neurotrófica]. Todas las relaciones financieras relevantes enumeradas han sido
mitigadas. Matthew F Gardiner, MD Consultores/Consejos asesores: Productos farmacéuticos genéricos
[degeneración macular]. Otro interés financiero: Alcon [Alimentos y bebidas – Curso de cataratas]. Todas
las relaciones financieras relevantes enumeradas han sido mitigadas. Jane Givens, MD, MSCE No hay
relaciones financieras relevantes con empresas no elegibles para revelar.
El grupo editorial revisa las divulgaciones de los contribuyentes para detectar conflictos de intereses.
Cuando se encuentran, estos se abordan mediante un proceso de revisión de varios niveles y mediante
requisitos de referencias que se deben proporcionar para respaldar el contenido. Se requiere que todos
los autores tengan contenido con las referencias adecuadas y deben cumplir con los estándares de
evidencia de UpToDate.
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27/4/24, 13:08 Conjuntivitis - UpToDate

Reimpresión oficial de UpToDate ®

Revisión de la literatura vigente hasta: marzo de 2024.

La conjuntivitis es un diagnóstico común en pacientes que se quejan de ojos rojos. Por lo

Este tema revisará las manifestaciones clínicas, el diagnóstico y el tratamiento de la

● (Ver "Glaucoma de ángulo cerrado" .)

La conjuntivitis leñosa se analiza por separado. (Consulte "Deficiencia de plasminógeno",

Conjuntivitis significa literalmente "inflamación de la conjuntiva". La conjuntiva es la membrana

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

CLASSIFICATION AND EPIDEMIOLOGY

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

CAUSES AND CLINICAL MANIFESTATIONS

Common presentations — Patients with bacterial conjunctivitis typically complain of redness

Bacterial conjunctivitis is commonly caused by Staphylococcus aureus, Streptococcus pneumoniae,

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

Chronic chlamydial infections

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

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

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

be an associated keratitis. This diagnosis should be considered in chronic cases among

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

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

Viral conjunctivitis typically presents as conjunctival injection with watery or mucoserous

Epidemic keratoconjunctivitis — One form of viral conjunctivitis, epidemic

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

Allergic conjunctivitis — Allergic conjunctivitis is caused by airborne allergens contacting the

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

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

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

EVALUATION AND DIAGNOSIS

Distinguishing between types of conjunctivitis — Key distinguishing features (including

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

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

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

● 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).

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

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 combination

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

Some alternative treatment options have specific limitations:

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

Adult inclusion conjunctivitis treatment — Antibiotic treatment for adult inclusion

Hyperacute bacterial conjunctivitis treatment — Hyperacute bacterial conjunctivitis

Symptomatic relief may be achieved with:

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

● Warm or cool compresses.

Noninfectious noninflammatory — The conjunctival surface regenerates rapidly from insults

Persistent symptoms — Patients with acute bacterial conjunctivitis usually respond to

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INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Causes – Conjunctivitis may be infectious (bacterial or viral) or noninfectious (allergic,

● Distinguishing between types – Distinguishing between bacterial, viral and allergic

• Bacterial – Bacterial conjunctivitis should only be diagnosed in patients with thick

• Viral – Viral conjunctivitis typically presents as injection, mucoid or serous discharge,

• Allergic – Allergic conjunctivitis typically presents as bilateral redness, watery

● Treatment of bacterial conjunctivitis - The use of antibiotics for bacterial conjunctivitis is

- Hyperacute bacterial conjunctivitis due to Neisseria – This requires systemic

- Chlamydial infection (typically a chronic infection) – This requires systemic