Conjunctivitis

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Conjunctivitis

Other names Pink eye

An eye with viral conjunctivitis

Specialty Ophthalmology

Symptoms Reddish eye, scratchiness[1]

Duration Viral conjunctivitis: up to two weeks[2]

Causes Viral, bacterial, allergies[3]

Diagnostic method Based on symptoms, microbial culture[1]

Prevention Handwashing[1]

1
Treatment Based on underlying cause[3]
 Frequency 3–6 million per year (USA)[1][3]

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the
eye and the inner surface of the eyelid.[4] It makes the eye appear pink or reddish. [1] Pain, burning,
scratchiness, or itchiness may occur.[1] The affected eye may have increased tears or be "stuck shut"
in the morning.[1] Swelling of the white part of the eye may also occur.[1] Itching is more common in
cases due to allergies.[3] Conjunctivitis can affect one or both eyes.[1]
The most common infectious causes are viral followed by bacterial.[3] The viral infection may occur
along with other symptoms of a common cold.[1] Both viral and bacterial cases are easily spread
between people.[1] Allergies to pollen or animal hair are also a common cause. [3] Diagnosis is often
based on signs and symptoms.[1] Occasionally, a sample of the discharge is sent for culture.[1]
Prevention is partly by handwashing.[1] Treatment depends on the underlying cause.[1] In the majority of
viral cases, there is no specific treatment.[3] Most cases due to a bacterial infection also resolve
without treatment; however, antibiotics can shorten the illness.[1][3] People who wear contact lenses and
those whose infection is caused by gonorrhea or chlamydia should be treated.[3] Allergic cases can be
treated with antihistamines or mast cell inhibitor drops.[3]
About 3 to 6 million people get conjunctivitis each year in the United States. [1][3] In adults, viral causes
are more common, while in children, bacterial causes are more common. [3] Typically, people get
better in one or two weeks.[1][3] If visual loss, significant pain, sensitivity to light, signs of herpes, or if
symptoms do not improve after a week, further diagnosis and treatment may be required.
[3]
Conjunctivitis in a newborn, known as neonatal conjunctivitis, may also require specific treatment.[1]

Contents

 1Signs and symptoms

o 1.1Viral
o 1.2Allergic
o 1.3Bacterial
o 1.4Chemical
o 1.5Other
 2Causes
o 2.1Viral
o 2.2Bacterial
o 2.3Allergic
o 2.4Other
 3Diagnosis
o 3.1Classification
o 3.2Differential diagnosis
 4Prevention
 5Management
o 5.1Viral
o 5.2Allergic
o 5.3Bacterial
o 5.4Chemical 2
 6Epidemiology
 7History
 8Society and culture
 9See also
 10References
 11External links

Signs and symptoms[edit]

Red eye, swelling of the conjunctiva, and watering of the eyes are symptoms common to all forms of
conjunctivitis. However, the pupils should be normally reactive, and the visual acuity normal.
Conjunctivitis is identified by irritation and redness of the conjunctiva. Except in obvious pyogenic or
toxic/chemical conjunctivitis, a slit lamp (biomicroscope) is needed to confirm the diagnosis.
Examination of the eyelid conjunctiva is usually more diagnostic than examination of the scleral
conjunctiva.
Viral[edit]

Conjunctivitis due to a viral infection resulting in some bleeding

Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold,
or a sore throat. Its symptoms include excessive watering and itching. The infection usually begins in
one eye, but may spread easily to the other eye.
Viral conjunctivitis manifests as a fine, diffuse pinkness of the conjunctiva, which is easily mistaken
for a ciliary infection of the iris (iritis), but corroborative signs on microscopy, particularly
numerous lymphoid follicles on the tarsal conjunctiva, and sometimes a punctate keratitis are seen.
Allergic[edit]

An eye with allergic conjunctivitisshowing conjunctival edema

Allergic conjunctivitis is inflammation of the conjunctiva due to allergy.[5] The specific allergens may
differ among patients. Symptoms result from the release of histamine and other active substances
by mast cells, and consist of redness (mainly due to vasodilation of the peripheral small blood
vessels), swelling of the conjunctiva, itching, and increased production of tears.

3
Bacterial[edit]

An eye with bacterial conjunctivitis

Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and a
sticky discharge. Typically, symptoms develop first in one eye, but may spread to the other eye
within 2–5 days. Conjunctivitis due to common pus-producing bacteria causes marked grittiness or
irritation and a stringy, opaque, greyish or yellowish discharge that may cause the lids to stick
together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may
also occur. The gritty or scratchy feeling is sometimes localized enough that patients may insist that
they have a foreign body in the eye.
Common bacteria responsible for nonacute bacterial conjunctivitis are Staphylococcus, Streptococcus,
[6]
and Haemophilus species. Less commonly, Chlamydia spp. may be the cause.[7]

Typical membranous conjunctivitis

Bacteria such as Chlamydia trachomatis or Moraxella spp. can cause a nonexudative but persistent
conjunctivitis without much redness. Bacterial conjunctivitis may cause the production of membranes
or pseudomembranes that cover the conjunctiva. Pseudomembranes consist of a combination
of inflammatory cells and exudates and adhere loosely to the conjunctiva, while true membranes are
more tightly adherent and cannot be easily peeled away. Cases of bacterial conjunctivitis that involve
the production of membranes or pseudomembranes are associated with Neisseria gonorrhoeae, β-
hemolytic streptococci, and Corynebacterium diphtheriae. C. diphtheriae causes membrane formation
in conjunctiva of unimmunized children.[8]
Chemical[edit]
Chemical eye injury may result when an acidic or alkaline substance gets in the eye.[9] Alkali burns are
typically worse than acidic burns.[10]Mild burns produce conjunctivitis, while more severe burns may
cause the cornea to turn white.[10] Litmus paper may be used to test for chemical causes.[9] When a
chemical cause has been confirmed, the eye or eyes should be flushed until the pH is in the range 6
—8.[10]Anaesthetic eye drops can be used to decrease the pain. [10]
Irritant or toxic conjunctivitis is primarily marked by redness. If due to a chemical splash, it is often
present in only the lower conjunctival sac. With some chemicals, above all with caustic alkalis such
as sodium hydroxide, necrosis of the conjunctiva marked by a deceptively white eye due to vascular
closure may occur, followed by sloughing off of the dead epithelium. A slit lamp examination is likely
to show evidence of anterior uveitis.
4
Other[edit]

An eye with chlamydial conjunctivitis

Inclusion conjunctivitis of the newborn is a conjunctivitis that may be caused by the
bacterium Chlamydia trachomatis, and may lead to acute, purulent conjunctivitis.[11] However, it is
usually self-healing.[11]

Causes[edit]
Infective conjunctivitis is most commonly caused by a virus.[12] Bacterial infections, allergies, other
irritants, and dryness are also common causes. Both bacterial and viral infections are contagious,
passing from person to person or spread through contaminated objects or water. Contact with
contaminated fingers is a common cause of conjunctivitis. Bacteria may also reach the conjunctiva
from the edges of the eyelids and the surrounding skin, from the nasopharynx, from infected eye
drops or contact lenses, from the genitals or the bloodstream. [13] Infection by human adenovirus
accounts for 65% to 90% of cases of viral conjunctivitis. [14]
Viral[edit]
Adenoviruses are the most common cause of viral conjunctivitis (adenoviral keratoconjunctivitis).
[15]
Herpetic keratoconjunctivitis, caused by herpes simplex viruses, can be serious and requires
treatment with aciclovir. Acute hemorrhagic conjunctivitis is a highly contagious disease caused by
one of two enteroviruses, enterovirus 70 and coxsackievirus A24. These were first identified in an
outbreak in Ghana in 1969, and have spread worldwide since then, causing several epidemics. [16]
Bacterial[edit]
The most common causes of acute bacterial conjunctivitis are Staphylococcus aureus, Streptococcus
pneumoniae, and Haemophilus influenzae.[15][17] Though very rare, hyperacute cases are usually caused
by Neisseria gonorrhoeae or Neisseria meningitidis. Chronic cases of bacterial conjunctivitis are those
lasting longer than 3 weeks, and are typically caused by S. aureus, Moraxella lacunata, or Gram-
negative enteric flora.
Allergic[edit]
Conjunctivitis may also be caused by allergens such as pollen, perfumes, cosmetics, smoke, [18] dust
mites, Balsam of Peru,[19] or eye drops.[20] The most frequent cause of conjunctivitis is allergic
conjunctivitis and it affects 15% to 40% of the population. [21] Allergic conjunctivitis accounts for 15%
of eye related primary care consultations - most including seasonal exposures in the spring and
summer or perpetual conditions. [22]
Other[edit]
Conjunctivitis is part of the triad of reactive arthritis, which is thought to be caused
by autoimmune cross-reactivity following certain
5 bacterial infections. Reactive arthritis is highly
associated with HLA-B27. Conjunctivitis is associated with the autoimmune disease relapsing
polychondritis.[23][24]

Diagnosis[edit]
Cultures are not often taken or needed as most cases resolve either with time or typical antibiotics. If
bacterial conjunctivitis is suspected, but no response to topical antibiotics is seen, swabs for
bacterial culture should be taken and tested. Viral culture may be appropriate in epidemic case
clusters.
A patch test is used to identify the causative allergen in allergic conjunctivitis. [25]
Although conjunctival scrapes for cytology can be useful in detecting chlamydial
and fungal infections, allergy, and dysplasia, they are rarely done because of the cost and the general
dearth of laboratory staff experienced in handling ocular specimens. Conjunctival incisional biopsy is
occasionally done when granulomatous diseases (e.g., sarcoidosis) or dysplasia are suspected.
Classification[edit]
Conjunctivitis may be classified either by cause or by extent of the inflamed area.
Causes[edit]

 Allergy
 Bacteria
 Viruses
 Chemicals
 Autoimmune

Neonatal conjunctivitis is often grouped separately from bacterial conjunctivitis because it is caused
by different bacteria than the more common cases of bacterial conjunctivitis.
By extent of involvement[edit]
Blepharoconjunctivitis is the dual combination of conjunctivitis with blepharitis (inflammation of the
eyelids).
Keratoconjunctivitis is the combination of conjunctivitis and keratitis (corneal inflammation).
Blepharokeratoconjunctivitis is the combination of conjunctivitis with blepharitis and keratitis. It is
clinically defined by changes of the lid margin, meibomian gland dysfunction, redness of the eye,
conjunctival chemosis and inflammation of the cornea. [26]
Differential diagnosis[edit]
Some more serious conditions can present with a red eye, such as infectious keratitis, angle-closure
glaucoma, or iritis. These conditions require the urgent attention of an ophthalmologist. Signs of
such conditions include decreased vision, significantly increased sensitivity to light, inability to keep
the eye open, a pupil that does not respond to light, or a severe headache with nausea. [27] Fluctuating
blurring is common, due to tearing and mucoid discharge. Mild photophobia is common. However, if
any of these symptoms is prominent, considering other diseases such as glaucoma, uveitis, keratitis,
and even meningitis or carotico-cavernous fistula is important.
A more comprehensive differential diagnosis for the red or painful eye includes: [27]

 Corneal abrasion
 Subconjunctival hemorrhage 6
 Pinguecula
 Blepharitis
 Dacryocystitis
 Keratoconjunctivitis sicca (dry eye)
 Keratitis
 Herpes simplex
 Herpes zoster
 Episcleritis - an inflammatory condition that produces a similar appearance to conjunctivitis,
but without discharge or tearing
 Uveitis
 Acute angle-closure glaucoma
 Endophthalmitis

Prevention[edit]
The most effective prevention is good hygiene, especially avoiding rubbing the eyes with infected
hands. Vaccination against adenovirus, Haemophilus influenzae, pneumococcus, and Neisseria
meningitidis is also effective.[28]
Povidone-iodine eye solution has been found to prevent neonatal conjunctivitis. [29] It is becoming more
commonly used globally because of its low cost.[29]

Management[edit]
Conjunctivitis resolves in 65% of cases without treatment, within 2-5 days. The prescription of
antibiotics is not necessary in most cases.[30]
Viral[edit]
Viral conjunctivitis usually resolves on its own and does not require any specific treatment.
[12]
Antihistamines (e.g., diphenhydramine) or mast cell stabilizers (e.g., cromolyn) may be used to
help with the symptoms.[12] Povidone-iodine has been suggested as a treatment, but as of 2008,
evidence to support it was poor.[31]
Allergic[edit]
For allergic conjunctivitis, cool water poured over the face with the head inclined downward
constricts capillaries, and artificial tears sometimes relieve discomfort in mild cases. In more severe
cases, nonsteroidal anti-inflammatory medications and antihistamines may be prescribed. Persistent
allergic conjunctivitis may also require topical steroid drops.
Bacterial[edit]
Bacterial conjunctivitis usually resolves without treatment. [12] Topical antibiotics may be needed only if
no improvement is observed after 3 days.[32] No serious effects were noted either with or without
treatment.[33] Because antibiotics do speed healing in bacterial conjunctivitis, their use may be
considered.[33] Antibiotics are also recommended for those who wear contact lenses,
are immunocompromised, have disease which is thought to be due to chlamydia or gonorrhea, have a
fair bit of pain, or have copious discharge.[12] Gonorrheal or chlamydial infections require both oral
and topical antibiotics.[12]
The choice of antibiotic varies based on the strain or suspected strain of bacteria causing the
infection. Fluoroquinolones, sodium sulfacetamide, or trimethoprim/polymyxin may be used, typically for
7–10 days.[15] Cases of meningococcal conjunctivitis can also be treated with systemic penicillin, as
long as the strain is sensitive to penicillin.
7
When investigated as a treatment, povidone-iodine ophthalmic solution has also been observed to
have some effectiveness against bacterial and chlamydial conjunctivitis, with a possible role
suggested in locations where topical antibiotics are unavailable or costly. [34]
Chemical[edit]
Conjunctivitis due to chemicals is treated via irrigation with Ringer's lactate or saline solution. Chemical
injuries, particularly alkali burns, are medical emergencies, as they can lead to severe scarring and
intraocular damage. People with chemically induced conjunctivitis should not touch their eyes to
avoid spreading the chemical.

Epidemiology[edit]
Conjunctivitis is the most common eye disease. [35] Rates of disease is related to the underlying cause
which varies by the age as well as the time of year. Acute conjunctivitis is most frequently found in
infants, school-age children and the elderly.[13] The most common cause of infectious conjunctivitis is
viral conjunctivitis.[21]
It is estimated that acute conjunctivitis affects 6 million people annually in the United States. [36]
Some seasonal trends have been observed for the occurrence of different forms of conjunctivitis.
The occurrence of bacterial conjunctivitis peaks from December to April, viral conjunctivitis peaks in
the summer months and allergic conjunctivitis is more prevalent throughout the spring and summer.
[13]

History[edit]
An adenovirus was first isolated by Rowe et al. in 1953. Two years later, Jawetz et al. published on
epidemic keratoconjunctivitis.[37]:437 "Madras eye" is a colloquial term that has been used in India for
the disease.

Society and culture[edit]

Conjunctivitis imposes economic and social burdens. The cost of treating bacterial conjunctivitis
alone was estimated to be $377 million to $857 million per year.[36] Approximately 1% of all primary
care office visits in the United States are related to conjunctivitis. Approximately 70% of all people
with acute conjunctivitis present to primary care and urgent care. [36]

See also[edit]
 Conjunctival suffusion
 Ophthalmia

References[edit]
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