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Infectious Conjunctivitis

(Pink Eye; Pinkeye)

By

Melvin I. Roat

, MD, FACS, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision Dec 2019| Content last modified Dec 2019
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Infectious conjunctivitis is inflammation of the conjunctiva usually caused by viruses or bacteria.

  • Bacteria and viruses can infect the conjunctiva.

  • Redness and tearing or discharge are common symptoms, and some people have sensitivity to light.

  • Good hygiene helps prevent the infection from spreading to the other eye or to someone else's eye.

  • Antibiotic eye drops are often given for bacterial conjunctivitis.

A variety of microorganisms may infect the conjunctiva (the membrane that lines the eyelid and covers the white of the eye). The most common organisms are viral, particularly those from the group known as adenoviruses. Bacterial infections are less frequent. Both viral and bacterial conjunctivitis are very contagious, easily passing from one person to another, or from a person's infected eye to the uninfected eye.

Some viruses that cause bodywide symptoms also cause red, irritated eyes. Such viral infections include measles, mumps, rubella, chickenpox, Zika, and some of the viruses that cause cold- and flu-like symptoms.

Fungal infections are rare and occur mainly in people who use corticosteroid eye drops for a long time or have eye injuries involving organic matter, such as plants or dirt.

An Inside Look at the Eye

An Inside Look at the Eye

Newborns are particularly susceptible to eye infections caused by Chlamydia trachomatis or Neisseria gonorrhoeae, which they acquire from organisms in the mother's birth canal (conjunctivitis of the newborn).

Inclusion conjunctivitis is a particularly long-lasting form of conjunctivitis caused by certain strains of the bacterium Chlamydia trachomatis. Inclusion conjunctivitis usually spreads by contact with genital secretions from a person who has a genital chlamydial infection. Trachoma, another type of conjunctivitis caused by Chlamydia trachomatis, is not due to a genital chlamydial infection.

Gonococcal conjunctivitis is conjunctivitis caused by Neisseria gonorrhoeae (gonorrhea), a sexually transmitted disease that also may spread to the eye by contact with genital secretions from a person who has a genital gonorrheal infection.

Severe infections may scar the conjunctiva, causing abnormalities in the tear film. Sometimes, severe conjunctival infections spread to the cornea (the clear layer in front of the iris and pupil).

Inflammation of the conjunctiva caused by an allergic reaction, as opposed to a virus or bacteria, is called allergic conjunctivitis.

Symptoms

When infected, the conjunctiva becomes pink from dilated blood vessels, and a discharge appears in the eye. Often the discharge causes the person's eyes to stick shut, particularly overnight. This discharge may also cause the vision to blur. Vision improves when the discharge is blinked away. If the cornea is infected, vision also blurs but does not improve with blinking. Sometimes the eye feels irritated, and bright light may cause discomfort. Very rarely, severe infections that have scarred the conjunctiva lead to long-term vision difficulties.

Viral conjunctivitis differs from bacterial conjunctivitis in the following ways:

  • Eye discharge tends to be watery in viral conjunctivitis and thicker white, green, or yellow in bacterial conjunctivitis.

  • An upper respiratory infection increases the likelihood of a viral cause.

  • A lymph node in front of the ear may be swollen and painful in viral conjunctivitis but is usually not in bacterial conjunctivitis.

These factors, however, cannot always accurately differentiate viral conjunctivitis from bacterial conjunctivitis.

People with inclusion conjunctivitis or with conjunctivitis caused by gonorrhea often have symptoms of a genital infection, such as discharge from the penis or vagina and burning during urination.

Conjunctivitis in the newborn causes inflammation of the eyelid and a discharge of pus.

Diagnosis

  • A doctor's evaluation of the symptoms and appearance of the eye

  • Sometimes culture of secretions

Doctors diagnose infectious conjunctivitis by its symptoms and appearance. The eye is usually closely examined with a slit lamp (an instrument that enables a doctor to examine the eye under high magnification). Samples of infected secretions may be sent to a laboratory to identify the infecting organism by a culture. However, doctors usually send samples to a laboratory only in certain situations:

  • When the symptoms are severe or recurring

  • When Chlamydia trachomatis or Neisseria gonorrhea is thought to be the cause

  • When the person has an immune system defect (such as human immunodeficiency virus [HIV]/AIDS)

  • When the person has had an eye problem, such as a corneal transplant or eye bulging caused by Graves disease

What Is Pink Eye?

Although most eye inflammations result in a pink discoloration of the eye (because of dilated blood vessels in the conjunctiva), doctors usually use the term "pink eye" for conjunctivitis caused by infection with a bacteria or virus.

One of the most severe forms of pink eye is the result of infection with several particular strains of adenovirus. This infection, called epidemic keratoconjunctivitis (see table Some Causes and Features of Eye Pain), is extremely contagious and often results in large outbreaks within a community or school. The infection is spread through contact with infected secretions. Such contact may take place person-to-person or through contaminated objects, possibly including improperly disinfected doctors’ instruments.

Many symptoms of epidemic keratoconjunctivitis, such as redness and thin, watery discharge and, less commonly, irritation and sensitivity to light, are similar to other types of viral conjunctivitis. However, some people with epidemic keratoconjunctivitis feel like grit or sand is in their eye and can have pain when the eye is exposed to bright light. The conjunctiva can swell and bulge around the cornea. Many people develop a swollen lymph node in front of the ear on the affected side. These symptoms typically last from 1 to 3 weeks. Some people have blurred vision, which may last for weeks or months before resolving.

Epidemic keratoconjunctivitis resolves completely without specific treatment. Doctors sometimes give corticosteroid drops to people with very blurred vision or severe sensitivity to light. Good hygiene, particularly the use of hand sanitizers, is needed to minimize the spread of the infection. Separate towels, washcloths, and bedding help minimize the spread to other members of the household. People generally stay home from work or school for several days or, in severe cases, even weeks.

Prognosis

Most people with infectious conjunctivitis eventually get better without treatment. However, some infections, particularly those caused by some bacteria, may last a long time if not treated.

Inclusion conjunctivitis may persist for months if not treated.

Conjunctivitis in the newborn may cause blindness if not treated.

Treatment

  • For the discharge of bacterial conjunctivitis, washing the eyelid and warm, wet washcloth compresses to remove the typically hard, dry secretions

  • For treating the infection of bacterial conjunctivitis, antibiotic eye drops or ointment

  • For severe viral conjunctivitis, where blurring and sensitivity to light are interfering with important daily activities, corticosteroid eye drops can be helpful

  • For decreasing the symptoms (swelling and discomfort) of viral conjunctivitis, cold compresses

  • Frequent use of hand sanitizers and other precautions to avoid spreading the infection

If discharge accumulates on the eyelid, particularly in bacterial conjunctivitis, people should gently wash the eyelid (with the eye closed) with warm tap water and a clean washcloth. Cold compresses sometimes soothe the feeling of irritation, particularly in viral conjunctivitis.

If severe viral conjunctivitis causes symptoms, such as blurring and sensitivity to light, that interfere with important daily activities, corticosteroid eye drops can help. Antibiotic eye drops or ointment can help treat bacterial conjunctivitis.

Because infectious (bacterial or viral) conjunctivitis is highly contagious, people should use hand sanitizers before and after cleaning the eye or applying drugs to the eye. Also, a person should be careful not to touch the infected eye and then touch the other eye. Towels and washcloths used to clean the eye should be kept separate from other towels and washcloths.

People with infectious conjunctivitis generally stay home from work or school for a few days, just as they would with a cold. In the most severe cases of viral conjunctivitis, people sometimes stay home for weeks. A person with conjunctivitis should avoid swimming in a pool.

Conjunctivitis caused by bacteria

Antibiotics are helpful only in bacterial conjunctivitis. However, because it is difficult to distinguish between bacterial and viral infections, some doctors prescribe antibiotics for everyone with conjunctivitis. Antibiotic eye drops or ointments, such as moxifloxacin, ciprofloxacin, or trimethoprim/polymyxin, which are effective against many types of bacteria, are used for 7 to 10 days. Drops are usually effective, but ointments are sometimes used because they last longer if the eye is watering a lot. However, some people may not want to use ointments because they can blur vision for up to 20 minutes after they are applied.

Inclusion conjunctivitis requires antibiotics, such as azithromycin, doxycycline, or erythromycin, which are taken by mouth.

Gonococcal conjunctivitis may be treated with a single injection of ceftriaxone and a single dose of azithromycin (or doxycycline for one week) taken by mouth.

Conjunctivitis of the newborn is prevented by routinely giving silver nitrate eye drops or erythromycin ointment to all infants at birth. If an infection develops despite these treatments, newborns are given drugs depending on which bacterium is causing the infection. Infections caused by Neisseria gonorrhoeae are treated with ceftriaxone given by vein (intravenously) or injected into a muscle. Infections caused by Chlamydia trachomatis are treated with erythromycin. The parents should also be treated.

Conjunctivitis caused by viruses

Most people with viral conjunctivitis get better in a week or two and do not need any specific treatment. However, corticosteroid eye drops may be needed in some people with the severe adenoviral conjunctivitis (see What Is Pink Eye?), particularly in those in whom blurring and sensitivity to light are interfering with important daily activities.

Antiviral eye drops are not helpful for conjunctivitis caused by viruses (antiviral eye drops are used for some cornea infections caused by viruses—see Herpes Simplex Keratitis).

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