What does a white discharge from the eye indicate?

White Eye Discharge: Differential Diagnosis and Clinical Significance

White discharge from the eye most commonly indicates viral conjunctivitis (particularly adenoviral infection), allergic conjunctivitis with mucoid secretions, or molluscum contagiosum-related follicular conjunctivitis, though the specific characteristics of the discharge and associated findings determine the exact etiology. 1

Primary Diagnostic Considerations

Viral Conjunctivitis (Most Common)

• Watery to white discharge is characteristic of adenoviral conjunctivitis, which presents with bulbar conjunctival injection, follicular reaction of the inferior tarsal conjunctiva, and often sequential bilateral involvement 1
• Preauricular lymphadenopathy is a distinctive feature that helps confirm viral etiology 1
• Self-limited course with resolution in 5-14 days, though severe cases can progress to epidemic keratoconjunctivitis with subepithelial infiltrates 1, 2

Allergic Conjunctivitis

• Mucoid white discharge suggests allergic etiology, typically accompanied by itching, chemosis, and papillary conjunctival reaction 1, 3
• Giant papillary conjunctivitis presents with mucoid discharge and papillary hypertrophy of the superior tarsal conjunctiva, often in contact lens wearers 1

Molluscum Contagiosum

• Produces follicular conjunctivitis with associated white discharge when dome-shaped umbilicated eyelid lesions are present 1
• Typically unilateral but can be bilateral, especially in immunocompromised patients 1, 2

Critical Red Flags Requiring Immediate Evaluation

Vision-Threatening Conditions to Rule Out

• Always examine the cornea with fluorescein staining in any case with discharge to detect early corneal involvement 2
• White-appearing lesions on the conjunctiva may represent melanoma (white-pink variant), squamous cell carcinoma, or lymphoma ("salmon patch"), which require urgent ophthalmology referral 1

High-Risk Populations

• Any purulent or white discharge in neonates is an emergency until gonococcal and chlamydial causes are excluded, as gonococcal infection can cause corneal perforation within 24-48 hours 2
• Immunocompromised patients may present with atypical manifestations, including multiple large molluscum lesions causing chronic white discharge 2

Distinguishing Discharge Characteristics

White vs. Other Discharge Types

• Watery white discharge: Viral conjunctivitis, HSV, VZV 1
• Mucoid white discharge: Allergic conjunctivitis, giant papillary conjunctivitis 1, 3
• Purulent (yellow-green) discharge: Bacterial conjunctivitis requiring different management 3, 4
• Serofibrinous discharge: Adenoviral pharyngoconjunctival fever 2

Associated Clinical Findings That Guide Diagnosis

Conjunctival Reaction Pattern

• Follicular reaction (inferior tarsal conjunctiva): Viral etiology, molluscum contagiosum 1
• Papillary reaction (superior tarsal conjunctiva): Allergic conjunctivitis, giant papillary conjunctivitis, contact lens-related 1, 3

Systemic Symptoms

• Fever and pharyngitis with white discharge suggests adenoviral pharyngoconjunctival fever 2
• Vesicular dermatomal rash indicates herpes zoster virus, which presents with watery discharge and severe pain 1, 2

Common Pitfalls to Avoid

• Do not dismiss white discharge as benign without corneal examination, as conditions like HSV can progress to keratitis, stromal scarring, and perforation 2
• Consider sexual abuse in children presenting with any unusual conjunctivitis pattern, particularly if chlamydial or gonococcal etiology is suspected 2
• White lesions are not always benign: Conjunctival melanoma can present as white-pink lesions and requires biopsy 1
• In contact lens wearers with white mucoid discharge, suspect giant papillary conjunctivitis and discontinue lens wear immediately to prevent tarsal scarring and ptosis 1