Presenting Signs and Symptoms of Conjunctivitis (Pink Eye)
Pink eye presents with a constellation of symptoms including eye redness, discharge (which varies by etiology), tearing, irritation, and eyelid mattering, with the specific pattern of these findings helping distinguish between viral, bacterial, and allergic causes. 1
Core Symptoms to Elicit
The key symptoms that patients report include: 1
- Mattering and adherence of eyelids (especially upon waking—strongly suggests bacterial etiology)
- Itching (the hallmark of allergic conjunctivitis) 2
- Tearing and watery discharge
- Eye irritation and foreign body sensation
- Pain (mild discomfort is common, but severe pain warrants concern for more serious pathology)
- Photophobia (light sensitivity)
- Blurred vision
- Discharge character (purulent suggests bacterial; watery suggests viral or allergic) 3
Clinical Signs on Examination
Universal Signs Across All Types
- Conjunctival injection (redness)—the cardinal sign of ocular inflammation 1, 4
- Discharge with varying characteristics based on etiology 1
Bacterial Conjunctivitis Specific Signs
- Purulent or mucopurulent discharge 3
- Mattering of eyelids (strongest predictor of bacterial cause) 2
- May be unilateral initially but often becomes bilateral 1
Viral Conjunctivitis Specific Signs
- Watery to serofibrinous discharge 5
- Follicular reaction of the inferior tarsal conjunctiva 5
- Preauricular or periauricular lymphadenopathy 1, 5
- Often bilateral presentation (though may start unilaterally) 5
- In pharyngoconjunctival fever: associated fever, pharyngitis, and tonsillar exudates 5
Allergic Conjunctivitis Specific Signs
- Severe itching (most consistent finding) 2
- Bilateral watery discharge 3
- Seasonal pattern often present 3
Chlamydial Conjunctivitis Distinctive Signs
- Follicles on the bulbar conjunctiva and semilunar fold (distinctive finding) 5
- Mucopurulent discharge 1
- May have associated genitourinary symptoms (cervicitis, urethritis) 1
Critical Red Flags Requiring Urgent Evaluation
Watch for these warning signs that indicate vision-threatening or life-threatening conditions: 5
- Severe purulent discharge (especially in neonates or sexually active adults—consider gonococcal infection which can cause corneal perforation within 24-48 hours)
- Corneal involvement (always examine with fluorescein staining in purulent conjunctivitis)
- Severe pain not relieved by topical anesthetics 4
- Vision loss 4
- Vesicular dermatomal rash (suggests herpes zoster) 5
- Unilateral granulomatous follicular conjunctivitis with ipsilateral lymphadenopathy (Parinaud oculoglandular syndrome) 5
Key Historical Context to Obtain
Beyond symptoms, gather: 1
- Duration and time course of symptoms
- Unilateral versus bilateral presentation
- Recent exposure to infected individuals
- Contact lens wear (requires aggressive treatment and corneal ulcer evaluation) 3, 4
- Sexual activity (for chlamydial/gonococcal consideration) 1
- Allergy history, asthma, eczema 1
- Recent upper respiratory infection 1
- Immunocompromised status 1
Common Clinical Pitfall
The absence of itching and presence of eyelid mattering on waking are the strongest predictors of bacterial conjunctivitis, while itching is virtually pathognomonic for allergic causes. 2 However, distinguishing viral from bacterial conjunctivitis based on clinical findings alone remains challenging, as presentation can overlap significantly. 2, 6