What is the recommended evaluation and management for a patient with new‑onset conjunctivitis presenting with eye redness, discharge, irritation, and tearing?

Evaluation and Management of Acute Conjunctivitis (Pink Eye)

For a patient presenting with new-onset conjunctivitis, determine the etiology through focused history and examination, then treat viral cases with supportive care only, bacterial cases with topical antibiotics if moderate-to-severe, and allergic cases with topical antihistamines—while avoiding indiscriminate antibiotic or corticosteroid use. 1, 2

Initial Diagnostic Approach

Critical History Elements

Obtain these specific details to guide diagnosis:

• Discharge character: Watery suggests viral or allergic; purulent/mucopurulent with matted eyelids indicates bacterial 2, 3
• Itching: Most consistent feature of allergic conjunctivitis; minimal in infectious causes 2, 4
• Laterality and timing: Viral often starts unilateral then becomes sequentially bilateral; allergic is bilateral from onset 1, 2
• Exposure history: Recent contact with infected individuals (especially school/daycare settings) suggests viral; concurrent upper respiratory infection supports viral etiology 1, 2
• Sexual activity: In sexually active adults, aggressive workup including Gram stain and culture is mandatory due to risk of sight-threatening Neisseria gonorrhoeae 2
• Contact lens wear: Requires immediate ophthalmology referral and treatment for bacterial infection due to corneal ulcer risk 2, 3

Physical Examination Findings

Document these specific findings:

• Visual acuity: Measure and document at every visit 5
• Discharge type: Watery (viral/allergic) vs. mucopurulent (bacterial) 2, 5
• Conjunctival reaction: Follicular pattern on inferior tarsal conjunctiva suggests viral; papillary reaction suggests bacterial or allergic 2
• Preauricular lymphadenopathy: Present in viral (especially adenoviral) and gonococcal; absent in most bacterial and allergic cases 1, 2
• Corneal examination: Check for infiltrates, ulcers, or epithelial defects—any corneal involvement requires ophthalmology referral 2, 5
• Subconjunctival hemorrhage: Distinctive finding in viral conjunctivitis 1, 2

Management by Etiology

Viral Conjunctivitis (Most Common Overall)

Do NOT prescribe antibiotics—they provide no benefit and cause unnecessary toxicity. 1, 2

Treatment approach:

• Artificial tears for symptomatic relief 2
• Cold compresses 2, 3
• Topical antihistamines for symptomatic relief if needed 1
• Patient education: highly contagious for 10-14 days from onset; strict hand hygiene, separate towels/pillows, avoid close contact 1, 2
• Self-limited course: typically resolves within 5-14 days 1

When to consider topical corticosteroids:

• Only for severe cases with marked chemosis, lid swelling, or subepithelial infiltrates 2
• Requires close ophthalmology follow-up for monitoring intraocular pressure and cataract formation 2
• Critical pitfall: Corticosteroids prolong viral shedding and can worsen HSV infections 2

Bacterial Conjunctivitis

Mild cases are self-limited and may not require antibiotics, but moderate-to-severe cases benefit from a 5-7 day course of broad-spectrum topical antibiotics. 1, 2

Antibiotic selection:

• No specific agent is superior—choose the most convenient or least expensive option 1, 2
• Options include: erythromycin ointment, polymyxin B/trimethoprim drops, or fluoroquinolones 2
• Erythromycin dosing: approximately 1 cm ribbon applied up to 6 times daily depending on severity 6

Special bacterial considerations:

• Gonococcal conjunctivitis (marked lid edema, copious purulent discharge, preauricular lymphadenopathy):

  • Requires immediate systemic therapy PLUS topical antibiotics 2
  • Hospitalization for parenteral therapy 2
  • Daily follow-up until resolution 2
  • Treat sexual contacts 2
  • Can cause corneal perforation if missed 2

• Chlamydial conjunctivitis:

  • Systemic therapy required; topical therapy alone is inadequate 2
  • Evaluate and treat sexual partners 1, 2
  • Confirm with PCR or immunofluorescent antibody testing 2

Allergic Conjunctivitis

First-line treatment is topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen). 2

Additional measures:

• Environmental modifications: sunglasses as barrier to airborne allergens 2
• Cold compresses and refrigerated artificial tears 2
• Avoid eye rubbing 2
• Oral antihistamines are less effective than topical agents for ocular symptoms 2
• For refractory cases: brief 1-2 week course of topical corticosteroids with low side-effect profile 2

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if ANY of the following are present:

• Visual loss or decreased vision 2
• Moderate or severe pain 2
• Severe purulent discharge 2
• Corneal involvement (infiltrate, ulcer, or opacity) 2
• Contact lens wear 2, 3
• Recent ocular surgery 2, 3
• History of herpes simplex virus eye disease 2
• Immunocompromised state 2, 3
• Vesicular rash on eyelids or nose (suggests HSV or varicella zoster) 2, 3
• Conjunctival scarring 2
• Lack of response to therapy 2
• Recurrent episodes 2
• Neonatal conjunctivitis (requires prompt evaluation and may need hospitalization) 1

Infection Control and Prevention

For infectious conjunctivitis:

• Wash hands frequently with soap and water 2
• Use separate towels and pillows 1, 2
• Avoid sharing personal items 2
• Disinfect surfaces with EPA-registered hospital disinfectant 2
• Avoid close contact with others for 10-14 days from symptom onset 1, 2
• Tonometer disinfection: Use dilute bleach (1:10 sodium hypochlorite) or single-use disposable tips; 70% isopropyl alcohol is no longer recommended 1

Follow-Up Recommendations

• Severe viral conjunctivitis: Re-evaluate within 1 week 2
• Patients not on corticosteroids: Return if symptoms persist beyond 2-3 weeks 2
• Patients on topical corticosteroids: Regular monitoring of intraocular pressure and periodic pupillary dilation 2
• Gonococcal conjunctivitis: Daily follow-up until resolution 2

Common Pitfalls to Avoid

• Never prescribe antibiotics indiscriminately for viral conjunctivitis—this contributes to resistance and causes unnecessary side effects 1, 2
• Never use topical corticosteroids without close ophthalmology follow-up—risk of elevated intraocular pressure, cataract formation, prolonged viral shedding, and worsening HSV infections 2
• Never miss gonococcal conjunctivitis in sexually active adults—requires aggressive workup with Gram stain and culture 2
• Never treat contact lens wearers without ophthalmology referral—high risk of corneal ulcer 2, 3
• Never document "conjunctivitis" without specifying laterality, discharge character, and corneal examination findings 5
• Recognize that prior empiric antibiotic use reduces diagnostic accuracy by suppressing bacterial growth on cultures 2

Age-Specific Considerations

Neonates:

• Gonococcal conjunctivitis typically occurs 1-7 days after birth; chlamydial 5-14 days after birth 5
• Cultures are mandatory 5
• Erythromycin 0.5% ointment (1 cm ribbon to each lower conjunctival sac) is standard prophylaxis for ophthalmia neonatorum 1, 6

Children:

• Bacterial conjunctivitis may be associated with concurrent otitis media 2
• If gonococcal or chlamydial conjunctivitis is diagnosed, assess for sexual abuse 5