What is the most likely diagnosis and appropriate management for a patient presenting with conjunctivitis and ocular drainage?

Conjunctivitis with Drainage: Diagnosis and Management

The most likely diagnosis is infectious conjunctivitis—either viral or bacterial—and management depends critically on distinguishing between these etiologies through careful assessment of discharge character, associated symptoms, and clinical context. 1

Diagnostic Approach

Key Historical Features to Elicit

• Character of discharge: Watery discharge strongly suggests viral etiology, while mucopurulent or purulent discharge with matted eyelids upon waking indicates bacterial conjunctivitis 1, 2
• Presence or absence of itching: Itching is the hallmark of allergic conjunctivitis and is typically absent in infectious causes 1, 2
• Unilateral versus bilateral presentation: Viral conjunctivitis often starts unilaterally but becomes sequentially bilateral, while bacterial can be either 2
• Recent exposure to infected individuals or concurrent upper respiratory infection (suggests viral) 1
• Sexual activity and genitourinary symptoms: Critical for identifying gonococcal or chlamydial conjunctivitis, which require systemic treatment 1, 2
• Contact lens wear: Raises concern for bacterial keratitis and requires urgent evaluation 1

Physical Examination Findings

• Follicular reaction on inferior tarsal conjunctiva with preauricular lymphadenopathy strongly indicates viral conjunctivitis 2
• Papillary reaction with purulent discharge suggests bacterial etiology 2
• Corneal involvement: Any corneal opacity, infiltrate, or ulceration requires immediate ophthalmology referral 1, 2
• Conjunctival scarring or pseudomembrane formation: Red flags for serious underlying pathology 1

Management Algorithm

Viral Conjunctivitis (Most Common Overall)

Supportive care is the mainstay, as viral conjunctivitis is self-limited and resolves within 5-14 days. 1, 2

• Preservative-free artificial tears for symptomatic relief and dilution of inflammatory mediators 2
• Cold compresses to reduce conjunctival swelling 2
• Topical antihistamines (e.g., olopatadine) may provide symptomatic relief of itching and redness 2
• Avoid topical antibiotics entirely—they provide no benefit and may cause unnecessary toxicity 1, 2
• Patient education on contagiousness: Wash hands frequently, avoid sharing towels/pillows, minimize contact with others for 10-14 days from onset 1, 2
• Disinfection: The virus can survive on dry surfaces for up to 28 days 2

Bacterial Conjunctivitis

Mild bacterial conjunctivitis is self-limited and may resolve without treatment, but topical antibiotics can shorten duration and allow earlier return to work/school. 1, 3

• For moderate to severe cases: 5-7 day course of broad-spectrum topical antibiotic 1, 2
• No specific antibiotic is superior—choose the most convenient or least expensive option (erythromycin ointment, polymyxin B/trimethoprim drops, or fluoroquinolones) 1, 2
• Delayed antibiotic prescribing has similar symptom control as immediate prescribing and may reduce unnecessary antibiotic use 4

Special Situations Requiring Immediate Systemic Treatment

Gonococcal conjunctivitis is a hyperacute, vision-threatening emergency requiring immediate systemic therapy in addition to topical treatment. 1, 2

• Presents with marked eyelid edema, bulbar conjunctival injection, severe purulent discharge, and can cause corneal perforation 2
• Requires hospitalization for parenteral therapy, daily follow-up until resolution, and treatment of sexual contacts 2

Chlamydial conjunctivitis requires systemic treatment and evaluation of sexual partners, as topical therapy alone is inadequate. 1, 2

Critical Red Flags Requiring Urgent Ophthalmology Referral

• Visual loss or decreased vision 1, 2
• Moderate to severe pain (not just irritation) 1, 2
• Severe purulent discharge suggesting gonococcal infection 2
• Corneal involvement (opacity, infiltrate, ulceration) 1, 2
• Conjunctival scarring 1, 2
• Recent ocular surgery or trauma 2
• History of herpes simplex virus eye disease 1, 2
• Immunocompromised state 1, 2
• Lack of response to therapy after 5-7 days 1, 2
• Contact lens wear with conjunctivitis (risk of bacterial keratitis) 1

When to Obtain Cultures

Routine bacterial conjunctivitis in otherwise healthy patients can be diagnosed clinically and treated empirically without laboratory testing. 2

Obtain conjunctival cultures and Gram stain in these high-risk situations:

• Neonatal conjunctivitis (mandatory) 2
• Suspected gonococcal conjunctivitis in any age group 2
• Sexually active patients with purulent discharge (heightened risk of Neisseria gonorrhoeae) 2
• Recurrent, severe, or chronic purulent conjunctivitis 2
• Failure to improve after initial 5-7 day course of topical antibiotics 2
• Collect cultures before initiating antibiotics whenever feasible to avoid false-negative results 2

Common Pitfalls to Avoid

• Indiscriminate use of topical corticosteroids: Can prolong adenoviral infections, worsen herpes simplex virus infections, and cause increased intraocular pressure and cataracts 1, 2
• Prescribing antibiotics for viral conjunctivitis: Contributes to resistance and causes unnecessary side effects 1, 2
• Missing gonococcal conjunctivitis: Can lead to corneal perforation and vision loss if not treated systemically 1, 2
• Inadequate patient education about contagiousness: Leads to community spread 1
• Chronic use of vasoconstrictive eye drops: Causes rebound vasodilation 2
• Failure to discard multi-dose containers that contact the ocular surface: Risk of cross-contamination 2

Follow-Up Recommendations

• Patients with severe viral conjunctivitis should be re-evaluated within 1 week 2
• Patients not on corticosteroids should return if symptoms persist beyond 2-3 weeks 2
• Patients on topical corticosteroids require regular monitoring of intraocular pressure and periodic pupillary dilation 2