How should I manage acute conjunctivitis (pink eye) in an otherwise healthy adult presenting with redness, watery or purulent discharge, mild irritation, and no vision loss?

Management of Acute Conjunctivitis in Healthy Adults

Most cases of acute conjunctivitis in healthy adults are viral and self-limited, requiring only supportive care with artificial tears and cold compresses—topical antibiotics should be avoided unless purulent discharge strongly suggests bacterial infection. 1, 2

Initial Clinical Assessment

Key Diagnostic Features to Identify

Viral conjunctivitis is the most common cause and presents with:

• Watery discharge (not purulent) 2, 3
• Photosensitivity or photophobia (suggests corneal involvement) 2
• Pain rather than just irritation 2
• Often bilateral, though may start unilaterally 4
• Preauricular lymphadenopathy 4
• Recent upper respiratory infection or sick contacts 1

Bacterial conjunctivitis presents with:

• Purulent or mucopurulent discharge (green/yellow) that mats eyelids on waking 4, 3
• Lack of itching 3
• No history of prior conjunctivitis 3
• Bilateral bulbar conjunctival injection 1

Critical red flags requiring immediate ophthalmology referral:

• Decreased vision 2, 5
• Severe pain (not mild irritation) 2, 5
• Corneal involvement on fluorescein staining 4
• Vesicular rash on eyelids or nose (suggests HSV/VZV) 4, 2, 5
• Recent ocular surgery 2, 5
• Immunocompromised state 5

Essential Physical Examination Steps

Perform fluorescein staining of the cornea in any case with purulent discharge to detect early corneal involvement—this is critical to avoid missing HSV keratitis or bacterial keratitis. 4

Examine for:

• Eyelid vesicles or ulceration (HSV/VZV) 4
• Preauricular lymph node enlargement 4
• Follicular reaction on tarsal conjunctiva (evert lower lid) 4
• Corneal infiltrates or ulcers 4

Treatment Algorithm

For Viral Conjunctivitis (Watery Discharge, Photosensitivity, Pain)

Supportive care only:

• Artificial tears for symptomatic relief 2
• Cold compresses to reduce inflammation 2
• Strict hand hygiene to prevent transmission 2
• Avoid touching eyes, sharing towels, or using eye cosmetics 2

Do NOT prescribe:

• Topical antibiotics (ineffective and promote resistance) 1, 2
• Topical antivirals (not indicated unless HSV with dendritic keratitis confirmed) 2

Expected course: Self-limited, resolving in 5-14 days 4

For Bacterial Conjunctivitis (Purulent Discharge, Matted Eyelids)

Delayed antibiotic prescribing is preferred for uncomplicated cases—provide a prescription but advise waiting 2-3 days before filling if symptoms don't improve, as most cases resolve spontaneously within 1-2 weeks. 4, 5

Immediate topical antibiotics are appropriate when:

• Purulent discharge is present (increases 7-day cure rate by absolute risk difference of 0.09) 4
• Rapid return to work/school is desired 4

First-line topical antibiotics:

• Fluoroquinolones, trimethoprim-polymyxin B, or aminoglycosides 4
• No evidence demonstrates superiority of any specific agent 1

Critical Exceptions Requiring Systemic Antibiotics

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

• Requires immediate systemic antibiotics PLUS topical therapy 4
• Can cause corneal perforation within 24-48 hours if untreated 4

Chlamydial conjunctivitis (follicular conjunctivitis with bulbar conjunctival follicles):

• Requires systemic antibiotics (topical alone is insufficient) 4
• Consider sexual abuse in children with this diagnosis 4

Common Pitfalls to Avoid

Indiscriminate antibiotic use: Viral conjunctivitis will not respond to antibiotics, and mild bacterial conjunctivitis is self-limited—avoid routine antibiotic prescribing. 1

Missing corneal involvement: Always perform fluorescein staining in purulent conjunctivitis to detect early corneal disease. 4

Ignoring sexually transmitted infections: In sexually active adults with severe purulent discharge, consider gonococcal or chlamydial causes requiring systemic treatment. 4, 3

Corticosteroid use: Avoid topical steroids in primary care—they risk prolonging viral infections, worsening HSV, and causing elevated intraocular pressure. 6

Infection Control

Educate patients on transmission prevention:

• Wash hands frequently 1
• Use separate towels 1
• Avoid close contact during contagious period 1
• Viral conjunctivitis is highly contagious until discharge resolves 2