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Conjunctivitis: Diagnosis and Management

Stella Winters, MD
Winfred Frazier, MD, MPH
Jacob Winters, MD

American Family Physician. 2024;110(2):134-144.

Author disclosure: No relevant financial relationships.

Conjunctivitis caused by viruses, bacteria, or allergies is one of the most common eye conditions in primary care. There is no single sign or symptom that accurately differentiates viral from bacterial conjunctivitis. A comprehensive history and physical examination can guide diagnosis. Viral and allergic conjunctivitis are more common in adults and typically present with watery discharge. Supportive care options for viral conjunctivitis include artificial tears, cold compresses, and antihistamine eye drops. Strict personal hygiene, including frequent handwashing, is essential to decrease the risk of transmission. Topical antihistamines with mast cell–stabilizing activity are the treatment of choice for allergic conjunctivitis. Bacterial conjunctivitis is more common in children and typically presents as mucopurulent discharge with the eyelids matted shut. Delayed antibiotic prescribing has been found to have similar symptom control as immediate prescribing. Ophthalmology referral is indicated for conjunctivitis in a neonate or patients with severe pain, decreased vision, recent ocular surgery, vesicular rash on the eyelids or nose, history of rheumatologic disease, or immunocompromised state.

Conjunctivitis is inflammation of the conjunctiva, which is a clear, vascularized membrane that covers the outer surface of the eye (except the cornea) and the inner surface of the eyelids1,2 (Figure 1). Data from nearly 12 million eye-related emergency room visits found that 44% were for nonemergent causes with conjunctivitis being the most common reason.3 There are significant direct costs (i.e., copays and prescriptions) and indirect costs (i.e., work or school absenteeism) associated with conjunctivitis, accounting for an estimated $1 billion annually in the United States alone.4–6 The most common etiologies of conjunctivitis are allergic, viral, and bacterial.2,7 Conjunctivitis is usually self-limited, but complications leading to decreased vision can occur. This article discusses the three most common causes of conjunctivitis, clinical features that can be used to differentiate them, and recommendations for treatment. Table 1 summarizes conjunctivitis treatment options.2,8–14

WHAT’S NEW ON THIS TOPIC

Conjunctivitis
A 2023 Cochrane review found that topical antibiotics likely improved the clinical cure rate of bacterial conjunctivitis by 26% compared with placebo. However, the results were limited by heterogeneity among trials, high potential for bias, and conclusion of only culture-proven cases.
In a 2015 systematic review, a serious noninfectious disease was found in an average of 27% of patients presenting with red eye. Two findings that accurately indicated serious disease were pain with pupillary constriction (true photophobia) and anisocoria (unequal pupil sizes of 1 mm or more, with the smaller pupil in the affected eye).

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
A comprehensive eye history and specific physical examination findings are helpful to distinguish bacterial from viral conjunctivitis because no single sign or symptom reliably differentiates them.1,2,16,17 C Consistent evidence from systematic reviews and a cohort study assessing disease-oriented outcomes
Pain with pupillary constriction (true photophobia), vision change, and anisocoria are indicative of serious eye disease and warrant immediate referral.1,18 C Evidence-informed practice guidelines and systematic review of studies assessing disease-oriented outcomes
Patients with viral conjunctivitis should avoid touching the face, practice strict handwashing, and not share personal items, especially towels, pillowcases, and eye makeup.1,2,7,16 C Evidence-informed practice guidelines and expert consensus
Topical antihistamines with mast cell–stabilizing activity are the standard of care for perennial and seasonal allergic conjunctivitis.1,8,10–12 B Consistent evidence from evidence-informed practice guidelines, systematic reviews, and expert consensus
For acute bacterial conjunctivitis, delayed antibiotic prescribing has similar symptom control as immediate prescribing and decreases antibiotic use by 50%.46,49 B Randomized controlled trial and systematic review

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

STELLA WINTERS, MD, FAAFP, is a clinical assistant professor at the University of Pittsburgh (Penn.) Medical Center St. Margaret Family Medicine Residency Program.

WINFRED FRAZIER, MD, MPH, FAAFP, is associate program director of the University of Pittsburgh Medical Center St. Margaret Family Medicine Residency Program.

JACOB WINTERS, MD, is a resident in the Department of Ophthalmology at the University of Pittsburgh Medical Center.

Address correspondence to Stella Winters, MD, FAAFP, at stellawintersmd@gmail.com.

Author disclosure: No relevant financial relationships.

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