1. Conjunctivitis (Pink Eye)
Presentation
The patient complains of a red eye, a sensation of fullness, burning, itching, or
scratching, and perhaps a gritty or foreign body sensat ion and tearing or purulent
discharge and crusting or mattering. Examination discloses generalized injection of the
conjunctiva, thinning out towards the cornea (localized inflammation suggests some
other diagnosis such as a foreign body, episcleritis, or a viral or bacterial ulcer). Vision
and pupillary reactions should be normal and the cornea and anterior chamber should
be clear. Any discomfort should be temporarily relieved by instilling topical anesthetic
solution. Deep pain, photophobia, decreased vision and injection more pronnounced
around the limbus (ciliary flush) suggest more serious involvement of the cornea and
iris.
Different symptoms suggest different etiologies. Tearing, preauricular lymphadenopathy
and upper respiratory symptoms suggest a viral conjunctivitis. Pain upon awakening
with lid crusting and a copious purulent exudate suggests a bacterial conjunctivitis. Few
symptoms upon awakening but discomfort worsening during the day suggest a dry eye.
Little conjunctival injection with a seasonal recurrence of chemosis and itching, and
cobblestone hypertrophy of the tarsal conjunctiva suggests allergic (vernal)
conjunctivitis. Physical and chemical conjunctivitis, caused by particles, solutions,
vapors, natural or occupational irritants that inflame the conjunctiva, should be evident
from the history.
What to do:
• Instill proparcaine anesthetic drops (Alcaine, Ophthaine) to allow for a more
comfortable exam and to help determine if the patient's discomfort is limited to
the conjunctiva and cornea or, if there is no pain relief, that the pain comes from
deeper eye structures.
• Examine the eye, including visual acuity, inspection for foreign bodies, pupillary
reaction fundoscopy, estimation of intraocular pressure by palpation of the globe
above the tarsal plate, slit lamp examination (when available), and fluorescein
and ultraviolet or cobalt blue light to assess the corneal epithelium.
• Ask about and look for any rash, arthritis, or mucous membrane involvement
which could point to Stevens-Johnson syndrome, Kawasaki's, Reiter's, or some
other syndrome that can present with conjunctivitis.
• For bacterial conjunctivitis, start the patient on warm compresses and seven
days of topical antibiotics such as erythromycin, sulfacetamide, tobramycin or
gentamycin ointment (which transiently blurs vision) every 4 hours, or solutions
such as sulfacetamide 10%, tobramycin 0.3% or ciprofloxacin every 2 hours,
with oral analgesics as needed. If it is unclear whether the problem is viral or
bacterial, it is safest to treat it as bacterial.
• For viral and chemical conjunctivitis, use cold compresses and weak topical
vasoconstrictors such as naphazoline 0.1% (Naphcon) every 3-4 hours, unless

2. the patient has a shallow anterior chamber that would be prone to acute angle-
closure glaucoma with mydriatics.
• For allergic conjunctivitis, use cold compresses and topical decongestant-
antihistamine combinations such as drops of naphazoline with pheniramine
(Naphcon A) or naphazoline with antazoline (Vasocon A) every 3-4 hours. Topical
corticosteroid drops provide dramatic relief, but prolonged use increases the risk
of opportunistic viral, fungal and bacterial corneal ulceration, cataract formation
and glaucoma. If a severe contact dermatitis is suspected, then a short course of
oral prednisone would be indicated.
• If the problem is dry eyes (keratoconjunctivitis sicca) use methylcellulose
(Dacriose) artificial tear drops.
• Have the patient follow up with the ophthalmologist if the infection does not
clearly resolve in 2 days. Obtain early consultation there is any involvement of
cornea or iris.
What not to do:
• Do not forget to wash your hands and equipment after examining the patient, or
you may spread herpes simplex or epidemic keratoconjunctivitis to yourself and
other patients. Also, do not forget to instruct the patient on the importance of
hand washing and separation of towels and pillows for ten days after the onset
of symptoms.
• Do not patch an affected eye, as this interferes with the cleansing function of
tear flow.
• Do not give steroids without arranging for ophthalmologic consultation, and
never give steroids if a herpes simplex infection is suspected.
Discussion
Warm compresses are soothing for all types of conjunctivitis, but antibiotic drops and
ointments should be reserved for when bacterial infection is likely. Neomycin-containing
ointments and drops should probably be avoided, because allergic sensitization to this
antibiotic is common. Any corneal ulceration requires ophthalmological consultation.
Most viral and bacterial conjunctivitis will resolve spontaneously, with the possible
exception of staphylococcus, meningiococcus, and gonococcus infections, which can
produce destructive sequelae without treatment.
Most bacterial conjunctivitis is caused by Streptococcus pneumoniae, Haemophilus
aegyptus and Staphylococcus aureus. Routine conjunctival cultures are seldom of value,
but you should Gram stain and culture a copious purulent exudate. Neisseria
gonorrhoeae infection confirmed by Gram-negative intracellular diplococci on Gram
stain requires immediate ophthalmologic consultation. Corneal ulceration, scarring and
blindness can occur in a matter of hours. Chlamydial conjunctivitis will usually present
with lid droop, mucopurulent discharge, photophobia and preauricular
lymphadenopathy. Small white elevated conglomerations of lymphoid tissue can be
seen on the upper and lower tarsal conjunctiva, and 90% of patients have concurrent
genital infections. Doxycycline 100mg bid or erythromycin 400mg tid by mouth plus
topical tetracycline (Achromycin Ophthalmic) for three weeks should control the
infection (also treat any sexual partner).

3. Epidemic keratoconjunctivitis is a bilateral, painful, highly contagious conjunctivitis
usually caused by an adenovirus. The eyes are extremely erythematous, sometimes
with subconjunctival hemorrhages. There is copious watery discharge and preauricular
lymphadenopathy. Treat the symptoms with analgesics, cold compresses, and, if
necessary, corticosteroids. Because the infection can last as long as three weeks and
may result in permanent corneal scarring, provide ophthalmologic consultation and
referral. Herpes simplex conjunctivitis is usually unilateral. Symptoms include a red eye,
photophobia, eye pain and mucoid discharge. There may be periorbital vesicles, and a
branching (dendritic) pattern of fluorescein staining makes the diagnosis. Treat with
trifluridine 1% (Viroptic), analgesics and cold compresses. Cycloplegics such as
homatropine may help control pain from iridocyclitis. Topical corticosteroids are
contraindicated, because they can extend the infection, and ophthalmological
consultation is required.
Herpes zoster ophthalmicus is shingles of the opthalmic branch of the trigeminal nerve,
which innervates the cornea and the tip of the nose. It begins with unilateral neuralgia,
followed by a vesicular rash in the distribution of nerve. Ophthalmic consultation is
again required, because of frequent ocular consultations, but topical corticosteroids may
be used. Prescribe systemic acyclovir (Zovirax) 800mg q4h (five times a day) for ten
days or famcyclovir (Famvir) 500mg tid for seven days.