Infective

• Gritty sensation & red eye - not painful? 

• Generalised redness with sticky purulent exudates. It is unlikely to cause severe photophobia. The pupil would react normally.

• Reduced visual acuity in a patient with an acute red eye should raise concerns as to other causes such as glaucoma and uveitis. Patients with conjunctivitis typically complain of redness and discharge in one eye, although it can also be bilateral. Blurring of vision is usually due to disturbance of the tear film, which clears with blinking, persistent blurred vision may indicate the development of corneal involvement. Viral conjunctivitis – particularly with adenovirus – can present with pre-auricular lymphadenopathy.

Management

• 1st-line: self-care. (the self-limiting nature of simple conjunctivitis should be stressed and eye care measures explained. Topical antibiotics are likely to be of marginal benefit, but if prescribing, a delayed prescription strategy should be considered)

• 2nd-line: chloramphenicol 0.5% drops (OTC if ≥ 2yrs), 2hourly for 2/7, then QDS OR ointment 1% QDS. 

• 3rd-line: fusidic acid 1% gel BD. Continue for 48 hours after resolution

Neonatal conjunctivitis/ophthalmia neonatorum

• Most likely cause of recurrent symptoms is naso-lacrimal duct obstruction. However it is essential to exclude ophthalmia neonatorum (usually resulting from Chlamydia infection). If swabs are negative most cases of acute conjunctivitis resolve without treatment and, if the cause of the problem is duct obstruction, gentle massage of the nose (cephalo caudally whilst feeding) might help.

• Ophthalmia neonatorum (neonatal conjunctivitis: in babies presenting with a purulent, mucopurulent or mucoid discharge from one or both eyes within the first month of life, it is important to look for an injected conjunctiva or eyelid swelling. There may be evidence of a systemic infection.

• Such cases should always be referred to an eye unit immediately as neonatal conjunctivitis may result in a severe and rapidly progressive eye infection, or be associated with a potentially serious systemic infection – both of which require urgent investigation and management in secondary care.

• Causes of opthalmia neonatorum include chlamydia, gonorrhoea, Streptocococcus, Staphylococcus and Pseudomonas infections.

Allergic

• Acute allergic conjunctivitis: intense itch – the cardinal sign.  It is unlikely to cause severe photophobia. Conjunctival redness would be generalised and there may be conjunctival oedema

• Topical mast cell stabilisers are recommended for use throughout a period of allergen exposure. Sodium cromoglicate is usually effective but newer agents, such as lodoxamide and nedocromil, can be used in those with an inadequate response to sodium cromoglycate

• (Fluorescein is used to stain the eye to help in identifying corneal abrasions or ulcers. Pilocarpine is used to treat glaucoma and cyclopentolate is used to dilate the pupil in conditions such as iritis)

• Conjunctivitis (NHS Choices)

• Conjunctivitis (CKS)

• Conjunctivitis - infective (CKS)

• Conjunctivitis (GOSH)

Keratitis

• Keratitis can cause ulceration of the cornea which can be sight threatening due to scarring if not treated rapidly.  If suspected, an immediate ophthalmology referral is necessary.