Conjunctivitis—Infective

Overview

This Guidelines summary has been developed for community pharmacy teams and covers the diagnosis and management of acute and persistent infective conjunctivitis in primary care. This summary does not cover the entirety of the guideline, but does include some detail for educational purposes. Refer to the full guideline for the complete set of recommendations.

This CKS topic does not cover the management of allergic conjunctivitis.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Definition

• Conjunctivitis is inflammation of the conjunctiva due to allergic or immunological reactions, infection (viral, bacterial or parasitic), mechanical irritation, neoplasia, or contact with toxic substances.
• Infective conjunctivitis can be acute (persisting for less than 4 weeks), chronic (persisting for more than 4 weeks) or recurrent.
  • Hyperacute conjunctivitis is a rapidly developing severe conjunctivitis typically caused by infection with Neisseria gonorrhoeae.
  • Ophthalmia neonatorum (ON) is conjunctivitis occurring within the first four weeks of life — it can be infectious or non-infectious.
    • Infectious ON, can be caused by Neisseria gonorrhoeae or Chlamydia trachomatis and is associated with serious complications if not treated promptly and appropriately.

Clinical Features

• The clinical features of conjunctivitis include:
  • Acute onset conjunctival erythema.
  • Discomfort, which may be described as ‘grittiness’, ‘foreign body’ or ‘burning’ sensation.
  • Watering and discharge, which may cause transient blurring of vision.
• It is difficult to differentiate viral and bacterial conjunctivitis clinically.
• Bacterial conjunctivitis may be associated with:
  • Purulent or mucopurulent discharge with crusting of the lids, which may be stuck together on waking.
    • If discharge is mucopurulent and copious, infection with Neisseria gonorrhoeae should be considered.
  • Mild or no pruritus.
  • Pre-auricular lymphadenopathy — often seen with hyperacute bacterial conjunctivitis (such as Neisseria gonorrhoea).
• Viral conjunctivitis may be associated with:
  • Mild to moderate erythema of the palpebral or bulbar conjunctiva, follicles on eyelid eversion and lid oedema.
  • Petechial (pinpoint) subconjunctival haemorrhages.
  • Pseudomembranes — may form on tarsal conjunctival surfaces in severe cases.
    • Epidemic keratoconjunctivitis (due to adenovirus) can lead to pseudomembrane formation along with severe pain, subconjunctival haemorrhage, visual changes and photophobia.
  • Less discharge (usually watery) than bacterial conjunctivitis.
  • Mild to moderate pruritus.
  • Upper respiratory tract infection and pre-auricular lymphadenopathy.
    • Pharyngoconjunctival fever (due to adenovirus) can lead to fever, pharyngitis, periauricular lymphadenopathy, and bilateral conjunctivitis occasionally with corneal involvement.
• Herpes virus may be indistinguishable from other viral infections:
  • Herpes simplex typically presents as unilateral red eye with vesicular lesions visible on the eyelid and watery discharge.
  • Ocular involvement in Herpes zoster infection should be assumed if lesions are present at the tip of the nose (Hutchinson’s sign).
• Contact lens associated conjunctivitis:
  • Inflammation may be seen in the superior conjunctiva especially under the upper lid — topical fluorescein may identify corneal staining (epithelial defect).
• Sexually transmitted infection (STI)—conjunctivitis due to STI is often more severe and associated with prolonged mucopurulent discharge.
  • Chlamydia trachomatis
    • Often presents with a chronic (longer than 2 weeks) low-grade irritation and mucous discharge in a sexually active person. Pre-auricular lymphadenopathy may be present.
    • Most cases are unilateral but may be bilateral.
  • Neisseria gonorrhoea (GC)
    • Symptoms usually develop rapidly (over 12–24 hours) with copious mucopurulent discharge, eyelid swelling, and tender preauricular lymphadenopathy.
    • GC conjunctivitis has a high risk of complications, including uveitis, severe keratitis and corneal perforation.
• Ophthalmia neonatorum (ON)
  • Chlamydial ON — typically presents with a watery or mucopurulent discharge about 5–14 days after birth.
  • Gonococcal ON — typically presents within the first 5 days of life but can also present up to 3 weeks after delivery. It is characterised by copious purulent discharge and eyelid swelling which may be severe.
  • Viral ON — most commonly due to adenovirus or Herpes simplex virus.  May present with petechial or occasionally large subconjunctival haemorrhages and lymphadenopathy.

Assessment

• Assess all people presenting with a unilateral red eye for features indicating a serious and potentially sight-threatening cause (such as acute glaucoma, corneal ulcer, anterior uveitis, scleritis, or trauma) — for further information, see the CKS topic on Red eye.

Take a History Asking About:

• Onset and duration of symptoms.
• Clinical features:
  • Distribution of symptoms — unilateral or bilateral.
  • Amount and character (watery, purulent, or mucopurulent) of discharge and when it is worst (for example on waking from sleep).
  • Itching.
  • Changes in vision such as blurring.
  • Eyelid changes such as swelling, flaking and vesicles.
• Recent exposure to an infected person.
• Red flags which indicate the need for urgent ophthalmological assessment such as:
  • Reduced visual acuity.
  • Marked eye pain, headache or photophobia — always consider serious systemic conditions such as meningitis in a person presenting with photophobia.
  • Red sticky eye in a neonate (within 30 days of birth).
  • History of trauma (mechanical, chemical or ultraviolet) or possible foreign body.
  • Copious rapidly progressive discharge — may indicate gonococcal infection.
  • Infection with a herpes virus.
  • Soft contact lens use with corneal symptoms (such as photophobia and watering).
• Associated symptoms such as:
  • Upper respiratory tract infection.
  • Enlarged tender lymph nodes.
• Past medical history, including:
  • History of atopy, allergy and similar episodes.
  • Immunocompromise for example HIV, chemotherapy or immunosuppressant treatment.
  • Associated systemic conditions such as rheumatoid arthritis, systemic lupus erythematous and reactive arthritis.
  • Ophthalmic surgery.
  • Drug history, including prescribed and over-the-counter topical and systemic drugs such as mydriatics, anticholinergics and anticoagulants.
  • Social history including smoking, occupation, hobbies, sexual activity, and travel.

Differential Diagnosis

• There are many causes of red eye, some of which are serious or sight threatening and require same-day assessment by ophthalmology — for further information, see the CKS topic on Red eye. The differential diagnosis for infective conjunctivitis includes:
• Serious conditions such as:
  • Acute glaucoma.
  • Scleritis.
  • Episcleritis.
  • Keratitis.
  • Uveitis.
  • Iritis.
  • Corneal ulcer, abrasion or foreign body.
• Non-infectious conjunctivitis:
  • Atopic or allergic conjunctivitis — may be recurrent due to seasonal or environmental factors.
  • Toxic conjunctivitis — for example drop allergy and preservative-related red eye.
    • Overuse of cosmetic drops to whiten the conjunctiva can lead to permanently dilated vessels and red eyes.
  • Irritative or mechanical conjunctivitis — for example due to contact-lens use, floppy eyelid syndrome, Pediculosis palpebrarum (Phthirus pubis) or medication.
  • Immune-mediated inflammation (such as Stevens–Johnson syndrome) or neoplasia (such as sebaceous carcinoma or melanoma).
• Other conditions affecting the eye such as:
  • Nasolacrimal duct obstruction — discharge without red eye in neonates can be due to congenital obstruction of the nasolacrimal duct(s).
  • Subconjunctival haematoma.
  • Dry eye.
  • Blepharitis.
  • Blepharokeratoconjunctivitis — chronic inflammation of the surface of the eye and eyelids which can lead to corneal scarring, vascularisation and opacity.
  • Thyroid eye disease.

Referral to Ophthalmology

• Arrange urgent assessment by ophthalmology if the person has:
  • A red flag indicating a serious cause of red eye — have a low threshold for referral to avoid missing sight-threatening conditions.
    • For further information, see the CKS topic on Red eye.
  • Ophthalmia neonatorum (sticky eye with redness in a neonate).
    • If infection with a sexually transmitted pathogen is confirmed — ensure that the child’s mother and her sexual partners have been referred for appropriate treatment.
  • Suspected gonococcal or chlamydial conjunctivitis.
  • Consider the possibility of gonorrhoea or chlamydia in sexually active individuals or children of any age in whom sexual abuse is suspected. For further information see the CKS topics on Chlamydia—uncomplicated genital, Child maltreatment—recognition and management, and Gonorrhoea.
  • Possible herpes infection.
  • Suspected periorbital or orbital cellulitis.
  • Severe disease, for example, corneal ulceration, significant keratitis or presence of pseudomembrane.
  • Recent intraocular surgery.
  • Conjunctivitis associated with a severe systemic condition such as rheumatoid arthritis or immunocompromise.
  • Corneal involvement associated with soft contact lens use:
    • Do not give antibiotics in the interim as this may interfere with corneal culture.
    • Advise the person to take their contact lenses with them to eye casualty as special diagnostic tests may be required.
• Discuss with/refer to ophthalmology (with urgency dependent on clinical situation) if:
  • There is diagnostic uncertainty or the appropriate diagnostic equipment is not available.
  • The person has recurrent or persistent conjunctivitis.
  • Conjunctivitis is thought to be due to molluscum contagiosum.

Management in Primary Care

• If the person does not require referral to ophthalmology, manage infective conjunctivitis in primary care according to likely cause:
• Acute (non-herpetic) viral conjunctivitis:
  • Reassure the person that most cases of acute, infectious conjunctivitis are self-limiting and do not require antimicrobial treatment — viral (non-herpetic) conjunctivitis usually resolves within one to two weeks without treatment.
  • Advise the person that symptoms may be eased with self-care measures such as:
    • Bathing/cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge.
    • Cool compresses applied gently around the eye area.
    • Use of lubricating drops or artificial tears.
  • Avoid antibiotic prescription.
  • Inform the person that infective conjunctivitis is contagious and they should try to prevent spread of infection to their other eye and other people by:
    • Washing hands frequently with soap and water.
    • Using separate towels and flannels.
    • Avoiding close contact with others, especially if they are a healthcare professional or child care provider — they may be infectious for up to 14 days from onset.
  • Public Health England does not recommend an exclusion period from school, nursery or childminders except if an outbreak or cluster of cases occurs.
  • Give written information, explain red flags for urgent review and advise the person to return/seek further help if symptoms persist beyond 7 days.
    • Patient information on Conjunctivitis is available from NHS A–Z at www.nhs.uk.
  • If the person re-attends with symptoms of conjunctivitis, consider sending swabs for viral PCR (for adenovirus and Herpes simplex virus [HSV]) and bacterial culture and if appropriate, offer empirical topical antibiotics. See the section on Prescribing for further information.
  • Consider discussion with/referral to ophthalmology if symptoms persist for more than 7-10 days after initiating treatment.
• Acute bacterial conjunctivitis:
  • Advise the person that most cases of bacterial conjunctivitis are self-limiting and resolve within 5-7 days without treatment.
  • Treat with topical antibiotics if severe or circumstances require rapid resolution. A delayed treatment strategy may be appropriate — advise the person to initiate topical antibiotics if symptoms have not resolved within 3 days. Options for topical antibiotics include:
    • Chloramphenicol 0.5% drops — apply 1 drop 2 hourly for 2 days, then reduce frequency depending on the severity of infection (3–4 times daily is usually sufficient for less severe infection). Continue use until 48 hours after infection has cleared.
    • Chloramphenicol 1% ointment — apply 3–4 times daily. Continue use until 48 hours after infection has cleared.
    • Fusidic acid 1% eye drops — apply 1 drop twice daily. Continue use until 48 hours after infection has cleared.
  • Advise the person that there is no recommended exclusion period from school, nursery or childminders for isolated cases but that many nursery and primary schools may nevertheless have an exclusion policy.
  • Give written patient information and explain red flags for urgent review.
    • Patient information on Conjunctivitis is available from NHS A–Z at www.nhs.uk.
  • Arrange follow-up to confirm diagnosis and ensure that symptoms have resolved.
    • If the person re-attends with ongoing symptoms of conjunctivitis, consider sending swabs for viral PCR (for adenovirus and Herpes simplex) and bacterial culture and empirical topical antibiotics (if not already prescribed). For further information, see the section on Prescribing.
  • Consider referral to ophthalmology if symptoms persist for more than 7 to 10 days after initiating treatment.
• Conjunctivitis associated with contact lens wear:
  • If topical fluorescein does not identify any corneal staining and the person does not require referral to ophthalmology:
    • Advise them to immediately stop contact lens use.
    • Advise regular bathing/cleaning of the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge.
    • Advise that contact lenses should be kept out until all symptoms of the infection have gone.
    • Treat and arrange follow up as described above.
• Have a low threshold for referral to ophthalmology if there is any suspicion of corneal involvement as this is a potentially sight-threatening condition.

Topical Chloramphenicol

Contraindications and Cautions

• Do not prescribe topical chloramphenicol to people who:
  • Are pregnant or breastfeeding.
  • Have hypersensitivity to the active substance or to any of the excipients.
  • Have had myelosuppression during previous exposure to chloramphenicol.
  • Have a personal or family history of blood dyscrasias including aplastic anaemia.
• Topical chloramphenicol should be not be used on a prolonged basis.
• Note: subsequent to a previous change in the manufacturer’s product licence which restricted use of borax or boric acid containing chloramphenicol eye drops in children aged under 2 years, the Medicines and Healthcare Products Regulatory Agency (MHRA) has reviewed the evidence and sought independent expert advice and has concluded that the benefits outweigh the potential risks for children, including those aged 0 to 2 years.
  • A typical regimen of one drop, applied typically 3 to 4 times a day, to both eyes, results in a daily exposure well below the safety limit for these children.

Adverse Effects

• Adverse effects are usually minor and include:
  • Transient irritation, burning, stinging and sensitivity reactions such as itching and dermatitis.
• Rare more serious adverse effects may occur and include:
  • Hypersensitivity reactions including angioedema, anaphylaxis, urticaria, fever, vesicular and maculopapular dermatitis.
  • Bone marrow depression and aplastic anaemia have been reported following topical use of chloramphenicol.
    • The summary of product characteristics states that while the hazard is a rare one, it should be borne in mind.
    • The British National Formulary states that the recommendation that chloramphenicol eye drops should be avoided because of an increased risk of aplastic anaemia is not well founded.

Drug Interactions

• Other drugs liable to depress bone marrow function — concomitant administration should be avoided.

Topical Fusidic Acid

Adverse Effects

• Adverse effects are usually minor, and include transient stinging and burning sensation or transient blurring of vision.

Contraindications and Cautions

• Do not prescribe topical fusidic acid to people with:
  • Hypersensitivity to the active substance or to any of the excipients.
• Topical fusidic acid should be not be used on a prolonged basis.
• People who wear contact lenses should be advised not to use them during treatment with fusidic acid.