Conjunctivitis : (Pink Eye)

Presentation

Conjunctivitis is the most common diagnosis in patients with a red eye and discharge, but not all red eyes are the result of conjunctivitis. With bacterial conjunctivitis the patient complains of a red, irritated eye and perhaps a gritty or foreign-body sensation; a thick, purulent discharge that continues throughout the day; and crusting or matting of the eyelids on awakening ( Fig. 14.1 ). It is most often unilateral. With viral conjunctivitis , the complaint may be of a similar discomfort or burning, with clear tearing, preauricular lymphadenopathy, or symptoms of upper respiratory tract infection ( Fig. 14.2 ). On the other hand, with allergic conjunctivitis , the main complaint may be itching, with minimal conjunctival injection, seasonal recurrence, and cobblestone hypertrophy of the tarsal conjunctivae or bubblelike chemosis of the conjunctiva covering the sclera ( Fig. 14.3 ). Ocular symptoms are usually accompanied by nasal symptoms, and there may be other allergic events in the patient’s history that support the diagnosis of ocular allergy. Examination discloses generalized injection of the conjunctiva, with thinning out toward the cornea. ( Localized inflammation suggests some other diagnosis, such as presence of a foreign body, an inverted eyelash, episcleritis, or a viral or bacterial ulcer.)

Vision and pupil reactions should be normal, and the cornea and anterior chamber should be clear. Any discomfort should be temporarily relieved by the instillation of topical anesthetic solution.

If few symptoms are present on awakening but discomfort worsens during the day, dry eye is probable. Eye opening during sleep, which leads to corneal exposure and drying, results in ocular redness and irritation that is worse in the morning.

Physical and chemical conjunctivitis caused by particles, solutions, vapors, and natural or occupational irritants that inflame the conjunctiva should be evident from the history.

Deep pain, pain not relieved by topical anesthetic, severe pain of sudden onset, photophobia, vomiting, decreased vision, and injection that is more pronounced around the limbus (ciliary flush) ( Fig. 14.4 ) suggest more serious involvement of the cornea or the globe’s internal structures (e.g., corneal ulcer, keratitis, acute angle–closure glaucoma, uveitis) and demand early or immediate ophthalmologic consultation.