Conjunctivitis

Overview

This is a very common condition to present to General Practice. This section will cover bacterial, conjunctival, chlamydia and gonorrhoea conjunctivitis. Allergic eye disease  is covered elsewhere.

The classic presentation would be a sudden onset red eye, which causes a lot of watering, eye lid oedema and a sticky, gunky eye in the mornings. Within the first 48 hours it often transfers to the other eye and the second eye is always less affected as the patient’s immune system would have started mounting a defence. 

• Eyelid Oedema
• Watery Eye
• Gunky Mucus
• Red Eye
• Irritation
• Conjunctival Chemosis
• Subtarsal Erythema
• Preauricular Lymph Nodes
• Blurred Vision which clears with blinking 

Viral Conjunctivitis tends to cause more watering, more eyelid oedema and less mucus. Preauricular lymph nodes are more commonly palpable.

Bacterial Conjunctivitis is generally more associated with less watering and more mucus production than viral conjunctivitis.

Chlamydia/gonorrhoeal conjunctivitis tend to be unilateral and cause persistent symptoms. They can present as an emergency with significant eyelid swelling, hyper-purulence and reduced vision.

Please see attached diagnostic photographs.

Investigations are often not necessary, if deemed necessary the standard investigations are three swabs: 

• Bacterial Swab
• Viral Swab
• Aptima Swab for Chlamydia and Gonorrhoea 

These swabs take between 5-7 days to be reported. Most patients are able to clear a bacterial or viral conjunctivitis without treatment, so investigations will only confirm the diagnosis and symptoms will often improve prior to swab results.

Who to refer

Referral is not usually necessary as it is a self-limiting condition. Ongoing symptoms should prompt the diagnosis to be reconsidered. 

Conjunctivitis can occasionally trigger an inflammation of the cornea, and these cases should be referred to the Emergency Department, please see below

Red Flags

Consider referral to the Emergency Department for the following cases:

• Severe Symptoms
• Light Sensitivity (As this indicates corneal involvement)
• Reduced Vision (As this indicates corneal involvement)
• Persistent Symptoms
• Exercise caution in diagnosing conjunctivitis in contact lens wearers, — make sure you are not missing a corneal ulcer.
• Chlamydia/Gonorrhoea conjunctivitis confirmed or suspected - see diagnostic photographs

Before referral

Self-Limiting

It is important to remember that for most viral and bacterial conjunctivitis is self-limiting and will usually worsen for the first 5-7 days before gradually improving after that. After a significant conjunctivitis it is not unusual for mild redness and irritation to persist (gradually improving) for 4-5 weeks after. 

Antibiotics

Antibiotics only make a modest improvement in symptoms; however, it is reasonable to consider a short course of chloramphenicol eye drops, options include: Chloramphenicol 0.5% eye drops 4 hourly (whilst awake) or Chloramphenical 1% ointment 3-4 times daily or just at night if using eye drops. Chloramphenicol is to be applied for 48 hours after resolution, typically for 5 days in total. Prolonged courses of antibiotics have limited benefit and will likely cause more irritation to the eye. 

General Advice

Keep the eyes clean and a cool compress can provide symptomatic relief. Viral conjunctivitis is very contagious, and the patient should be advised to wash their hands plenty and avoid sharing towels and pillows. The patient should be advised not to wear contact lenses when symptomatic.

School/Nursery

Public Health England do not recommend school exclusion for children with conjunctivitis (please see https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf).

Referral

If referral is required please submit to Ophthalmology via eRS requesting Cornea clinic.

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photos.

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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