Conjunctivitis and pharyngitis have many parallels. Usually viral, fairly contagious, they drive parents and daycares crazy, and typically they get better with no help from me… except for some. Whether or not to treat with antibiotics is the never-ending discussion.

Conjunctivitis, aka pink eye, comes in a variety of flavors in adults and children. Viral is by far most common. If your kid just had a cold, and the nose is still running, stand down. No antibiotics necessary. Your doc will suggest you keep junior from rubbing the unaffected eye, but we know it’s futile. Try to protect siblings and yourself with frequent hand washing, but expect resolution over just a few days.

Bacterial conjunctivitis on the other hand is more concerning, but fairly rare. Consider this if fevers, pain, copious pus drainage, and red swollen lids… especially for contact lens users. It’s not pretty and is hard to ignore.

Red Flags:

• Fevers
• Pain
• Vision loss
• Pouring pus
• Red/swollen eyelids
• Neonatal, Elderly, Diabetic
• Immunosuppressed (chronic steroids, asplenic, HIV, chemo, corneal transplant, etc.)
• Contact lens use (Don’t sleep with your contacts!)

Happy Words

• “Junior has been sniffling all week and when he wakes up I have to wipe gunk from his eyes. Then he starts playing again and doesn’t seem to care.”
• “I can see with no problem, but my eyes just itch, tear and burn after staring at my screen all day.”
• “My nose and eyes just won’t stop itching and running with all the pollen lately.”

Noninfectious causes for red eyes worth mention include:

  1. Chemical conjunctivitis, which is caused by a chemical splash. The solution is dilution… and quick. Stop reading and don’t wait for advice from your nurse hotline. Rinse now! (As an aside, one of the most caustic chemicals is hydrofluoric acid. If you ever get that in your eyes, 911 is your next step. Don’t call Pre-R!)
  2. Welder’s keratitis is essentially sunburn of the eyes. Pain and redness will ramp up gradually and eventually become excruciating. Ibuprofen with food, wet compresses and rest usually suffice. But beware prolonged exposure to UV light whether from welding, tanning booths, or direct sunlight, especially at high altitudes.
  3. Allergic conjunctivitis comes hand in hand with other allergy symptoms like runny nose, rash, itching etc. It’s treated with meds like diphenhydramine or loratidine, sometimes steroids.

But back to infectious causes, and probably the reason you’re still reading – “When do I need antibitiocs?!”

Even more so than for pharyngitis, history and exam are everything. No rapid swab drives our decisions whether or not to treat with antibiotics. Actually, nobody would blink an eye if I treated 100% of my conjunctivitis patients with erythromycin ointment, sulfacetamide, gentamicin or tobramycin. I see colleagues and ophthalmologists use all of these with no apparent consistency. However, for patients who have contact lens related conjunctivitis or corneal abrasions/ulcers, ciprofloxacin drops (Ciloxan), seems to be the favorite.

My approach for patients with infectious conjunctivitis is similar to my approach for pharyngitis. I deliver some version of the conversation above. I then suggest a 24-48 hour trial of no antibiotics unless the red flags are many. If better after 24-48 hours then carry on with nothing. If worse, then call me or use the prescription provided. In some cases I’ll dispense a tube of erythromycin ointment from the ER. I prefer this to sulfacetamide because it seems to sting less, it has less risk for causing a sulfa-related reaction, and the placebo effect of using a goopy ointment seems more potent. (I’m all ears if you prefer another approach.)

That said, I’m a highly biased fan of Pre-R for conjunctivitis. A glimpse in the ER is OK, but following its evolution over time makes all the difference for diagnosis and treatment.

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