Treating Pink Eye in Primary Care

Patients routinely come to primary care clinics with a chief complaint of conjunctivitis or “pink eye.” Often, the cause is infectious, but there are multiple noninfectious causes of pink eye to consider as well. Although many causes of conjunctivitis may be safely treated in primary care, others should be referred to an eye specialist for further evaluation and treatment.¹Conditions generally suitable for primary care include allergic conjunctivitis, hordeolum (stye), chalazion, bacterial conjunctivitis, viral conjunctivitis, and some corneal abrasions. More complex conditions such as trauma, closed angle glaucoma, keratitis, and uveitis, as well as certain types of lid lesions and severe bacterial or viral infections should be referred to an ophthalmologist.²Primary care clinicians should be well versed in the treatment of straightforward conditions and should also able to recognize red flags that signify the need for prompt referral to a higher level of care.

Common Causes of Pink Eye

Bacterial Conjunctivitis

This is typically caused by Staphylococcus aureus,Streptococcus pneumoniae,Haemophilus influenzae, orMoraxella catarrhalis.³For patients who wear contact lenses, another common culprit isPseudomonas.⁴Less frequently, it may be caused byNeisseria gonorrhoeae.⁵With bacterial conjunctivitis, patients tend to present with unilateral symptoms, although bilateral involvement does not rule out a bacterial cause. Signs and symptoms include erythema, copious purulent discharge, and mild swelling.⁶

The clinical examination for pink eye should always include a measurement of visual acuity. The Snellen chart is considered the gold standard, but the patient’s ability to read regular-sized print will also provide a reasonable measurement of vision. The eyes should be tested separately, and any visual correction normally used by the patient should be allowed. Another central feature is penlight examination. The pupils should be examined for reactivity to light, the cornea should be checked for opacities or foreign bodies, and the conjunctiva should be examined to discern the pattern of injection.⁷

Contact lens wearers are at high risk for developing pseudomonal keratitis, which can lead to ocular perforation. Patients with infectious keratitis may have corneal opacity, foreign body sen- sation and difficulty keeping the affect- ed eye open. Patients with suspected keratitis should be referred to an ophthalmologist for treatment.⁴

Diagnosis of bacterial conjunctivitis is generally presumptive—based on history and physical exam. Cultures are generally not required for uncomplicated cases.⁷Preferred treatment includes erythromycin ophthalmic ointment and trimethoprim-polymyxin B drops. Other treatments available are fluoroquinolone drops azithromycin drops, and tobramycin drops.⁸Due to cost and concern of antibiotic resistance, fluoroquinolone drops are not considered first-line therapy, except for contact lens wearers to cover pseudomonas infection.⁹Bacterial conjunctivitis caused by neisseria gonorrhoeae is sight-threatening, and patients should be referred to an emergency department immediately. It is characterized by severe amounts of purulent discharge, erythema, marked lid swelling, and tenderness to palpation. Treatment involves systemic and topical antibiotics as well as close monitoring for keratitis and ocular perforation.⁵

All forms of bacterial conjunctivitis are highly contagious and may be spread by contact with secretions and by fomites on contaminated surfaces. Patients should be considered contagious until they have been on an antibiotic for 24 hours.⁸Contact lens wearers should discontinue wearing contacts until treatment is completed and infection has been resolved for 24 hours.⁴Patients should also be counseled to refrain from playing sports until they have been on an antibiotic for at least 24 hours and drainage has resolved.¹

Viral Conjunctivitis

Usually caused by various serotypes of adenovirus, viral conjunctivitis may present as an isolated complaint or accompanied by systemic viral symptoms such as fever, pharyngitis, congestion and cough.¹⁰Less frequently, it is caused by herpes simplex virus or herpes zoster virus.¹¹Patients tend to present with bilateral involvement. Signs and symptoms include injection, watery or mucoserous discharge, and burning. It is also common for patients to complain of a gritty feeling in the eye.

Diagnosis may be based on history and exam or confirmed with a rapid adenovirus test. There is no antiviral medication for treating viral conjunctivitis. However, symptoms may be relieved by ocular antihistamines, artificial tears, and warm or cool compresses.¹⁰Certain serotypes of adenovirus my cause keratoconjunctivitis in predisposed patients. It manifests with acute foreign body sensation and affects visual acuity. Keratoconjunctivitis is sight-threatening and warrants immediate referral to an ophthalmologist for treatment.¹²Other serious viral causes of pink eye include herpes simplex virus and herpes zoster virus. Clinicians should consider all patients with suspected eye involvement from herpes virus emergent because early detection and treatment are paramount for preserving vision.¹¹

Patients with viral conjunctivitis should be considered highly contagious until symptoms have resolved. The virus may be spread directly through secretions or from fomites on contaminated surfaces. Viral conjunctivitis is generally a self-limiting process. Its acute phase is the first 3 to 5 days with waning symptoms lasting up to 2 weeks. Patients should be counseled that using antibiotic medications for viral infections will not make them less contagious or accelerate the speed of their recovery.¹⁰

Allergic Conjuntivitis

This is a manifestation of environmental allergens making contact with the eyes. Patients generally present with bilateral inflammation, erythema, watery discharge, and frequently complain of itching eyes. Allergic conjunctivitis is an immunoglobulin-mediated response that causes mast cell degranulation.¹³The mainstays of care include allergen avoidance, artificial tears, cool compresses, and eye drops containing antihistamines with mast cell stabilizing properties such as olopatadine drops, alcaftadine, bepotastine, azelastine HCl, epinastine, ketofen fumarate, and emedastine. Patients who do not respond to any of these therapies should be referred to an ophthalmologist.³Primary care providers should counsel patients to refrigerate artificial tears for extra relief and to refrain from rubbing or scratching their eyes. Also, contact lens wearers should be counseled to switch to eyeglasses during allergy flares because allergens may adhere to contact lenses.¹³

Eyelid Lesions

Benign conditions that cause eyelid lesions include chalazion and hordeolum (stye). Both arise when glands in the eyelids or eyelash follicles become obstructed. Patients generally present with eyelid swelling and erythema.¹⁴Unless there is concurrent infection, neither condition requires treatment with antibiotic eyedrops.¹⁵Rather, the mainstay of treatment is warm, moist compresses applied 4 times per day for up to 15 minutes.¹⁴If there is no resolution in 1 to 2 weeks, patients should be referred to ophthalmologist since incision and curettage may be required.¹⁵

Malignant conditions that cause eyelid lesions include basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma, melanoma.¹⁶Patients with recurrent eyelid lesions or eyelid lesions that do not respond to treatment should be referred to an eye specialist for further evaluation and possible biopsy.¹⁷

Corneal Abrasion Although sometimes caused by contact lens use, foreign object, or trauma, corneal abrasions less commonly may occur spontaneously. Patients tend to present with pain, severe photophobia, and sensation of a foreign body. The gold standard for diagnosis of corneal abrasion is fluorescein stain exam. However, before fluorescein stain is applied, visual acuity should be measured. Additionally, lid eversion should be performed to rule out foreign body, penlight exam to assess pupils, and fundoscopic exam to verify presence of red reflex. At times, it is appropriate to begin treatment for corneal abrasion at primary or urgent care, but patients should be counseled to follow up with an eye specialist.¹⁸

Uveitis and Iritis

Uveitis (intraocular inflammation) and iritis (inflammation of the iris) should be managed by an ophthalmologist. Patients may present with photophobia, vision changes, or ciliary flush. Ciliary flush is pronounced injection at the transition zone between the sclera and the cornea.¹⁹Primary care providers should be able to recognize the cardinal signs and symptoms of these conditions to ensure prompt referral.

Angle-Closure Glaucoma

This is caused by a narrowing or closure of the anterior chamber angle. A normal anterior chamber angle allows for drainage of the fluid that fills the eyeball. Lack of drainage leads to increased intraocular pressure and damage to the optic nerve. When the block happens suddenly, intraocular pressure rises rapidly and causes acute symptoms. Patients often present with severe headache, nausea, fixed pupil, and reduced visual acuity. Without treatment, vision loss can occur in a matter of hours, therefore acute angle-closure is considered an ophthalmic emergency.²⁰

Trauma

Ocular and orbital injuries have many diverse causes. Commonly seen injuries occur from fingernails, contact lenses, tennis balls, tree branches, fireworks, gunshot wounds, air bags, fights, pucks, pets, and wood or metal shrapnel from drilling or hammering. All patients presenting with trauma-related causes of pink eye should be referred to ophthalmology for evaluation and treatment. Significant eye injuries can lead to vision loss and even blindness. Prompt involvement of an eye specialist is critical to obtaining the best outcome.²¹

Summary

Clinicians must also be able to recognize red flags during exams. General red flag symptoms for optic conditions include reduced visual acuity, photophobia, severe foreign body sensation, pain that makes keeping the eye open difficult, corneal opacity, fixed pupil, severe headache, and nausea.²With any of these conditions, primary care clinicians should facilitate prompt referral to an ophthamologist. Additionally, any patient who is not responding to treatment as expected should be advised to follow up with an eye specialist. With presumed bacterial conjunctivitis, improvement should be seen within 48 hours of initiating treatment.³For viral conjunctivitis, allergic conjunctivitis, or eyelid complaints, improvement should be seen within 2 weeks of initiating treatment.¹⁰Patients with corneal abrasions should be encouraged to follow up if there is no improvement within 24 hours of initiating treatment.¹⁸

Felicia Spadini is a board-certified nurse practitioner. She began her career as a registered nurse in emergency medicine and then worked in the cardiothoracic stepdown unit for several years as a certified diabetes resource nurse and a certified wound/skin care nurse. As a nurse practitioner, she has worked in the retail health care setting since graduating in 2013. Her passion is research and providing education for peers and patients alike.

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