Conjunctivitis is inflammation of the palpebral and/or bulbar conjunctiva, the mucous membrane covering the inside of the eyelids and the outer part of the eye. There are several types of conjunctivitis.

• Viral conjunctivitis
• Bacterial conjunctivitis
• Allergic conjunctivitis
• Contact conjunctivitis
• Giant papillary conjunctivitis
• Traumatic conjunctivitis

• Viral infection: Most common. Generally rhinovirus or adenovirus, often as a result of a respiratory infection spread to the eye via contaminated fingers, towels, or handkerchiefs. May start in one eye and spread to the other.
• Bacterial infection: Generally Staphylococcus aureus, Staphylococcus pneumoniae, or Haemophilus influenzae; occasionally Pseudomonas, Neisseria, or Chlamydia. Neonatal conjunctivitis may be caused by gonorrhea or chlamydia transmitted from the mother.
• Exposure to chemical irritants such as cigarette smoke, chlorine from swimming pools, and cosmetics.
• Giant papillary conjunctivitis is caused by long-term contact lens use. There is some controversy over the specific etiology. The condition may result from hypersensitivity to protein buildup on the lens, or from cumulative physical irritation/trauma to the eye.

• Recent upper-respiratory infection
• Allergies
• Group day care situations
• Contact lens use, or other foreign body contact
• Exposure to severe wind, heat, or cold

Conjunctivitis produces the following in one or both eyes.

• Redness
• Itching, tearing, burning
• Discharge (watery or purulent)
• Overnight crusting
• Sensitivity to light
• Gritty sensation

• Foreign body
• Blepharitis
• Scleritis and episcleritis
• UV keratitis
• Herpes simplex keratitis
• Subconjunctival hemorrhage
• Iritis or iridocyclitis
• Acute angle closure glaucoma

Examine conjunctiva while having patient look up, down, right, and left. Evert eyelids. The redness of conjunctivitis is nonspecific, as opposed to the localized appearance of a subconjunctival hemorrhage. Palpable pre-auricular lymph nodes and a clear discharge are indicative of viral conjunctivitis. Bilateral presentation, itching, and a clear or absent discharge without lymph node enlargement is generally indicative of allergic conjunctivitis. A thick purulent discharge is seen in bacterial conjunctivitis. In giant papillary conjunctivitis, enlarged papillae (0.3 mm in diameter or greater) will have formed on the superior palpebral conjunctiva due to the eruption of subepithelial collagen. Check for corneal abrasions or other defects using a slit lamp and fluorescein staining.

Cultures may be done to determine infectious organism if necessary. The appearance of cells stained with gram stain or giemsa may indicate the presence of eosinophils, supporting the diagnosis of allergic conjunctivitis.

Visual acuity may be tested with Snellen chart if necessary for diagnosis. Reduced visual acuity is not common with conjunctivitis and may be a sign of iritis or iridocyclitis, acute angle closure glaucoma, or herpes simplex keratitis. Intraocular pressure significantly elevated from the normal 10 to 20 mm Hg would not result from conjunctivitis and may be a sign of glaucoma. Culture and immunofluorescence for herpes simplex.

Viral conjunctivitis does not respond to antibiotics and is generally self-limiting. Treatment such as vasoconstrictive drops and/or cool compresses ease symptoms. For bacterial conjunctivitis, local antibiotics are indicated.

• Viral conjunctivitis: Cool compresses tid for one to three weeks; may also use antihistamines to relieve inflammation. Trifluridine 1% drops, every two hours. Acyclovir oral and topical as indicated.
• Allergic conjunctivitis: Attempt to eliminate contact with allergen. Treat with cool compresses, OTC or topical antihistamines, mast cell stabilizers such as cromolyn sodium, NSAIDs (particularly ketorolac). Vasoconstrictor/antihistamine combination of naphazoline 0.05%/antazoline 0.5%. Possibly mild corticosteroids.
• Bacterial conjunctivitis: Polytrim drops (trimethoprim sulfate, polymixin B sulfate, Allergan), 1 drop tid for one week, or polymixin B-bacitracin ointment (Polysporin). Fluoroquinolones as second-line therapy. Tobramycin (0.3%) or gentamicin as drops, or 10% sodium sulfacetamide as drops, every four hours.
• Giant papillary conjunctivitis: Avoid use of lenses until condition clears up and then consider prescribing a different material or design. The NSAID suprofen has been shown to be helpful in treatment, as are antihistamines. A short course of low-dosage topical corticosteroids may be necessary initially to reduce inflammation.

Mild to moderate cases of conjunctivitis may respond well to alternative treatment. Antibiotics may be needed for bacterial infections. For mild cases, begin with compresses. For moderate infection, use an eyewash as well. In the case of chronic or recurrent infection, nutritional support is suggested. Homeopathic remedies may be used for symptomatic relief.

Doses listed are for adults. Decrease by one-half to two-thirds for children. Vitamin A (10,000 IU/day), vitamin C (1,000 mg tid to qid), and zinc (30 to 50 mg/day) enhance the immune response and promote healing.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Compresses and eye washes are external treatments. A compress is made with a clean cloth, gauze pads, or cotton balls soaked in a solution then applied over eyes. Washes may be used with an eye cup or sterile dropper.

Compress:

Use 5 drops of tincture in 1/4 cup water or steep 1 tsp. herb in 1 cup hot water for 5 to 10 minutes and strain. Soak compress in solution and apply for 10 minutes, tid to qid.

• Eyebright (Euphrasia officinalis): antimicrobial, astringent, specific for eyes
• Chamomile (Matricaria recutita): antimicrobial, astringent, vulnerary, calming
• Fennel seed (Foeniculum vulgare): antimicrobial, astringent, vulnerary, soothing
• Marigold (Calendula officinalis): soothing vulnerary
• Plantain (Plantago lanceolata, P. major): antimicrobial, astringent, and demulcent. Plantago lanceolata is specific to inflammation in the eye. The fresh leaves are superior in action.
• Flax (Linum usitat issimum) as a soothing poultice made with 1 oz. of bruised flaxseed steeped for 15 minutes in 4 oz. of water, wrapped in cheesecloth, then applied directly to the affected eye. Reheated poultice can be applied many times.
• Grated fresh potato has astringent properties. Wrap in cheesecloth and apply.

Eyewash: Use above herbs singly or in combination. Mix equal parts together then steep 1 tsp. herb in 1 cup of hot water to make a tea.

Goldenseal (Hydrastis canadensis) and boric acid: 10 drops of goldenseal tincture with 1 tsp. of boric acid mixed in 1 cup of water.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Aconite for after exposure to wind or cold; thin discharge
• Apis mellifica for red, burning, and swollen eyelids that feel better with cold applications
• Combination remedies containing Apis, Euphrasia, and Sabadilla may be effective for allergic conjunctivitis.
• Allium cepa for red, burning, tearing eyes that are sensitive to light.

Treatment may be administered for pain relief and resolving congestion.

Viral and bacterial conjunctivitis are both very contagious. Patients should be advised to take appropriate steps such as frequent hand washing and using separate towels, and family members should be monitored for signs of infection. Children are generally excluded from school and day care situations while infection is active. In giant papillary conjunctivitis, monitoring is especially important once contact lens use has been resumed, in order to avoid recurrence. Any patient on corticosteroids must be carefully monitored for increase in intraocular pressure, infections, and incipient cataracts.

General hygiene is important in the prevention and treatment of conjunctivitis, especially in the use of contact lenses. Contact lens patients who have had giant papillary conjunctivitis should avoid heat disinfection and thimerosal in their cleaning regimen.

To prevent neonatal gonococcal conjunctivitis, silver nitrate is administered to the eyes of infants shortly after birth.

Allergic conjunctivitis is uncomplicated in most cases. However, some patients who are hypersensitive to allergens and develop atopic disorders such as asthma, hay fever, urticaria, or eczema may present with a severe form, called atopic keratoconjunctivitis, generally bilateral. Chronic marginal blepharitis and corneal ulcers or perforations are possible with bacterial conjunctivitis. Corneal scars are possible with viral conjunctivitis.

Patients with infectious conjunctivitis should assume they will be contagious for approximately seven days. Bacterial conjunctivitis will resolve in one to two weeks without treatment, two to five days with treatments. Some minor effects, such as dryness, irritation, and discomfort with contact lenses, may linger for a few weeks. If symptoms have not improved or get worse, contact an ophthalmologist.

High doses of vitamin A and vitamin C are contraindicated in pregnancy.

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