2.4 2.

Review

Pediatric Conjunctivitis: A Review

of Clinical Manifestations,
Diagnosis, and Management

Matthew J. Mahoney, Ruegba Bekibele, Sydney L. Notermann, Thomas G. Reuter and

Emily C. Borman-Shoap

Special Issue
Advances in Pediatric Ophthalmology
Edited by
Dr. Courtney L. Kraus and Dr. Susan M. Culican

https://doi.org/10.3390/children10050808
 children
Review
Pediatric Conjunctivitis: A Review of Clinical Manifestations,
Diagnosis, and Management
Matthew J. Mahoney * , Ruegba Bekibele, Sydney L. Notermann, Thomas G. Reuter
and Emily C. Borman-Shoap

Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA

* Correspondence: [email protected]

Abstract: Conjunctivitis is a common pediatric problem and is broadly divided into infectious and
non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and
often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with
an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom
duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily
caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive.
Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge.
Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines.
Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact
lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal
ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This
review covers essential information for the primary care pediatric provider as they assess cases
of conjunctivitis.

Keywords: pediatric conjunctivitis; pink eye; pediatric ophthalmology

Citation: Mahoney, M.J.; Bekibele, R.;

Notermann, S.L.; Reuter, T.G.;
1. Introduction
Borman-Shoap, E.C. Pediatric
Conjunctivitis: A Review of Clinical
Conjunctivitis, commonly called “pink eye”, refers to inflammation or infection of
Manifestations, Diagnosis, and
the conjunctiva. The conjunctiva is the thin mucous membrane that lines the inside of the
Management. Children 2023, 10, 808. eyelids and the surface of the globe up to the limbus, where the sclera and cornea meet. It
https://doi.org/10.3390/ is divided into the following two portions: the bulbar portion, covering the globe, and the
children10050808 tarsal portion, covering the lids. It is usually transparent; however, it can become injected
and pink or red when inflamed, leading to the colloquial term “pink eye”. Conjunctivitis
Academic Editors: Courtney L. Kraus
can vary in severity, ranging from mild redness associated with tearing to subconjunctival
and Eric C. Beyer
hemorrhage with purulent discharge and edema of the conjunctiva or eyelid.
Received: 10 November 2022 The classification of pediatric conjunctivitis is typically by etiology, broadly catego-
Revised: 26 April 2023 rized into infectious and non-infectious causes. Most cases of pediatric conjunctivitis are
Accepted: 28 April 2023 infectious, either bacterial or viral. Non-infectious conjunctivitis includes allergic conjunc-
Published: 29 April 2023 tivitis as well as conjunctivitis due to foreign bodies, environmental causes, or contact lens
overwear. There are certainly other, more serious, causes of pink eye such as cellulitis,
uveitis, endophthalmitis, and acute glaucoma, which may have a similar presentation;
however, those causes are beyond the scope of this discussion.
Copyright: © 2023 by the authors.
The majority of cases of pediatric conjunctivitis are managed by primary care providers
Licensee MDPI, Basel, Switzerland.
rather than eye-specific providers [1]. There are no widely accepted guidelines for the
This article is an open access article
management of conjunctivitis in children and widely varying practices from clinician to
distributed under the terms and
conditions of the Creative Commons
clinician have been noted [2]. The goal of this literature review is to summarize the current
Attribution (CC BY) license (https://
evidence on the clinical manifestations, diagnosis, and management of conjunctivitis for
creativecommons.org/licenses/by/
primary care providers.
4.0/).

Children 2023, 10, 808. https://doi.org/10.3390/children10050808 https://www.mdpi.com/journal/children

Children 2023, 10, 808 2 of 9

2. Making the Diagnosis

When a child presents with “pink eye”, the evaluation should first start with a review
of the history, signs, and symptoms to determine the etiology. It is essential to obtain
information such as the length of symptoms, whether one or both eyes are affected, and
a description of drainage from the eye(s), if any. Associated symptoms may also give a
clue for the etiology, particularly if there are co-occurring viral symptoms such as a cough,
sore throat, fever, or rash. If the patient has had trauma to the eye or if their symptoms
have a predominance for certain times of the year, this may also provide guidance toward
understanding the etiology. Depending on the age of the child, it may be appropriate to ask
if they have noticed any changes to their vision or if a foreign body sensation is present.
The physical examination should always begin with a vision measurement, testing
each eye separately with a Snellen chart. For children too young to participate with a
Snellen chart test, near vision can be broadly measured by seeing if patients can focus on
a book, toy, or their caregiver. If visual acuity appears to be affected, a referral should be
made to a pediatric ophthalmologist for further evaluation.
Physical examination should continue with the use of a penlight. When examining
the pupils and anterior segment, attention should be given to the size of the pupil and if
it is reactive to light. If there is discharge present, it is important to note the consistency,
color, and amount of it. In addition, the conjunctiva should be examined to determine if
the entire conjunctiva is affected or if there is a specific area that is more erythematous. For
clinicians that are comfortable with it, inverting the eyelid can also provide clues to the
etiology. A fundoscopic exam is not typically useful in differentiating between the various
etiologies. Laboratory testing and imaging are also not typically necessary for cases of
uncomplicated conjunctivitis.
A thorough history and physical exam can give clues to the etiology and management
of “pink eye,” as seen in Tables 1 and 2, respectively. However, it is important to note that
clinical presentation is often non-specific. While significant research has been devoted to
predicting the causative agent based on symptoms, few studies have demonstrated the
ability to successfully achieve this. A 2003 meta-analysis did not find any evidence for the
diagnostic usefulness of clinical signs and symptoms to differentiate bacterial from viral
conjunctivitis [3]. However, a more recent meta-analysis from 2022 found that bacterial
conjunctivitis may in fact be the more common cause of conjunctivitis in children [4], with
as many as 70% of conjunctivitis cases in children. The same meta-analysis found that
adults presenting with acute conjunctivitis had an identified bacterial etiology much less
often, only about 16% of the time.
A multi-center study of adults with bacterial conjunctivitis demonstrated that the
symptoms can widely vary. Of those patients with positive bacterial cultures, 65% had
burning, 58% had itching, and 35% had serous or no discharge at all [5]. Associated
symptoms may give clinical clues to the bacterial, viral, or other causes of conjunctivitis.
For example, the presence of mucopurulent discharge or otitis media is suggestive of a
bacterial etiology. Concomitant pharyngitis, pre-auricular lymphadenopathy, and known
contacts with red eye all suggest viral etiologies [4].

2.1. Bacterial Conjunctivitis

Acute bacterial conjunctivitis is common in children, with more than 50% of con-
junctivitis cases being bacterial in origin [6,7]. Common pathogens include Haemophilus
influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Of those, H. influenzae, most
commonly non-typeable H. influenzae, remains the most common cause of bacterial conjunc-
tivitis, present in up to 70% of cases [8]. Presenting symptoms are commonly eye redness
and significant mucopurulent discharge, frequently yellow to green in color. Patients with
acute bacterial conjunctivitis often complain of eyes that are mattered and adhered in the
morning [3]. On examination, patients typically have mucopurulent discharge at the lid
margins that reappears quickly after wiping the lids, usually within minutes.
Children 2023, 10, 808 3 of 9

2.2. Viral Conjunctivitis

Viral conjunctivitis makes up a significant portion of acute conjunctivitis cases, and the
vast majority are caused by adenoviruses. Presentation often consists of a burning or gritty
feeling with watery discharge. This typically has an abrupt onset, starts with one eye, and
infects the other eye within 24 to 48 h. This can be accompanied by a viral prodrome with
fever, lymphadenopathy (particularly preauricular), pharyngitis, and/or upper respiratory
tract infection. A clinical exam typically demonstrates prominent conjunctival injection
with watery discharge and a follicular appearance of the tarsal conjunctiva.
While adenoviruses cause most of these cases, other viral causes must be considered.
Herpes simplex virus (HSV) can present in a similar manner to adenoviral conjunctivitis
with watery eye discharge, often co-occurring with characteristic HSV vesicular eruptions
on the face [9]. Fluorescein examination will reveal multiple small branching epithelial
dendrites on the surface of the cornea [10]. Molluscum contagiosum, a poxvirus known for
causing skin colored, umbilicated papules, can present with lesions on the eyelid and lead to
follicular conjunctivitis [11]. Picornaviruses such as Enterovirus 70 and Coxsackievirus A24
can cause acute hemorrhagic conjunctivitis and have led to multiple pandemics, particularly
in developing countries [12].
Coronaviruses have not been known to cause ocular manifestations in the past; how-
ever, the novel coronavirus disease 2019 (COVID-19) led to viral conjunctivitis. A meta-
analysis demonstrated that approximately 1 in 10 cases of COVID-19 had ocular involve-
ment, primarily characterized by dry eye, redness, and tearing [13]. In pediatric patients
specifically, conjunctivitis is the most common ocular manifestation of COVID-19. A study
of 15 neonates with COVID-19 showed that more than 70% had chemosis (conjunctival
edema) and hemorrhagic conjunctivitis [14]. Conjunctivitis appears to be more likely as-
sociated with a systemic inflammatory reaction rather than a direct viral infection [13,14].
More serious complications, such as orbital cellulitis, retinal vein occlusion, and optic nerve
abnormalities, have been associated with COVID-19; however, these are more rare [13].

2.3. Allergic Conjunctivitis

Allergic conjunctivitis is a type I hypersensitivity reaction, most commonly to airborne
allergens such as pollen, dander, dust, or molds. This IgE-mediated reaction causes mast cell
degranulation, leading to the release of histamine and other pro-inflammatory mediators.
This occurs in approximately 1 in 5 children, with a peak age from late childhood to
adolescence [15]. In fact, allergic conjunctivitis is the most common ocular complaint to
the pediatric healthcare provider [16]. Its presentation is typically bilateral with watery
discharge, chemosis, and crusting on lid margins in the morning. It tends to occur when
allergen levels, such as pollen, are at their peak. The key differentiating factor is itching,
sometimes occurring with other atopic symptoms such as nasal congestion, cough, or
sneezing. The clinical exam findings are similar to viral conjunctivitis with watery discharge
and a follicular appearance of the tarsal conjunctiva. A clinical algorithm from a 2017
review laid out helpful features to help rule out allergic conjunctivitis [17]. For example,
photophobia, eye pain, and blurry vision are not expected with allergic conjunctivitis and
should prompt referral to an eye specialist. Conditions that can serve as mimickers of
allergic conjunctivitis include blepharitis and meibomian gland dysfunction [18].

2.4. Foreign Body

Foreign bodies in the eye can present with eye pain, foreign body sensation, and
sensitivity to light. These injuries occur in approximately 2 per 1000 in the US and make up
31% of eye-related diagnoses during ER visits [19]. Ocular foreign bodies are particularly
prevalent in the setting of recent eye trauma [20]. Nearly half of eye foreign bodies in
pediatric patients are due to wood, sand, and dust and high velocity injuries from BB,
paintball, and airsoft guns are especially common in adolescent males [21]. Even without a
history of trauma, a physical examination of the eyes is vital in both assessing the acuity of
the injury and visualizing any potential foreign bodies. The physical exam should include
Children 2023, 10, 808 4 of 9

visual acuity, full eyelid evaluation, and pupillary exam; however, if symptoms such as
sudden eye pain or vision loss cause concern for globe rupture, applanation tonometry and
scleral depression are not recommended. Slit lamp evaluation with fluorescein staining can
be used to visualize corneal abrasions caused by foreign objects [20].

Table 1. Clinical Symptoms and Physical Exam Findings of Various Etiologies of Conjunctivitis.

Conjunctivitis Clinical Symptoms Physical Exam

Acute bilateral or unilateral purulent discharge with mattering
Bacterial Significant discharge, typically green or yellow
and adherence
Acute burning or gritty feeling often accompanied by prodromal Watery discharge and follicular appearance
Viral
symptoms, such as fever, cough, and rhinorrhea to conjunctiva
Bilateral eye itchiness often accompanied by atopic symptoms, Watery discharge, chemosis, and follicular
Allergic
typically chronic and seasonal appearance to conjunctiva
Foreign body visualized and/or corneal abrasion
Foreign Body Acute eye pain with foreign body sensation and sensitivity to light
visualized with fluorescein staining

2.5. Contact Lens Overwear

Conjunctivitis in a patient who wears contact lens always necessitates further investi-
gation. Common complications from contact lens wear include discomfort and dry eyes,
which may lead to red, irritated eyes, oftentimes secondary to corneal hypoxia. Overwear
of lenses can result in giant papillary conjunctivitis, an inflammation caused by multiple
factors including mechanical rubbing from the contact lens on the upper eyelid, corneal
hypoxia, and cellular mitosis. Two serious complications that can result from contact lens
use include corneal ischemia leading to neovascularization and infectious keratitis, which
can lead to a corneal ulcer [22]. Examination, particularly by an eye-specific provider,
can help differentiate between giant papillary conjunctivitis requiring a lens break or a
contact lens-related corneal ischemia or ulcer, which must be treated immediately to avoid
vision loss.

2.6. Non-Allergic Environmental Causes

Conjunctivitis that is not infectious or allergic in etiology is broadly defined as unspe-
cific conjunctivitis of unknown origin (UCUO). This commonly presents with eye redness
and foreign body sensation. There appears to be a specific link between pollution in the
environment and the prevalence of UCUO. A study of 132 children demonstrated a sig-
nificant increase in the incidence of UCUO compared to the total conjunctivitis cases in
residents of areas with higher air pollution [23]. In Taiwan, a study identified that high
levels of specific air pollutants, including ozone, nitrogen dioxide, particulate matter, and
sulfur dioxide, significantly increased the prevalence of outpatient visits for non-specific
conjunctivitis [24]. Particularly in patients who live in settings with higher air pollution,
non-allergic environmental causes and UCUO should be considered.

2.7. Neonatal Conjunctivitis

Neonatal conjunctivitis, also known as ophthalmia neonatorum, is conjunctivitis that
occurs during the first 28 days of life. Similar to conjunctivitis in older children, neonates
with bacterial conjunctivitis typically present with purulent discharge, while those with
viral conjunctivitis more commonly have watery discharge [25]. Most neonatal conjunc-
tivitis is bacterial in etiology, with Chlamydia trachomatis causing the majority of cases
(approximately 40% of total cases [26]). Chlamydial conjunctivitis typically presents five
days to two weeks after birth with unilateral or bilateral conjunctival redness and wa-
tery secretions [27]. This can progress with time to purulent discharge and the formation
of pseudomembranes, yellow-white membranes visible on the tarsal conjunctiva [28].
Neisseria gonorrhoeae is another cause of bacterial conjunctivitis and results in significant red-
ness and swelling, lid edema, and purulent discharge. This occurs earlier than chlamydial
conjunctivitis, typically around two to five days after birth [27].
Children 2023, 10, 808 5 of 9

Viruses cause a significantly lower proportion of neonatal conjunctivitis and are

primarily caused by the herpes simplex virus (HSV). HSV conjunctivitis in neonates usually
occurs from infection in the birth canal and a neonate who presents with conjunctivitis
after known exposure to HSV should receive extra attention [29]. On examination, clues
for HSV conjunctivitis are similar to those in older children with vesicular eruptions on the
face, conjunctival injection, and a hazy cornea secondary to edema [29].
Chemical conjunctivitis typically presents in the first 24 h of life. Silver nitrate drops
have been used as prophylaxis against infectious causes of neonatal conjunctivitis; however,
they frequently result in irritation to the conjunctiva [26]. Since the removal of silver
nitrate from general use in the 1980s, the prevalence of neonatal chemical conjunctivitis
has decreased significantly [30]. Today, most causes of neonatal chemical conjunctivitis
in the United States are thought to be linked to the use of prophylactic antibiotics such as
erythromycin ophthalmic ointment or drops and gentamycin drops [31].
Another cause of eye drainage that can mimic neonatal conjunctivitis is congenital
nasolacrimal duct obstruction. The nasolacrimal duct starts with the puncta in the eye and
carries tears through the lacrimal canaliculi to the nasal cavity. Congenital nasolacrimal
duct obstruction can cause a so-called overflow of tears and lead to either a watery or
purulent discharge, depending on whether the proximal or distal portion of the duct is
affected [32]. It is a common presentation and is present in around 20% of infants, with 95%
of those affected showing symptoms in the neonatal period [25].

3. Treatment
3.1. Bacterial Conjunctivitis
The vast majority of cases of bacterial conjunctivitis are self-limiting, lasting 7 to 10 days
without treatment. While antibiotics have been shown to decrease the duration of symp-
toms, no differences in sight threatening outcomes have been observed between treatment
and non-treatment groups. In a meta-analysis consisting of 11 randomized clinical trials
and 3673 patients, there was a 10% increase in the rate of clinical improvement for patients
who received early antibiotic treatment compared with the placebo group [33]. A recent
study from Finland supported this, showing a more rapid clinical cure in patients treated
with antibiotic eye drops, from a mean of 4.0 days with a placebo to a mean of 3.8 days with
moxifloxacin treatment [34]. Antibiotics are not without risk, with adverse drug reactions
reported by 8% of patients using ophthalmic antibiotics [35]. In addition, studies have
shown acquired resistance to pathogenic bacteria in the conjunctiva of children prescribed
antibiotics [6,36]. While antibiotics are not required for all cases, contact lens wearers
should always be treated with antibiotics due to the increased risk of infection with gram
negative organisms and subsequent keratitis.
With that in mind, no treatment, a delayed treatment approach, and immediate treat-
ment all are appropriate responses to suspected uncomplicated bacterial conjunctivitis [37].
A study of 20 clinicians in Colorado demonstrated that the main drivers behind choos-
ing to prescribe or withhold antibiotics were the patient’s clinical presentation, family
expectations, antibiotic stewardship concerns, diagnostic uncertainty, and daycare and
school policies. They noted that the most critical features to help clinicians differentiate
between viral and bacterial conjunctivitis were the association with other upper respiratory
symptoms and laterality [2].
Overprescribing of antibiotics is common, particularly in cases where the etiology is
uncertain. The COVID-19 pandemic worsened this, likely due to the increase in children
being treated over the telephone or virtually without being seen directly by a physician [38].
In many cases, families will assert that treatment with antibiotics is necessary for their child
to return to school or daycare [2]. School specific policies widely vary from state to state,
but the American Academy of Pediatrics specifically notes that antibiotics should not be
required for return to care [2,39]. If treatment is desired, initial treatment would begin with
erythromycin ointment or trimethoprim-polymyxin B ophthalmic drops. Symptoms would
be expected to improve within one to two days.
Children 2023, 10, 808 6 of 9

3.2. Viral Conjunctivitis

Treatment of viral conjunctivitis, including COVID-19 conjunctivitis, is primarily
symptomatic through the use of cool compresses and lubricating artificial tears. Adenoviral
conjunctivitis is generally self-limited and highly contagious. A study of 56 adults with
adenoviral conjunctivitis who were treated in clinics with a single drop of 5% povidone
iodine demonstrated reduced viral load and a more rapid improvement in symptoms [40].
While not standard practice at this time, this is likely to be an emerging therapy if larger
studies in the future can demonstrate similar symptomatic improvement. Patients should
be educated on the ways to prevent the spread of viral conjunctivitis, such as avoiding
shared towels or bed linens and washing their hands frequently. In fact, a study of 26 adults
with conjunctivitis showed that 46% had positive adenovirus cultures grown from swabs of
their hands [41]. Patients should be encouraged to make every attempt to minimize contact
with others for 10 to 14 days from symptom onset [37].

3.3. Allergic Conjunctivitis

Treatment of allergic conjunctivitis consists of minimizing exposure to the allergen
and controlling symptoms. Topical lubricants such as artificial tears or saline can be
used to physically wash out the offending allergens. Mild allergic conjunctivitis can be
treated with topical antihistamine agents, preferably second generation topical H1-receptor
antagonists [42]. If persistent, ophthalmic drops that have both antihistamine activity and
mast cell stabilizing properties, such as azelastine or olopatadine, can be used. A step-wise
approach may be helpful, starting with topical lubricant, then antihistamines, and finally
topical steroids [17]. Of note, topical steroids should only be used in a time-limited fashion,
limited to 7 days or less. Systemic antihistamines are frequently used to reduce histamine
release, improving both allergic conjunctivitis and other systemic symptoms.

3.4. Foreign Body

Many foreign bodies are superficial and benign, yet cause significant pain. All patients
with suspected corneal foreign bodies should receive a complete eye examination. Topical
NSAIDs such as ketorolac and oral analgesics have been shown to reduce pain and improve
patients’ tolerance of the examination [43]. If a foreign body is identified, removal should be
completed as soon as possible, usually within 24 h. If foreign body accessibility is limited,
emergent foreign body removal should be completed by an ophthalmologist [44]. Upon
removal, topical prophylactic antibiotics should be prescribed to prevent superimposed
infection. Even if a foreign body is not identified, individuals wearing contact lenses should
receive anti-pseudomonal coverage such as ciprofloxacin or gentamicin. For those without
contacts, topical bacitracin or erythromycin have been utilized; however, the efficacy of
prophylactic antibiotics is still uncertain.

Table 2. Treatments of Various Etiologies of Conjunctivitis.

Conjunctivitis Treatment
Bacterial Self-limiting within 7–10 days; however, consider erythromycin ointment or trimethoprim-polymyxin B drops
Viral Symptomatic treatment with cool compresses and artificial tears
Allergic Avoid allergic exposures and consider use of topical antihistamines
Foreign Body Foreign body removal with saline irrigation, pain relief with topical NSAIDs or oral analgesics, and topical antibiotics

3.5. Neonatal Conjunctivitis

In the United States, ocular prophylaxis against neonatal conjunctivitis with 0.5%
erythromycin ophthalmic ointment is the common practice. However, there is an ongoing
conversation about the necessity of ocular prophylaxis, given that the rates of gonorrhea
in pregnant people have decreased steadily since the 1970s [45]. All pregnant people are
screened throughout their pregnancy; thus, the majority of neonates are treated prophy-
lactically despite a minimal risk of them developing gonococcal conjunctivitis [31]. The
Children 2023, 10, 808 7 of 9

data surrounding the efficacy of erythromycin ointment on gonococcal conjunctivitis are

limited and there is concern for N. gonorrhoeae developing resistance to erythromycin [31].
Despite this, the United States Preventative Service Task Force (USPSTF) continues to
recommend erythromycin prophylaxis for all newborns. In the USPSTF’s most recent
reaffirmation statement on ocular prophylaxis, they cite that the rate of gonococcal neonatal
conjunctivitis is currently estimated to be 0.4 cases per 100,000 live births per year and
without ocular prophylaxis, transmission rates are as high as 30% to 50% [45]. Despite
the fact that all pregnant people are screened for N. gonorrhoeae, approximately 6.2% of
individuals in the United States do not receive prenatal care, thus would have an increased
risk of unknowingly transmitting N. gonorrhoeae to their newborn [45]. With this in mind,
erythromycin ophthalmic ointment remains the standard of care.
One side effect that is important for clinicians to be aware of is that erythromycin
ophthalmic ointment can lead to a form of chemical conjunctivitis in the first 24 h of life [31].
Neonatal chemical conjunctivitis, whether from erythromycin or silver nitrate, is typically
self-limited and resolves within two to four days [30]. For other cases of conjunctivitis, the
treatment depends on the etiology. For conjunctivitis caused by C. trachomatis, treatment is
typically erythromycin ophthalmic drops plus oral erythromycin for a total course of two
to three weeks [37]. For cases of conjunctivitis caused by N. gonorrhoeae, the treatment is a
third-generation cephalosporin, such as ceftriaxone, in a single dose. This is started along
with normal saline irrigation to the eyes with hopes to remove the mucopurulent discharge
typically present. As with most cases, neonates treated for gonococcal conjunctivitis should
also be treated for chlamydial conjunctivitis, given the prevalence of co-infection [37].

4. When to Refer
Although certain symptoms and clinical exam findings tend to correspond with
specific causes of pink eye, it must be emphasized that clinical manifestations are non-
specific and that considerable overlap exists in actual clinical practice. When in doubt,
primary care providers should not hesitate to make appropriate referrals to ophthalmology.
The American Academy of Ophthalmology recommends specific symptoms and con-
ditions that should be referred for further evaluation [37]. Symptoms that should prompt
further evaluation include moderate to severe pain, vision loss, constant blurred vision,
and severe purulent discharge. Photophobia should also prompt further evaluation, partic-
ularly if out of proportion to other symptoms or found in cases of allergic conjunctivitis.
In addition, referral should be considered for those with symptoms lasting more than
7 to 10 days, recurrent symptoms, or who do not respond to treatment.
Specific cases also require further evaluation. Patients who wear contact lenses should
always be treated, encouraged to discontinue lens wear, and referred for a slit lamp exam
to rule out a contact lens-related corneal ulcer. Many cases of allergic conjunctivitis can be
treated without a referral; however, if vernal conjunctivitis is suspected, patients should be
referred, since it can be vision-threatening.

5. Conclusions
Conjunctivitis is a common complaint in the pediatric primary care office. A clinician
can use diagnostic clues from the patient’s history and exam to help determine the likely
etiology. In general, bacterial conjunctivitis makes up the majority of cases of pediatric
conjunctivitis and presents with purulent discharge and mattering of eyes. Viral conjunc-
tivitis leads to a gritty feeling with watery discharge and is often associated with other
upper respiratory symptoms. Allergic conjunctivitis is usually bilateral and coincides with
seasonal allergen levels. Other causes of conjunctivitis occur in particular groups, including
contact lens wearers, those in high pollution environments, and those with symptoms that
go beyond conjunctivitis. The treatment of most cases is supportive with topical lubricants;
however, antibiotics are indicated on an individual basis for cases of bacterial conjunctivitis,
depending on patient and family preference and the clinician’s approach to treatment.
Children 2023, 10, 808 8 of 9

Cases that do not resolve as expected should be referred for additional evaluation by an
eye-specific provider.

Author Contributions: Conceptualization, E.C.B.-S. and M.J.M.; writing—original draft preparation,

M.J.M., R.B., S.L.N. and T.G.R.; writing—review and editing, E.C.B.-S. and M.J.M. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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