october 2018 • American Academy of Ophthalmology

Conjunctivitis Preferred Practice Pattern

Varu D. M., et al.

DOI: https://doi.org/10.1016/j.ophtha.2018.10.020

Content curated by:Clara Jasmins

Key message

Preferred Practice Pattern (PPP) guidelines include clinically relevant information, supported by the best evidence and each recommendation is rated according to SIGN and GRADE methods. The Highlighted Findings and Recommendations for Care section lists points determined by the PPP panel to be of particular importance to vision and quality of life outcomes.



The patient population includes individuals of all ages who present with symptoms and signs suggestive of conjunctivitis, such as red eye or discharge


Preferred Practice Pattern (PPP) guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) group are used. - All recommendations for care in this PPP were rated using the system described above. - Literature searches to update the PPP were undertaken in February 2017 and June 2018 in PubMed and the Cochrane Library.


HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE 1 - Conjunctivitis rarely causes permanent visual loss or structural damage, but the economic impact of conjunctivitis is considerable and largely due to lost work or school time and the cost of medical visits, testing and treatment 2 - Chronic and/or recalcitrant conjunctivitis may be indicative of an underlying malignancy, such as sebaceous or squamous cell carcinoma. 3 - The ophthalmologist plays a critical role in breaking the chain of transmission of epidemic adenoviral conjunctivitis, primarily by educating the patient and family about proper hygiene. Infected individuals should be counseled to wash hands frequently and use separate towels, and to avoid close contact with others during the period of contagion. 4 - Dilute bleach soak (sodium hypochlorite) at 1:10 concentration is an effective disinfectant for tonometers. Notably, 70% isopropyl alcohol (e.g., alcohol wipes), 3% hydrogen peroxide, and ethyl alcohol are no longer recommended for tonometer disinfection 5 - Surfaces should be disinfected with an EPA-registered hospital disinfectant in accordance with the directions and safety precautions on the label. 6 - Indiscriminate use of topical antibiotics or corticosteroids should be avoided. Viral conjunctivitis will not respond to anti-bacterial agents, and mild bacterial conjunctivitis is likely to be self-limited. No evidence exists demonstrating the superiority of any topical antibiotic agent. [I+, Good, Strong] 7 - In adults, conjunctivitis caused by ocular mucous membrane pemphigoid (OMMP), graft-versus- host disease (GVHD), gonococcus, and chlamydia are important to detect early because it is necessary to treat the concomitant systemic disorder. Diagnosis of superior limbic keratoconjunctivitis (SLK) may lead to further investigations that reveal a thyroid disorder. Early detection of conjunctivitis associated with neoplasms may be lifesaving. 8 - Herpes Zoster vaccination should be strongly recommended in patients 50 years or older.


As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients’ needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients’ needs are the foremost consideration.