Conjunctiva

 

Introduction

This guideline summarises the most common conjunctiva problems that may require referral from Primary Care.

 

In scope:          

• Allergic Conjunctivitis
• Bacterial Conjunctivitis
• Viral Conjunctivitis

 

Not in scope:           

• Eye inflammation/infection not involving the conjunctiva

 

Red Flags

• Preseptal Cellulitis
• Reduced visual acuity
• Marked eye pain, headache or photophobia
• Red sticky eye in a neonate (within 30 days of birth)
• History of trauma (mechanical, chemical or ultraviolet) or possible foreign body
• Copious rapidly progressive discharge – may indicate gonococcal infection
• Suspected herpes virus
• Recent intraocular surgery
• Corneal involvement (positive fluorescein staining) or symptoms such as photophobia and watering associated with contact lens use
• Concerns regarding Herpes Zoster Ophthalmicus.

This list is not exhaustive

 

Primary care management prior to referral

Conjunctivitis associated with contact lens wear

Key factors to consider:

• If fluorescein identifies corneal staining refer urgently to Eye Casualty.
  • If possible, send patient with any recently worn lenses (silver top pot with saline)

• If topical fluorescein does not identify any corneal staining and no immediate clinical need to refer to Ophthalmology:
  • Advise them to immediately remove and stop contact lens use. Consider sending any recently worn lenses to microbiology – silver top pot with saline.
  • Self-care measures
  • Consider use of topical antibiotic effective against gram -ve organisms, e.g. gentamycin or levofloxacin³ as per CKS
  • Consider referral if symptoms persist for more than 7 to 10 days after initiating treatment

 

Bacterial Conjunctivitis

Key Factors to Consider:

• Most cases of bacterial conjunctivitis are self-limiting and resolve without treatment within 5-7 days³.
• Symptoms eased with self-care measures:
• bathing/cleaning the eyelids with cotton wool soaked in cooled boiled water
• cool compresses applied around the eye area
• lubricating agents or artificial tears³ as appropriate
• Consider topical antibiotics if severe or symptoms not resolving after 3 days. e.g. Chloramphenicol, Fusidic acid
• Suspect Chlamydial if sexually active and resistant to above drugs. Consider swab and GUM referral. If severe consider referral to Ophthalmology (Eye Casualty if red flags) alongside GUM as clinically appropriate.
• UKHSA does not recommend an exclusion period from school³.

 

Allergic Conjunctivitis

Key factors to consider:

• Often self-limiting. Avoid allergens if possible. Use ocular surface lubricants as necessary and appropriate.
• If patient is on brimonidine for glaucoma this may be a delayed hypersensitivity response - stop brimonidine and write to consultant in charge
• Topical ocular antihistamines and mast cell stabilizers | Prescribing information | Conjunctivitis - allergic | CKS | NICE

 

Viral (non-herpetic) Conjunctivitis

Key factors to consider: 

• Often preceded by URTI and has associated pre-auricular lymphadenopathy.
• Usually, self-resolving within one or two weeks³. No indication for antibiotics.
• Self-care measures (see bacterial above)
• UKHSA does not recommend an exclusion period from school³.

 

Herpes Zoster Ophthalmicus

Key factors to consider:

• Suspect if a history of herpes simplex and or a recent history of blepharoconjunctivitis which is not resolving as expected⁵.
• Refer all cases urgently to Eye Casualty

 

Investigations prior to referral

Consider sending swabs for viral PCR and bacterial culture if appropriate. Do not delay urgent referral to Eye Casualty if concerns about herpes zoster.

 

Advice and Guidance

Please send advice and guidance requests to Ophthalmology via eRS

 

Referral instructions

Urgent Eye Casualty Referral:

• Any red flag feature (as above)
• Worsening symptoms despite treatment

 

Routine Referral:

• No resolution of bacterial conjunctivitis, in the absence of red flags or worsening symptoms, after two courses of antibiotics or symptoms persist for more than 7 to 10 days after initiating treatment³.

 

Supportive Information

For Professionals

• Peri-orbital and orbital cellulitis - Symptoms, diagnosis and treatment | BMJ Best Practice
• Acute GP - Infections
• Health protection in education and childcare settings: exclusion table

 

For Patients

• Master Patient Information Document
• Infective Conjunctivitis: Causes, Symptoms, and Treatment

 

References

• Acute conjunctivitis - Symptoms, diagnosis and treatment | BMJ Best Practice
• https://cks.nice.org.uk/topics/conjunctivitis-infective/
• Scenario: Management in primary care | Management | Conjunctivitis - infective | CKS | NICE
• Scenario: Management in primary care | Management | Conjunctivitis - allergic | CKS | NICE
• Diagnosis | Diagnosis | Herpes simplex - ocular | CKS | NICE

 

Page Review Information

Date Reviewed       19 January 2026

Next Review Due    19 January 2028

GP Sifter                Dr Kate Northridge

Contributor             Mr Nazih Toumia, Consultant Ophthalmologist Royal Cornwall Hospital Trust