What doctors wish patients knew about pink eye

Bright red eyes, relentless itching and an incessant urge to rub your eye. These are telltale signs of conjunctivitis, commonly known as pink eye. Often dismissed as a minor nuisance, pink eye can cause significant discomfort and spread quickly if not properly cared for.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Herbert John Ingraham, MD, an ophthalmologist at the Geisinger health system, discusses what patients need to know about pink eye. Geisinger is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Pink eye is when there’s a certain amount of inflammation on the surface of the eye and as a result of that inflammation, you have blood vessels that become more engorged,” said Dr. Ingraham. “The eye, instead of being nice and white, becomes more inflamed and gets pink in color.”

“In general, that’s just a regular old virus. Most of the time it’s just the same thing that you have going on somewhere else,” he said. For example, “you might have an upper-respiratory infection and you develop a little viral conjunctivitis along with that. That’s the most common.”

Additionally, “sometimes you can get an adenovirus, which can cause a much more severe form of pink eye, which is called epidemic keratoconjunctivitis, or EKC,” Dr. Ingraham said. “That one’s a little bit different because it’s longer in its duration. It tends to get worse for the first three or four days and then starts to get better.

That is “unlike regular viral conjunctivitis, which tends to be bad for a couple of days and then starts to taper off from there,” he added. “When we have someone with the adenovirus infection, that tends to be a little bit more severe and we have to do a few extra things to take care of that.”

“The other things that we worry about are the possibility of a bacterial infection,” Dr. Ingraham said, noting that “because there’s so much discharge and goop coming out of the eye, they assume this seems much worse than most of the viral conjunctivitis I’ve seen, so this must be bacterial.

“But bacterial conjunctivitis is relatively rare and because of that, in most cases of conjunctivitis, there’s really not any indication for using antibiotics, even topical antibiotics, because they’re just not going to make that big of a difference,” he added. “The viral conjunctivitis is going to run its course no matter what you do.”

Other symptoms of conjunctivitis include “a fair amount of discharge from the eye. Typically, during the day it’s very watery without a lot of pus, without a lot of goopy stuff coming out of the eye,” Dr. Ingraham said. “At night it tends to get crusted over, so patients will tell you they woke up in the morning and their eye was crusted shut.”

“In addition to that, people will complain about some itching, some burning and vague irritation to the eye that they just know something's not going well,” he said. “It tends to start in one eye, and then very commonly it goes over into the other eye as well. And when it does that, it tends to not be quite as significant and quite as serious in the second eye as it was in the first time.”

How pink eye spreads and how long it is contagious “depends on whether it’s a regular viral conjunctivitis or whether it’s EKC,” Dr. Ingraham said. With “EKC, the adenovirus can live on surfaces for up to 30 days.”

“Most studies suggest that you are contagious probably a day or so before you start having symptoms to until you are no longer having symptoms,” he said. “That could be a week. That could be a couple of weeks.”

“It’s usually spread by direct contact, but that direct contact can be pretty simple,” Dr. Ingraham said. That is because “you’ve been around your eyes, you’ve got it on your hands” and it can spread by touching a doorknob, using the same towel someone in your house used or being in the same bed with someone who has pink eye and touching their pillow. 

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In the United States, kids miss 3 million school days each year because of pink eye, according to the Centers for Disease Control and Prevention.

“You see a lot of it in children and in the parents of the children,” Dr. Ingraham said. “If your kids are in day care, it just goes ripping through there. If they’re in kindergarten and first grade, it goes ripping through those populations too. Then they bring it home to their parents.”

It can be found in other settings too, such as in nursing homes, “but it tends to be more in that younger population and often they can trace and say, ‘My little one came home from day care with it and three or four days later I had the same thing,’” he said.

“There are other things that can mimic pink eye that are more serious. So, if someone had pink eye and it’s now a week or two in and they just don’t seem to be getting better and their vision is worse, you start thinking about other things,” Dr. Ingraham said. For example, “could this be herpes simplex? That same virus that you could get cold sores from can certainly break out in the eye.”

Additionally, “it could be shingles, particularly in a population in a nursing home,” he said. “The other one that I didn’t think I would ever have to talk to people about again—but, unfortunately, we do—is measles.

“As we get more and more people who are choosing to not immunize their children and measles is making a comeback, you can certainly have a typical measles rash and then a few days later get conjunctivitis, which can be much more serious,” Dr. Ingraham added.

“In the vast majority, when you’re taking a history, the patient will say they had an upper-respiratory infection for a few days, some aches and pains or other things that we associate with a cold and then this started,” Dr. Ingraham said. “In most cases, it’s just a manifestation of that cold that they have.”

But “it’s mostly looking at the surface of the eye and taking a patient’s history,” he said. “When we look at the eye, we can see that there’s a lot of debris on the surface of the eye. We can also see that there are little bumps when we pull down the eyelid and look at the conjunctiva that’s on the underside of the eyelid.”

“If you’ve got someone who you feel has bacterial conjunctivitis, it tends to be much more severe—the eye is much more red, there’s a lot of pus and stuff coming out of the eye,” Dr. Ingraham said. “So, you can take a culture and send that off and if it is bacterial, that will come back positive.”

“If it’s a straightforward viral conjunctivitis, maybe associated with an upper-respiratory infection, we’re mostly trying to keep the patient comfortable,” Dr. Ingraham said. “We might use a preservative-free artificial tear.”

“During the day, I have patients use a cool compress, so just a washcloth running under cold tap water—not ice. That will make the eyes a little bit less inflamed. It’ll make them feel a little bit more comfortable,” he said. “When you first wake up in the morning and your eyes are crusted shut, use a warm compress for that.

“So, warm to hot tap water—about the temperature you would wash your face with, not any hotter than that,” Dr. Ingraham added. “And just lay that across your eye or eyes for five or 10 minutes. That’ll soften up the new crusty stuff so you can just wipe it away without having to dig in there.”

“For allergic conjunctivitis, there’s a lot of over-the-counter antihistamines that used to be prescriptions such as Naphcon and Pataday,” he said. After using these antihistamines, a person “usually feels better pretty quickly.”

“If you’re concerned about bacterial conjunctivitis, that is when you’re going to start an antibiotic,” Dr. Ingraham said. “If there are other signs of inflammation in the cornea or other places where you’re concerned it may lead to some visual issues from scarring, then you might use steroids. But generally, steroids aren’t indicated for just run of the mill conjunctivitis.”

Patients who develop conjunctivitis-like symptoms while wearing contact lenses “should be seen by an ophthalmologist because it may not be pink eye,” Dr. Ingraham said. “It may actually be a more serious infection—what we call a corneal ulcer.”

“Certainly, while you have conjunctivitis, you’re not going to feel like putting that contact lens in the eye that’s already inflamed,” he said, noting “it’s already angry and putting a foreign body on there at that time is not going to help matters.”

To prevent transmitting pink eye, trying not to touch your eyes or face “is obviously easier said than done when you’ve got all these tears running down your face, when your eyes itch or burn,” Dr. Ingraham said. “It’s just not practical to say: I’m just going to sit here and keep my hands away and not do anything.”

Instead, it is important to practice hand hygiene, wash with soap and water, or if soap and water are not available, use an alcohol-based hand sanitizer, he said.

Another thing “that you can do if you’re worried about surfaces that you’re touching: use a bleach-based cleaner,” Dr. Ingraham said. Widely available wipes and sprays “that are based with bleach that will kill most of the viruses on surfaces.”

“You can certainly wipe down doorknobs and anything that you’re sharing in the house where that other person is touching the door or the refrigerator,” he said. “Wiping those surfaces should, at least theoretically, make it less likely that you’re going to spread it.”

“But if you’ve got small children, you can’t just tell them to stay away from you for a few days, so do the best you can to keep things clean,” Dr. Ingraham said.