What Is Pink Eye?
Pink eye, known medically as conjunctivitis, is a common condition that can affect both children and adults.
The “bloodshot” appearance of your eye comes from inflammation of the conjunctiva, a thin membrane lining the inside surface of your eyelids and the whites of your eyes. Normally transparent in appearance, your conjunctiva contains blood vessels which become visible due to the inflammation.
The result is a uniform pink or red hue across the white of your eye which medical professionals call “injection.” Pink eye can also be accompanied by a gooey liquid discharge, itching, burning, and your eyelid getting stuck shut when you wake up in the morning.
Are There Different Types of Pink Eye?
There are four main categories of pink eye:
- And a group encompassing other less specific causes of irritation
Pink eye tends to be caused most often by viruses in adults, but bacteria in children.
Each type has distinct characteristics and unique treatment strategies, so it’s important to distinguish between them. Further, while all types of conjunctivitis cause a pink eye, it’s important to know that not everyone with a pink eye necessarily has conjunctivitis.
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Pink Eye Signs and Symptoms
Viral Pink Eye
Symptoms of viral conjunctivitis include eye redness accompanied by burning, a stringy watery discharge, and a gritty feeling like you have sand in your eye. You may also wake up with your eye crusted close in the morning.
In most cases, your second eye will also become affected within one to two days.
The most common cause of viral pink eye is adenovirus, which can also cause the common cold. For this reason, it is not uncommon for individuals with viral conjunctivitis to have cold-like symptoms in addition to their pink eye.
These symptoms may include:
- Swollen lymph glands in the neck
- Sore throat
- Runny nose
When caused by a virus, pink eye is highly contagious.
It can quickly be spread through contact, most often via objects that have been exposed to secretions from the infected eye. Pillows and towels are frequent offenders, mainly when shared with others. Infection can also be transmitted indirectly, through touching your eye and then touching a shared surface such as a doorknob.
Fortunately, viral conjunctivitis will eventually get better on its own. Your symptoms will typically get worse for three to five days first, then gradually resolve over the course of a week or two.
You may still experience some crusting of your eyelid in the morning toward the end of this period, however, the redness and irritation will have resolved.
If you do experience a persistent and painful sensation of a foreign object stuck in your eye, you may have a rare and severe variant of viral pink eye known as keratitis.
Patients with keratitis typically experience a considerable worsening of vision and have difficulty even opening their eyes.
Keratitis can cause blindness if left untreated, so you should seek the care of a doctor immediately if you have these symptoms!
Bacterial Pink Eye
Symptoms of bacterial conjunctivitis include eye redness with a thick, yellow or green discharge that continues to drain throughout the day. Draining pus will usually reappear within only minutes of wiping it off.
The infected eyelid is very often stuck shut after waking up in the morning, albeit in a more severe fashion. Bacterial infections most commonly affect only one eye, however, it is possible for both eyes to be affected simultaneously.
In adults, the most common cause of bacterial pink eye is the bacteria Staphylococcus aureus. Children are usually infected by a broader spectrum of bacteria that includes Moraxella catarrhalis, Streptococcus pneumoniae, and Haemophilus influenzae.
Bacterial pink eye is also highly contagious, easily spread among family members or classmates. In the early 2000s, bacterial pink eye spread rapidly among students at Dartmouth College, infecting nearly 14% of the 5,000 enrolled students!
Like its viral counterpart, bacterial conjunctivitis is spread through contact with the eye or its secretions.
Allergic Pink Eye
Allergies of the eyes are thought to affect up to 40% of the population each year, with some researchers suggesting this is on the rise.
It occurs most commonly in young adults, starting on average at 20 years old.
Symptoms of allergic conjunctivitis are similar to viral causes, with widespread redness, burning, a watery, stringy discharge, and occasional eyelid crusting in the morning.
However, in cases of allergic pink eye, you are more likely to experience persistent, bothersome itchiness and some swelling of your eyelids. Patients with extreme cat allergies may even experience a bulging of the eye beyond the eyelid, known medically as “bullous chemosis.”
Rubbing your eyes should be avoided as it will typically make your symptoms worse. Allergic pink eye usually affects both eyes simultaneously but can also affect one eye more than the other.
Allergic conjunctivitis is due to allergens in the air that come into contact with your eye. Symptoms can occur suddenly, seasonally, or last all year long, depending on your allergy.
If you have allergic pink eye, odds are you have probably experienced allergies at some point in the past, whether it be seasonal or when you are near your neighbor’s cat. If your pink eye developed after being around something you know you have been previously allergic, this makes it even more likely your eye’s redness is allergic in nature.
However not all allergic pink eye needs to necessarily occur right after allergen exposure, as some people suffer from a year-round allergic pink eye that comes and goes, typically attributed to common molds and dust mites
Non-Specific Pink Eye
You can also develop pink eye that is not from infection or allergy, but rather another source of irritation.
For instance, your eyes can become red and irritated after being splashed with liquids containing various chemicals.
Furthermore, a foreign object such as an eyelash can get stuck in your eye and cause redness and discomfort for up to a day after being removed. Even still, some individuals will occasionally just have dry eyes that will manifest as redness and tearing.
Contact lens wearers are particularly vulnerable to eye redness unrelated to infection or allergies.
Most often if you wear contacts and are frequently experiencing red eyes, you are due for a change in your prescription. If you wear contacts and experience these symptoms, you should stop wearing your contacts immediately. If your symptoms do not resolve in 12 to 24 hours, you should seek medical care as contacts can also make you more vulnerable to a rare, more severe infection of your cornea.
In general, all causes of non-specific pink eye will resolve on their own within 24 hours.
How Can Pink Eye Be Diagnosed?
Diagnosis of conjunctivitis usually requires an examination by your healthcare provider or eye care specialist. In patients with a pink eye and liquid discharge, the determination of conjunctivitis can be made by a healthcare professional after more serious causes of eye redness are ruled out.
Your doctor will then need to ask you some questions to distinguish between the different types of pink eye.
What Questions Might My Doctor Ask Me About My Pink Eye?
- When did your pink eye start?
- Do you know anyone else who has recently had eye redness?
- Are you experiencing discharge? Is it watery and clear, or thick and colored? Does it persist all day?
- Do you have other symptoms such as fever, sore throat, cough, or a runny nose?
In some instances, your doctor may order a test to detect viruses or culture the discharge to see if it contains certain types of bacteria. However, this is usually unnecessary and reserved for infections that may be dangerous. (7)
What Are Some Signs My Pink Eye May Be Serious?
Some symptoms are red flags that should alert you to a potentially more severe cause of your pink eye. If you experience any of the following symptoms, you should be evaluated by an eye doctor emergently:
- Worsening vision
- Extreme sensitivity to light
- Feeling that an object is stuck in your eye to the degree it keeps you from keeping your eye open
- An immobile, fixed pupil
- A severe headache associated with nausea
- Severe redness only around your iris, and not throughout the entire white of the eye. This can be a sign known as “ciliary flush,” caused by severe infections or rapidly evolving glaucoma.
Pink Eye Treatment
Treatment for pink eye will vary depending on the cause. In general, pink eye due to viruses, allergies, and non-specific causes will resolve on their own.
Medications for these types of pink eye can relieve symptoms but will not make them get better any quicker. While bacterial pink eye will also usually resolve on its own, its duration can be shortened by treatment with antibiotic eye drops or ointment.
Viral Pink Eye Medications
The primary goal in viral pink eye treatment is symptom relief while allowing the viral pink eye to resolve on its own over time.
Eye drops containing an antihistamine combined with a decongestant are frequently used for this purpose and can be purchased over-the-counter at your local pharmacy. Some examples include Ocuhist and Naphcon-A. When using antihistamine eye drops for symptom relief, you should take extra care to avoid transferring the infection to your other eye.
Be sure to only apply the drops in the affected eye and always wash your hands with soap and warm water afterward.
As mentioned previously, these options are not directly treating the infection but instead are intended to make the symptoms more tolerable. Its best to use antihistamine drops judiciously, as prolonged use over a period of weeks can also cause eye irritation. You should anticipate your symptoms will continue to worsen for several days before starting to improve.
Bacterial Pink Eye Medications
Bacterial pink eye can be treated with antibiotic eye drops or ointments to shorten the length of infection and symptoms, as long as they are given before you’ve had pink eye for six days.
First-line antibiotics for adults typically include trimethoprim-polymyxin B drops or erythromycin ointment for five to seven days. You should apply one to two drops four times a day or half an inch of ointment inside the lower eyelid, respectively. If your symptoms begin to improve after a few days, you can start to apply treatment twice a day.
Most patients will experience improvements in redness, irritation, and discharge within a day or two. Other antibiotics which can be used include azithromycin and fluoroquinolone drops, or bacitracin and sulfacetamide ointments. These antibiotics are all active against the most common bacteria causing pink eye.
Contact lens wearers should not continue use during the first 24 hours of treatment. If you use disposable contacts, you should replace them before your next use. Otherwise, contacts should be disinfected, and they should not be stored in the same case.
Since contact lens wearers are at risk for a more severe infection caused by the bacteria Pseudomonas, they are typically treated initially with fluoroquinolone eye drops. This class of antibiotics has been shown to be very effective against potentially severe infections with this bacterium.
In children with bacterial pink eye, antibiotic ointments are typically the preferred treatment due to their ease of application. Even in children in whom the ointment is challenging to apply to the lower eyelid, it will likely still be effective as it spreads naturally with the child’s blinks. Ointments can make vision blurry for a short period of time after use, so you should warn your kids of this in advance.
In addition, it may be worthwhile to switch products if one brand of drop or ointment is irritating, as different medications consist of various active and inactive ingredients and preservatives.
Allergic Pink Eye Medications
Similar to viral pink eye, combined antihistamine and decongestant drops are a popular over-the-counter treatment for allergic pink eye. The decongestant component causes the blood vessels to tighten, decreasing swelling of the eye.
Antihistamines block the allergic reaction from continuing to occur. These combination eye drops can be used up to four times a day for symptom relief, however, you should take caution in using one of these drops for more than two weeks.
Prolonged use can result in a phenomenon known as rebound hyperemia, in which the blood vessels re-expand after the medication is stopped – subsequently increasing your eye redness for several days!
Another option for mitigating symptoms in allergic pink eye is with drops containing antihistamines with mast cell-stabilizing properties. These drops block allergic reactions at two distinct points of the allergy cascade, decreasing inflammation and swelling. Antihistamines with mast cell-stabilizers are given once or twice a day and can start working within minutes of application.
Some examples include:
- Pazeo (olopatadine)
- Lastacaft (alcaftadine)
- Optivar (epinastine)
These drops have a reputation for causing burning after use, which can be minimized by keeping the drops in your refrigerator.
Mast cell stabilizers are an option if you routinely develop symptoms over long periods of time, such as those with allergic pink eye from seasonal allergies. This class of medication takes up to two weeks to start working, making them less than ideal for sudden-onset symptoms. However, for those anticipating symptoms, mast cell stabilizers can be started a couple weeks before allergy season.
Examples of mast cell stabilizers include:
- Opticrom (cromolyn sodium)
- Alocril (nedocromil)
- Alomide (lodoxamide tromethamine)
For patients with symptoms unresponsive to other treatment, topical glucocorticoids can be an option. Glucocorticoids are a class of steroids capable of suppressing the late-phase of an allergic reaction. These medications should only be used for a maximum of two weeks, as they carry a risk for serious side effects including vision loss and infection.
Glucocorticoids specially formulated for the eye have decreased the risk by making them inactive once they reach the cornea.
These “soft” steroids include:
- Lotemax (loteprednol)
- Vexol (rimexolone)
- FML (fluorometholone)
They are administered up to four times daily and can help patients with stubborn cases of allergic pink eye begin to recover.
Non-Specific Pink Eye Medications
Non-specific pink eye typically resolves within just a few days without treatment as the conjunctiva is capable of quickly healing following an injury. Lubricants in the form of drops or ointments can be used to relieve mild irritation during this process.
As drops, lubricants can be administered as often as every hour without side effects. Lubricant ointments tend to provide longer-term relief, however cause short-term blurry vision so are usually reserved for bedtime. Both lubricant drops and ointments are available over-the-counter.
While formulations without preservatives are available, these are only necessary for those with very severe dryness or pre-existing allergies. Symptoms lasting longer than two weeks should be evaluated by an eye doctor.
Natural Remedies for Pink Eye
With many cases of pink eye resolving spontaneously over time, you may wish to alleviate your symptoms with natural remedies at home and wait it out.
One option is to apply either cold or warm compresses to your affected eye, which can help reduce eyelid swelling and itchiness. In one research study, this effect was enhanced even further when combined with frequent use of refrigerated artificial tears throughout the day.
Limited research has also supported other household items as helpful in decreasing inflammation and relieving symptoms.
A study in 2012 showed that stingless bee honey shortened both the duration of infection and time until symptom resolution in patients with bacterial pink eye.
A plastic surgeon from Iowa similarly recalled his experience in India, where many used turmeric as a successful treatment for pink eye.
Research in Nigeria has even shown that garlic extract can inhibit the growth of the bacteria Staphylococcus aureus causing bacterial pink eye.
Pink Eye Prevention
Bacterial and viral pink eye are both extraordinarily contagious and spread through contact with the eye or its secretions. Therefore, the most effective way to minimize spread is to practice meticulous hygiene.
Be sure to clean items you touch and avoid rubbing or scratching your affected eye. Hand washing with warm water and soap is very useful and vital to preventing the spread of infection. Be sure to create friction between your hands when washing, as the mechanical force can promote the shearing of viruses and bacteria from your skin.
When Can I Return to Work or School After Pink Eye?
Ideally, you should avoid going to school or work until you no longer have discharge from the affected eye. This isn’t always practical though, so most places will request at least one full day of treatment with antibiotic drops before your return.
Of course, this is only really effective for bacterial conjunctivitis and will have no impact on viral or allergic pink eye.
Read more on our Pink Eye Series: