1. Ancillary and Lab test

2. Basic eye examination Test Snellen visual acuity. Look for conjunctival hyperemia, chemosis, superior and inferior subconjunctival hemorrhages, follicles, lid swelling, and watery discharge. Palpate for preauricular lymphadenopathy. Inspect the bulbar and palpebral conjunctival surface. Consider performing a rapid in-office immunoassay to aid in differentiating viral from bacterial disease. Refer patient to an ophthalmologist for examination of the corneal surface with fluorescein dye and slit lamp if there is significant blurred vision, severe pain, and photophobia suggesting corneal involvement, or a history of concurrent contact lens use.

3. History and Physical Examination Elements for Viral Conjunctivitis CategoryElementNotes HistoryPink eyeUsually starts in one eye and can spread to the second within 2-4 days. Acute infection lasts 7-14 days* HistoryWatery discharge Suggests viral infection HistoryLight sensitivity May indicate corneal involvement HistoryForeign body sensation and pain May indicate corneal involvement with epithelial keratitis and infiltrates HistoryClinical contacts Indicates epidemic nature of disease HistoryRecent upper respiratory infection Suggests a viral conjunctivitis

4. Physical examConjunctival injectionIndicates conjunctival inflammation Physical examBilateralityMay present with both eyes simultaneously or second eye involvement after 3-5 days Physical examConjunctival folliclesFollicles are accumulations of lymphocytes and other inflammatory cells forming a little mound with a vascular frill around the base. Indicate viral infection Physical examPseudomembrane formation in palpebral conjunctiva of upper and lower lids Exudative response causes formation of pseudomembranes Physical examSubconjunctival hemorrhageIndicative of severity of disease Physical examPreauricular lymphadenopathyConsistent with adenoviral infection Physical examCorneal infiltratesTypically seen in epidemic keratoconjunctivitis. Refer to an ophthalmologist for visualization with slit lamp or high magnification with direct ophthalmoscope

5. Use selected tests to assist in the differential diagnosis Virus can be grown on HeLa cells and identified by neutralizing antibody Rapid, point-of-care immunoassays to detect adenovirus Cytology specimen of conjunctival epithelium, which may show intracytoplasmic inclusions in suspected chlamydial conjunctivitis PCR to screen for chlamydia, atypical HSV, or adenovirus Cytology specimen, which may show eosinophilia in suspected allergic conjunctivitis Culture of the conjunctiva in suspected chlamydia or herpes virus Bacterial culture if there is purulent discharge, particularly in patients with hyperacute purulent conjunctivitis, which may reveal N. gonorrhea Conjunctival biopsy specimen in patients with suspected sarcoid and ocular cicatricial pemphigoid