BACKGROUND: Infective conjunctivitis is common and mostly responds well to supportive management and/or empiric antibiotic treatment. At times the differential diagnosis includes more serious conditions that potentially threaten vision. Recurrence and treatment failures are relatively common. OBJECTIVE: To outline the usual clinical appearance of conjunctivitis and its management. To explore the clinical appearance (with the help of case studies) of conditions that have been mistaken for conjunctivitis, and to consider some of the conditions that may coexist that contribute to recurrence and nonresponsiveness. DISCUSSION: Empiric treatment for presumed bacterial conjunctivitis remains an appropriate course of action. Care must be taken in certain groups who are at high risk of complications. Careful review of the clinical appearance and consideration of other possible diagnoses is mandatory in nonresponding patients.