History

Fact Explanation
Sticky eye lids Sticky eye lids is commonly encountered with bacterial conjunctivitis. Patients often complain of inability to open their eyes in waking up in the mornings. [1,3]
Red eye Conjunctivitis causes inflammation of the conjunctiva resulting in red eyes. [1,3]
Discharge Purulent discharge is common presentation of bacterial conjunctivitis. Neonatal conjunctivitis presents with unilateral or bilateral purulent discharge once the neonate is about a week old. Gonococcal conjunctivitis presents with profuse discharge and it presents in the first week of life. Viral and allergic conjunctivitis presents with watery discharge. [1,3]
Pain Pain in the eye can be a presenting complain of some patients especially in gonococcal conjunctivitis but severe eye pain should be considered a red flag and immediate referral to an ophthalmologist is indicated. This is due to the risk of developing corneal opacities, corneal perforations and endophthalmitis with gonococcal conjunctivitis. Bacterial conjunctivitis usually presents with no pain. [1,3]
Itching Itchy eyes is another complain of conjunctivitis, commonly seen in allergic and viral conjunctivitis. [1,3]
Symptoms of upper respiratory tract infection Patients with viral conjunctivitis present with symptoms of upper respiratory tract infection like cough and runny nose. [1]
Symptoms of otitis media Commonly Haemophilus influenzae and less commonly Streptococcus pneumoniae can cause conjunctivitis-otitis syndrome which is commonly seen in children. Earache and discharge are common symptoms. [1]
Reduced vision Reduced vision is a symptom that should be concerned serious. Bacterial conjunctivitis usually do not cause impaired vision unless the discharged pus obscure the vision. [1]
Contact history Conjunctivitis can spread from person to person. Some infants with neonatal conjunctivitis due to Chlamydia infection can develop chlamydial pneumonitis which then result in recurrent conjunctivitis in about 50% of the affected neonates. [1]
Risk factors Conjunctivitis is commoner among contact lens users. Chronic dry eye and lagophthalmos (inability to close the eyes completely) are predisposing factors for recurrent conjunctivitis. Immunodeficiency syndromes and systemic immunosuppression are other predisposing factors for bacterial conjunctivitis. [1,3]
History of gonococcal or chlamydial infection Genital infections can be asymptomatic in some patients. Neonatal conjunctivitis is a common sequale of untreated cervical chlamydial infection in pregnant mothers. [1,3]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 22 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. FROOM J, CULPEPPER L, GROB P, BARTELDS A, BOWERS P, BRIDGES-WEBB C, GRAVA-GUBINS I, GREEN L, LION J, SOMAINI B. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network.. BMJ [online] 1990 March, 300(6724):582-586 [viewed 22 August 2014] Available from: doi:10.1136/bmj.300.6724.582
  3. HøVDING GUNNAR. Acute bacterial conjunctivitis. [online] 2008 June, 86(1):5-17 [viewed 22 August 2014] Available from: doi:10.1111/j.1600-0420.2007.01006.x

Examination

Fact Explanation
Discharge Purulent discharge can be seen in bacterial conjunctivitis commonly with gonococcal conjunctivitis. In gonococcal conjunctivitis it is often thick and yellow green in color. [1,2]
Erythema Erythema of the conjunctiva can be seen due to inflammation. It is common inside of the eyelids and over the periphery of the bulbar conjunctiva. [1,2]
Chemosis Conjunctival edema can be detected due to the presence of inflammation. This occurs with dilatation and increased permeability of the vessels in the conjunctiva. [1]
Visual acuity Visual acuity should be checked in every patient. It can be reduced due to excessive purulent discharge. [1]
Lymphadenopathy Presence of ipsilateral preauricular lymphadenopathy strongly suggest a viral etiology. [1]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 22 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. HøVDING GUNNAR. Acute bacterial conjunctivitis. [online] 2008 June, 86(1):5-17 [viewed 22 August 2014] Available from: doi:10.1111/j.1600-0420.2007.01006.x

Differential Diagnoses

Fact Explanation
Acute glaucoma [1] Glaucoma refers to raised intraocular pressure (IOP). Closed angle glaucoma is commoner and it presents with sudden onset pain in the eye, visual halos, red eye, nausea and vomiting. Measurement of IOP gives very high values (usually more than 30 mmHg).
Anterior uveitis [1] Anterior uveitis refers to intraocular inflammation. Patients usually present with pain and photophobia of the affected eye. Circumlimbal redness, presence of anterior chamber cells and flare are suggestive of the diagnosis. [2]
Blepharitis [1] Blepharitis is an inflammation of the eyelids. It can be infectious (staphylococcal blepharitis) or associated with atopic dermatitis. Patients complain of burning sensation, itching, and foreign-body sensation in the eye. On examination eyelids are swollen and hyperemic. [3,4]
Dry eye [1] Patients with dry eyes experience pain, photosensitivity, sensation of a foreign body, itching, redness and blurring of vision. It can occur in autoimmune diseorders and in Grave's disease as well. [5,6]
Episcleritis [1] Episcleritis is the inflammation of the eposclera. This is often self-limiting. Patients complain of pain and redness of the eye. [8]
Foreign body [1] Presence of foreign bodies in the eye should be suspected especially in children presenting with pain and redness of an eye.
Keratitis [1] Keratitis can be caused by fungal or bacterial infection. Presence of cells in the anterior chamber and hypopyon. are indicative of keratitis. [9,10,11]
Scleritis [1] Scleritis refers to the inflammation of the sclera. This can be either infectious or secondary to trauma. [7,8]
Subconjunctival hemorrhage [1] Subconjunctival hemorrhage causes extravasation of blood in to the tissue plane underneath the conjunctiva. Sudden and severe sneezing or coughing and hypertension can be etiological factors.
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 22 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. AGRAWAL RV, MURTHY S, SANGWAN V, BISWAS J. Current approach in diagnosis and management of anterior uveitis Indian J Ophthalmol [online] 2010, 58(1):11-19 [viewed 22 August 2014] Available from: doi:10.4103/0301-4738.58468
  3. ASANO-KATO N, FUKAGAWA K, TAKANO Y, KAWAKITA T, TSUBOTA K, FUJISHIMA H, TAKAHASHI S. Treatment of atopic blepharitis by controlling eyelid skin water retention ability with ceramide gel application Br J Ophthalmol [online] 2003 Mar, 87(3):362-363 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771555
  4. BEZDETKO PA, SERGIENKO N, DYOMIN Y, KOROL A, NIKITIN N, MERZBACHER M, GROß D, KOHNEN R. Successful treatment of blepharitis with bibrocathol (Posiformin® 2 %) Graefes Arch Clin Exp Ophthalmol [online] 2012 Dec, 250(12):1869-1875 [viewed 22 August 2014] Available from: doi:10.1007/s00417-012-2001-0
  5. VIJMASI T, CHEN FY, CHEN YT, GALLUP M, MCNAMARA N. Topical administration of interleukin-1 receptor antagonist as a therapy for aqueous-deficient dry eye in autoimmune disease. Mol Vis [online] 2013:1957-65 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24068863
  6. ACHTSIDIS VASILIS, TENTOLOURIS NICHOLAS, THEODOROPOULOU SOFIA, PANAGIOTIDIS DIMITRIS, VAIKOUSSIS EMMANUEL, SALDANA MANUEL, GOUWS PIETER, THEODOSSIADIS PANAGIOTIS G.. Dry eye in Graves ophthalmopathy: correlation with corneal hypoesthesia. EJO [online] December, 23(4):473-479 [viewed 22 August 2014] Available from: doi:10.5301/ejo.5000259
  7. PRADHAN ZS, JACOB P. Infectious scleritis: clinical spectrum and management outcomes in India. Indian J Ophthalmol [online] 2013 Oct, 61(10):590-3 [viewed 22 August 2014] Available from: doi:10.4103/0301-4738.121085
  8. WATSON PG, HAYREH SS. Scleritis and episcleritis. Br J Ophthalmol [online] 1976 Mar, 60(3):163-91 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1268179
  9. KAYE R., KAYE A., SUEKE H., NEAL T., WINSTANLEY C., HORSBURGH M., KAYE S.. Recurrent Bacterial Keratitis. Investigative Ophthalmology & Visual Science [online] December, 54(6):4136-4139 [viewed 22 August 2014] Available from: doi:10.1167/iovs.13-12130
  10. KALKAN AKçAY E, AçıKGöZ ZC, CAN ME, CELIKBILEK N, DERELI CAN G, CAğıL N. [Fungal keratitis caused by Scedosporium apiospermum: first report from Turkey]. Mikrobiyol Bul [online] 2013 Oct, 47(4):727-33 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24237443
  11. LAVINSKY F, AVNI-ZAUBERMAN N, BAREQUET IS. Clinical characteristics and outcomes of patients admitted with presumed microbial keratitis to a tertiary medical center in Israel. Arq Bras Oftalmol [online] 2013 May-Jun, 76(3):175-9 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23929079

Investigations - for Diagnosis

Fact Explanation
Culture Although culture is not a must infectious organism can be isolated form the cultures. Neisseria gonorrhoeae and Chlamydia trachomatis are common organisms causing neonatal conjunctivitis. Staphylococcus aureus, Haemophilus influenzae, and Streptococcus pneumoniae less commonly isolated organisms which can cause neonatal conjunctivitis. The first two organisms however common to cause conjunctivitis in children and less commonly Moraxella species, S aureus, and coagulase-negative staphylococci can also be the etiological factor for bacterial conjunctivitis in children. H influenzae and S aureus cause conjunctivitis in adults. S pneumoniae, coagulase-negative staphylococci, and Moraxella and Acinetobacter species are less commonly isolated from adults, [1,2]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 22 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. HøVDING GUNNAR. Acute bacterial conjunctivitis. [online] 2008 June, 86(1):5-17 [viewed 22 August 2014] Available from: doi:10.1111/j.1600-0420.2007.01006.x

Management - General Measures

Fact Explanation
Health education Patients with conjunctivitis should keep their eyes clean with minimal touching. Infected persons should use a handkerchief and should wash their hands before touching the eyes. Patients who had gonococcal or chlamydial conjunctivitis should be educated about the barrier methods of contraception and their sexual partners should be traced and treated as well. Patients should refrain form using contact lenses until the infection settles. Disposable lenses should replaced with new ones. They should adhere to proper cleaning of the lenses as recommended. Patients should seek the help of an ophthalmologist if there is no improvement after 24 hours of antibiotic treatment. [12,]
Lubricating eye drops Although not always necessary these may be helpful to fasten the recovery. [1,2]
Washing Infected eyes should be washed with sterile saline water. [1,2]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 22 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. HøVDING GUNNAR. Acute bacterial conjunctivitis. [online] 2008 June, 86(1):5-17 [viewed 22 August 2014] Available from: doi:10.1111/j.1600-0420.2007.01006.x

Management - Specific Treatments

Fact Explanation
Conservative management Most of the patients with bacterial conjunctivitis recover uneventfully. [1]
Antibiotics Most of the infective organisms causing conjunctivitis can be treated with topical antibiotics however gonococcal and chlamydial conjunctivitis need systemic antibiotics for the treatment. Single dose of intramuscular ceftriaxone is indicated for the treatment of gonococcal conjunctivitis. Neonatal chalamydial conjunctivitis is treated with oral erythromycin for 14 days. Single dose of azithromycin (1 g) is recommended for the treatment of chlamydial conjunctivitis in adults. [1,2]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 22 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. SHEIKH A, HURWITZ B. Topical antibiotics for acute bacterial conjunctivitis: a systematic review. Br J Gen Pract [online] 2001 Jun, 51(467):473-477 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314030