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06-06-2012, 02:47 PM

Conjunctival injection may be present segmentally or diffusely. The palpebral conjunctival pattern may hold clues to the etiology.

Using slit-lamp biomicroscopy and everting both the upper and lower eyelids, follicles or papillae can be identified on the inflamed conjunctiva. Follicules have blood vessels that circumscribe the base of tiny elevated lesions. Follicules are characteristic of a viral or chlamydial conjunctivitis. Papillae have vessels coming up the center of the tiny elevated lesion and are characteristic of bacterial or allergic conjunctivitis.

The discharge in bacterial conjunctivitis is typically more purulent than the watery discharge of viral conjunctivitis. Thus, there is more "mattering" of the lid margins and associated difficulty in prying the lids open following sleep. The mucopurulent discharge can appear white, yellow, or even greenish in color.

In uncomplicated bacterial conjunctivitis, slit lamp examination reveals a quiet anterior chamber that is devoid of cells and flare. The vitreous is also unaffected.

A preauricular lymph node is unusual in bacterial conjunctivitis but is found in severe conjunctivitis caused by N gonorrhoeae. It is associated with viral ocular syndromes, typically herpes simplex keratitis and epidemic keratoconjunctivitis.

Eyelid edema is often present, but it is mild in most cases of bacterial conjunctivitis. Severe lid edema in the presence of copious purulent discharge raises the suspicion N gonorrhoeae infection.

Visual acuity is preserved in bacterial conjunctivitis as long as the cornea is intact, except for the expected mild blur secondary to the discharge and debris in the tear film.

The pupil reacts normally in bacterial conjunctivitis. A fixed pupil in the setting of a red eye should raise the suspicion for angle-closure glaucoma or iritis with posterior synechiae.

Dilation and tortuosity of the major vessel injection suggests a cavernous sinus-carotid artery fistula rather than conjunctivitis.


Topical Antibiotic Therapy
Practice patterns for prescribing topical antibiotics vary. Most practitioners prescribe a broad-spectrum agent on an empirical basis without culture for a routine, mild-to-moderate case of bacterial conjunctivitis. Always be aware of the differential diagnosis, and instruct patients to seek follow-up care if the expected improvement does not occur or if vision becomes affected.

Commonly used first-line topical agents include the following:

Trimethoprim with polymixin B
Topical antibiotics can be administered in the form of eye drops or ointments. Eye drops have the advantage of not interfering with vision. Ointments have the advantage of prolonged contact with the ocular surface and an accompanying soothing effect.

Neonatal Chlamydial and Gonococcal Infection
Chlamydial infection of the newborn requires systemic treatment of the neonate, the mother, and at-risk contacts. The neonate may be treated with erythromycin orally in liquid form 50 mg/kg/d in 4 divided doses for 2 weeks. The mother and at-risk contacts may be treated with doxycycline 100 mg orally twice daily for 7 days.

N gonorrhoeae infection of the newborn also requires systemic treatment of the neonate, the mother, and at-risk contacts. The neonate may be treated with intravenous aqueous penicillin G 100 units/kg/d in 4 divided doses for 1 week. The mother and at-risk contacts may be treated with a single dose of intramuscular ceftriaxone 125 mg followed by oral doxycycline 100 mg twice daily for 7 days.

Prophylaxis against ophthalmia neonatorum
Prophylaxis against ophthalmia neonatorum is a major force in the worldwide effort to prevent blindness. Common regimens are the instillation of 1% silver nitrate solution, 1% tetracycline ointment, or 0.5% erythromycin ointment.

Prevention of Bacterial Conjunctivitis
Hygiene and avoidance of close contact accomplish deterrence of bacterial conjunctivitis with infected individuals. Patients and household members should be educated to pay attention to hygiene and the avoidance of close contact with the infected individual. It is customary to advise the infected individual to avoid sharing towels and linens.

A patient with bacterial conjunctivitis should wash hands often and avoid contaminating public swimming pools. Workers and students often are excused during the first several days of treatment to decrease the possibility of spread.