AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Bacterial conjunctivitis is a microbial infection involving the mucous membrane of the surface of the eye. This condition, which is usually a benign self-limited illness, sometimes can be serious or signify a severe underlying systemic disease. Occasionally, significant ocular and systemic morbidity may result.

The purpose of this article is to help the practitioner recognize the character and significance of the condition, to avoid pitfalls in diagnosis, and to convey appropriate treatment modalities.

Pathophysiology

The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as streptococci, staphylococci, and Corynebacterium strains. Alterations in the host defense or in the species of bacteria can lead to clinical infection. An alteration in the flora can occur by external contamination, by spread from adjacent sites, or via a blood-borne pathway.

The primary defense against infection is the epithelial layer covering the conjunctiva. Disruption of this barrier can lead to infection. Secondary defenses include hematologic immune mechanisms carried by the conjunctival vasculature; tear film immunoglobulins and lysozyme; and the rinsing action of lacrimation and blinking.

Frequency

United States

Bacterial conjunctivitis is a common condition in all areas of the United States. It is likely that most people will experience an episode. Most of the benign cases probably are treated by primary physicians or resolve spontaneously.

International

Bacterial conjunctivitis is common worldwide. Community sequelae can be devastating in areas affected by blinding infections of newborns as well as in areas heavily affected by Chlamydia trachomatis.

Mortality/Morbidity

Mortality in the setting of bacterial conjunctivitis is related to the failure to recognize and treat the underlying disease. Sepsis and meningitis caused by Neisseria gonorrhoeae can be life threatening. Chlamydial infection in the newborn can lead to pneumonia and/or otitis media. Morbidity in terms of discomfort, ocular discharge, and redness are common in benign cases and often lead to absence from work and school. Morbidity can be associated with misdiagnosis. Since many eye diseases cause the eye to be red, it is beneficial to have a solid approach to diagnosis.

Race

• Bacterial conjunctivitis occurs in all races.
• Differences in frequencies among races are likely to reflect geographical variations in the prevalence of pathogens.

Sex

• Probably, both sexes have an equal natural resistance to bacterial conjunctivitis.


• Differences in rates of infection probably reflect behavioral patterns, such as the exposure of female elementary school teachers to children affected by the condition.

Age

• Age is a relevant factor in the significance of bacterial conjunctivitis.


• The practitioner must be vigilant in considering sexually transmitted diseases caused by N gonorrhoeae and Chlamydia in sexually active age groups and in newborns who may have been exposed during birth. Tactful and confidential history taking are a necessary skill. It is important not to violate HIPPA Regulations during history taking and treatment. If a practitioner is mired in an ethical or medicolegal situation, it is a good idea to seek advice from administration and/or colleagues.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Eliciting a clinical history from the patient is influenced by such factors as age and social habits and may occasionally focus on sensitive issues that can be embarrassing to discuss.

• Most cases of bacterial conjunctivitis occur in otherwise healthy individuals. In these cases, the history should take the following factors into consideration:
• • Age is a consideration in determining whether the case may be related to defective host resistance of the elderly patient. If this is a consideration, it is appropriate to inquire about concomitant or recent increased susceptibility to other types of infections, for example, urinary tract or respiratory tract infections, which may hold clues as to the bacterial source.
  
  
  • Patients at a sexually active age should be considered for venereal diseases.
    
    
    • If the conjunctivitis is associated with copious purulence, severe injection, and chemosis, then a discussion of possible exposure to N gonorrhoeae must take place. Bacterial cultures, including Thayer-Martin and chocolate agar, and a Gram stain must be taken.
    
    
    • A history of sexual partners must be obtained if the cultures/stain verify this condition so that they also can be treated.
    
    
    • The practitioner must be aware that laws require reporting incidences of this disease to the appropriate Board of Health.
    
    
    • A similar history must be obtained when chlamydial conjunctivitis is suspected.
    
    
    • Clinical suspicion may be present at first presentation or upon treatment failure of an unsuspected case.
    
    
    • It is probably desirable to have the nurse or other office-related personnel take the sexual history to avoid a sense of inappropriateness.
    
    
    • It is better to ask the patient if friends or family members should leave the room for this aspect of the evaluation.
  
  
  • Duration of the disease and previous attempts at therapy should be documented.
  
  
  • It is usual for symptoms to be present for several days or weeks at the time of presentation. An uncommonly long duration or a frequent recurrence suggests that other factors or conditions may be present.
  
  
  • For instance, a molluscum lesion at the lid margin may be shedding virus into the eye. Chlamydial infection or viral keratoconjunctivitis may be present. A history of resistance to therapy may prompt the practitioner to obtain a culture.
  
  
  • History of recent exposure to other cases is helpful. An exposure to a case that healed uneventfully would be comforting, whereas exposure to someone with known epidemic keratoconjunctivitis or herpes simplex would raise concern.
  
  
  • A brief history to assess possible occupational exposure may be appropriate.
  
  
  • A brief history of systemic illness should be obtained to determine if a recent viral upper respiratory tract infection has occurred or if there are any major known systemic illnesses, such as AIDS or diabetes.
  
  
  • A medication history is important to document what already has been tried and to rule out medicamentosa or other drug causes for the condition.
  
  
  • Ocular redness and irritation may occur due to an antibacterial eye drop solution or the preservatives in the solution.
  
  
  • Systemic chemotherapeutic agents can cause an irritative conjunctivitis.
  
  
  • A history of allergies to medications should be established for avoidance purposes and recorded in the medical record prominently since this is often the only medical encounter with an otherwise healthy individual.
  
  
  • Patients with typical bacterial conjunctivitis do not complain of photophobia. Sensitivity to light is a symptom of intraocular inflammation as in iritis or corneal lesions, such as those found in viral keratitis.
  
  
  • A history of contact lens wear opens up an array of possibilities in the setting of a red eye. Corneal ulcers, which are infections within the stroma of the cornea, may occur with contact lens wear. Improper contact lens care and/or contaminated solutions can lead to corneal infections with bacteria, Acanthamoeba, or fungi. In early 2006, an outbreak of fungal infections with Fusarium species occurred due to a contact lens solution. In these cases, the infection involves the cornea and may be associated with a red eye.

Physical

The physical examination should evaluate the following signs:

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


• Using slit lamp biomicroscopy, the inflammation of the conjunctiva can be characterized as being follicular or papillary.
• • A follicular pattern has blood vessels circumferentially around the base of the tiny elevated lesions. This pattern is characteristic of a viral or chlamydial conjunctivitis.
  
  
  • A papillary pattern has vessels coming up the center of the tiny elevated lesion and is 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.


• In uncomplicated bacterial conjunctivitis, slit lamp examination reveals a quiet anterior chamber that is devoid of visible cells. 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, 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.

Causes

• Bacterial conjunctivitis occurs in otherwise healthy individuals.
• Risk factors include frequent exposure to infected individuals, sinusitis, immunodeficiency states, and exposure to agents of sexually transmitted disease at birth.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Nongranulomatous iritis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Conjunctival scrapings and cultures most often are used in laboratory studies.
• • Cultures can be completed for viral, chlamydial, and bacterial agents.
  • If testing for N gonorrhoeae, specific procedures should be followed to optimize the yield.
  • Fungal culture would be unusual, except in the setting of a corneal ulcer or in the case of known contamination of a contact lens solution such as occurred in early 2006.
  • Conjunctival scrapings can be performed with topical anesthetic and gentle use of a platinum spatula or similar blunt metallic object.
  • Gram stain is useful to identify bacterial characteristics.
  • Giemsa stain is helpful to screen for intracellular inclusion bodies of Chlamydia.
  • Additionally, the nature of the inflammatory reaction is reflected in the cellular response. Lymphocytes predominate in viral infections, neutrophils in bacterial infections, and eosinophils in allergic reactions.

Imaging Studies

• Imaging studies do not play a significant role in the workup of bacterial conjunctivitis unless an underlying condition, such as sinusitis, is suspected.
• • MRA, CT scan, and orbital color Doppler may play a role in a suspected cavernous sinus fistula.
  
  
  • Orbital CT scan may be indicated to rule out an orbital abscess or pansinusitis, when the conjunctivitis is part of an orbital cellulitis.

Procedures

• Certain procedures may address a known or suspected underlying cause for conjunctivitis or conditions that mimic it.
• • Removal of offending lashes with epilation forceps or by electrolysis may be indicated for trichiasis.
  • Nasolacrimal duct irrigation may be attempted to see if an obstruction that predisposes to infection is present. An obstruction should be suspected in chronic and intermittent purulent conjunctivitis.
  • Eversion of the eyelid at the slit lamp is indicated when a foreign body is suspected.

Histologic Findings

Gram and Giemsa stains in the presence of bacteria demonstrate the expected inflammatory cell response in the stroma. However, this consideration is only academic because the condition is not an indication for biopsy. Cultures and scrapings are usually diagnostic.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• The mainstay of medical treatment of bacterial conjunctivitis is topical antibiotic therapy.


• Systemic antibiotics are indicated for N gonorrhoeae and chlamydial infections.


• 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.
• • Sodium sulfacetamide, gentamicin, tobramycin, neomycin, trimethoprim and polymyxin B combination, ciprofloxacin, ofloxacin, gatifloxacin, and erythromycin are representatives of commonly used first-line agents.
  
  
  • 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.


• 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/day 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 per kg per day 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 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.

Surgical Care

• Surgical intervention is not required in the setting of bacterial conjunctivitis, except when indicated for the treatment of causative conditions, such as hordeolum, nasolacrimal duct obstruction, and sinusitis.

Consultations

• Consultations with infectious disease specialists and/or pediatricians may be indicated in suspected or proven chlamydial or N gonorrhoeae infections.
• An experienced ophthalmic pathologist can be an excellent resource in determining the cause of a resistant conjunctivitis by interpreting conjunctival scrapings.

Diet

• Dietary factors do not play a role in bacterial conjunctivitis, except in situations where a severe deficiency leads to an immunocompromised state.

Activity

• Activity precautions pertain to limiting the spread of the infection.
• • 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.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Many antibiotic eye preparations can be used as first-line therapy in bacterial conjunctivitis. The justification for treating this condition empirically with a broad-spectrum topical agent is that relatively high levels of the drug are delivered directly to the site of infection. This level of drug concentration exceeds what is normally achieved in body tissues by oral or parenteral routes. Therefore, the antibiotic spectrum of the individual drug is enhanced.

This list of medicines is limited to a few common choices. Many other agents are available. Combination antibiotic-steroid medications are not discussed in this article, as these medicines play a role in postoperative care and only are used with extreme care in the setting of bacterial conjunctivitis.

Drug Category: Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Most cases of routine bacterial conjunctivitis respond to the commercially available combination of antibiotics.

Although the aminoglycosides are used in other fields of medicine primarily to treat gram-negative bacteria, the spectrum of efficacy expands to include gram-positive bacteria when used topically for conjunctivitis.

Fluoroquinolones have gained popularity in ocular therapy due to their efficacy in the treatment of bacterial corneal ulcers. Fluoroquinolones have been used mostly as second-line agents in routine bacterial conjunctivitis.

Neonatal chlamydial infection is treated with oral erythromycin.

Doxycycline is used to treat the mother of a neonate with chlamydial infection as well as her at-risk contacts.

Intravenous penicillin G is used for neonatal gonorrhea infections.

Third-generation cephalosporins are used in the treatment of adult gonorrhea infections.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care for bacterial conjunctivitis would be provided only in the setting of hospitalization for other reasons. It is important to realize that, in the inpatient setting, the differential diagnosis must be carefully considered since the patients tend to be ill. Therefore, it is more common to see a red eye due to endogenous endophthalmitis or an infected corneal ulcer in this population.
• Serious consideration should be given to admitting patients with hyperacute bacterial conjunctivitis if the entire cornea cannot be visualized, as there may be an early corneal ulceration, especially in Neisseria infections. Topical antibiotic, proper hygiene, and isolation are considerations for these patients.

Deterrence/Prevention

• Hygiene and avoidance of close contact accomplish deterrence of bacterial conjunctivitis with infected individuals.

Complications

• Bacterial conjunctivitis seldom leads to complications. General concerns include membrane formation and subsequent scarring of the punctum; corneal ulcer when the epithelium is not intact; and symblepharon from severe inflammation.
• In eyes with previous intraocular surgery, particularly with filtering blebs, endophthalmitis could result.

Prognosis

• The prognosis for complete recovery without sequelae is excellent in bacterial conjunctivitis.


• Only cases with extremely pathogenic bacteria, such as Chlamydia trachomatis or N gonorrhoeae, are expected to develop complications.

Patient Education

• Patients and household members should be educated to pay attention to hygiene and the avoidance of close contact with the infected individual.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Medicolegal concerns do arise in connection with bacterial conjunctivitis. As with all medical practice, careful discussion and documentation is paramount. A few general guidelines are helpful.
• • Know the differential diagnosis.
  
  
  • Perform an eye examination and, in particular, document that iritis and acute glaucoma have been ruled out.
  
  
  • The physician should be aware of more unusual conditions, such as carotid-cavernous fistula.
  
  
  • Always consider Chlamydia or N gonorrhoeae in the differential diagnosis. Be sure to treat systemically and ask for advice from other specialists when needed.
  
  
  • Instruct patients to report to the clinic if they do not recover completely in a timely manner, so that therapy can be reassessed.
  
  
  • Consider culture and conjunctival scrapings for resistant cases.
  
  
  • Be aware of drug alerts, such as the one in early 2006 related to a contaminated commercial contact lens solution.

Special Concerns

• Of special concern is the care of ophthalmia neonatorum. The practitioner should make sure that appropriate prophylaxis is administered and that suspected cases are managed properly. 


• Also of special concern is trachoma, a devastating disease. See Trachoma.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Hammerschlag MR, Cummings C, Roblin PM, Williams TH, Delke I. Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis. N Engl J Med. Mar 23 1989;320(12):769-72. [Medline].
• Rapoza PA, Quinn TC, Kiessling LA, Taylor HR. Epidemiology of neonatal conjunctivitis. Ophthalmology. Apr 1986;93(4):456-61. [Medline].
• Schachter J, Lum L, Gooding CA, Ostler B. Pneumonitis following inclusion blennorrhea. J Pediatr. Nov 1975;87(5):779-80. [Medline].
• Tabbara KF, Hyndiuk RA. Infections of the Eye. Little, Brown and Company; 1996.
• Ullman S, Roussel TJ, Culbertson WW, Forster RK, Alfonso E, Mendelsohn AD, et al. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. May 1987;94(5):525-31. [Medline].

Article Last Updated: May 10, 2007