Examination of the eye

A. Visual acuity should be tested before the examination. Regional lymphadenopathy should be sought and the face and eyelids examined. Viral or chlamydial inclusion conjunctivitis typically presents with a tender, preauricular or submandibular lymph node. Palpable adenopathy is rare in acute bacterial conjunctivitis. Herpes labialis or a dermatomal vesicular eruption (suggestive of shingles) is indicative of a herpetic conjunctivitis. B. Purulent discharge suggests a bacterial infection. Stringy mucoid discharge suggests allergy. Clear watery discharge suggests viral infection.

Discharge Associated with Conjunctivitis

Serous

Mucoid

Mucopuru

Purulent

Etiology

lent

Viral

+

-

-

-

Bacterial

-

-

+

+

Allergic

+

+

-

-

Chlamydial

-

+

+

-

III. Cultures and Gram stain usually are not required in patients with mild conjunctivitis of suspected viral, bacterial or allergic origin. However, bacterial cultures should be obtained in patients who have severe conjunctivitis.

IV. Treatment of bacterial conjunctivitis

A. Acute bacterial conjunctivitis typically presents with burning, irritation, tearing and a mucopurulent or purulent discharge. The three most common pathogens in bacterial conjunctivitis are Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus.

B. Topical broad-spectrum antibiotics such as erythromycin ointment and bacitracin-polymyxin B ointment as well as combination solutions such as trimethoprim-polymyxin B provide excellent coverage for most conjunctival pathogens. Ointments are better tolerated by young children. Solutions are preferred by adults.

1. Erythromycin ophthalmic ointment, apply to affected eye(s) q3-4h.

2. Bacitracin-polymyxin B (Polysporin) ophthalmic ointment or solution, apply to affected eye(s) q3-4h.

3. Trimethoprim-polymyxin B (Polytrim), ointment or solution, apply to affected eye(s) q3-4h.

C. Conjunctivitis due to H. influenzae, N. gonorrhoeae, and N. meningitidis requires systemic antibiotic therapy in addition to topical treatment. Gonococcal conjunctivitis may be treated with ceftriaxone (Rocephin) 1 g IM and topical erythromycin.

D. Chlamydial conjunctivitis can be present in newborns, in sexually active teenagers and in adults. Diagnosis is by antibody staining of ocular samples. Treatment includes oral tetracycline, doxycycline (Vibramycin) or erythromycin for two weeks.

V. Viral conjunctivitis

A. Adenovirus is the most common cause of viral conjunctivitis. Viral conjunctivitis often occurs in epidemics, typically presenting with an acutely red eye, watery discharge, conjunctival swelling, a tender preauricular node, photophobia and a foreign-body sensation. Some patients have an associated upper respiratory tract infection.

B. Treatment consists of cold compresses and topical vasoconstrictors (Vasocon-A, Naphcon-A). Patients should avoid direct contact with other persons for at least one week after the onset of symptoms.

C. Ocular herpes simplex and herpes zoster is managed with topical agents, including trifluridine (Viroptic) and systemic acyclovir, famciclovir or valacyclovir.

References: See page 195.

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