Immediate Questions

A. How old is patient? Age of child is important in determining the etiology of conjunctivitis. In newborns, typical cause is chemical, chlamydial, or bacterial (including gonococcal). Chemical conjunctivitis is related to irritation from eye drops (silver nitrate) administered at birth. Gonococcal and chlamydial conjunctivitis are infections acquired by passage through the birth canal of an infected mother. In older children, bacteria, viruses, and allergies are more likely causes. Large outbreaks may occur in day-care settings or schools. Bacterial etiologies include Haemophilus influenzae (most common bacterial cause), Streptococcus pneumoniae, Moraxella catarrhalis, staphylococci, and Pseudomonas. Viruses include adenovirus (most common viral cause), enteroviruses (coxsackievirus), herpes simplex virus (HSV), Epstein-Barr virus, rubeola, rubella, and mumps. Allergic conjunctivitis is typically seasonal (pollen) and may also be caused by mold, fungus, dust, and food.

B. When did symptoms appear? Time of onset is especially important in the neonatal period. With chemical conjunctivitis, inflammation begins a few hours after drops have been placed and usually lasts 24-36 hours. Gonococcal conjunctivitis develops between 2 and 5 days of life (later if prophylaxis was given). Chlamydial conjunctivitis occurs between 5 and 23 days of life.

C. Is discharge unilateral or bilateral? Although this finding is not useful to differentiate among viral and bacterial causes (one or both eyes involved), occasionally it can help in distinguishing an allergic cause (typically bilateral).

D. Characteristics of discharge? Viral conjunctivitis typically causes watery or serous discharge. Bacteria cause purulent or mucopurulent discharges. Allergies produce serous or mucoid discharge, often very stringy.

E. Associated symptoms? Viral conjunctivitis is often associated with upper respiratory symptoms or other systemic complaints (pharyngitis and conjunctivitis with adenovirus). Preauricular adenopathy or rashes may be present. With vesicles or corneal ulcerations, HSV must be ruled out. Bacterial conjunctivitis may have associated infections (eg, ipsilateral otitis media with conjunctivitis suggests H influenzae). Allergic conjunctivitis is associated with intensely itchy eyes, runny nose, and sneezing. Pain with movement of the eye is never normal; orbital cellulitis must be ruled out (see III, G, later).

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