II. Pathophysiology
- Transmission typically via direct contact with contaminated items (esp. fingers)
- Infectious for first 48 hours of treatment
- Timing: Acute or chronic
- Gonorrhea Conjunctivitis presents with Hyperacute Bacterial Conjunctivitis
III. Causes
- Newborns (see Conjunctivitis in Newborns)
- Children
- Streptococcus Pneumoniae (*)
- HaemophilusInfluenzae (*)
- Staphylococcus species
- Moraxella species
- Adults
- Staphylococcus aureus (*)
- Staphylococcus epidermidis
- Streptococcus species
- Escherichia coli
- Pseudomonas species (especially with Contact Lens wear)
- Moraxella species
- Chlamydial Conjunctivitis
- Gonorrheal Conjunctivitis (NeisseriaGonorrhea)
IV. Symptoms
- Sudden onset
- Unilateral
- Progresses to other eye in 2-5 days
- Mucopurulent discharge
- Often watery discharge for the first 1-2 days prior to mucopurulent appearance
- Copious gray, yellow, or green discharge
- Consider Gonococcal Conjunctivitis (excessive pus)
- Matting of lashes and Eyelids in morning
- Significant irritation with stinging Sensation or foreign body Sensation
- Eyelid may appear puffy
V. Signs
- Variable Conjunctival injection
- Palpebral Conjunctiva is more affected than bulbar
- Lid edema
- No preauricular adenopathy
- No Corneal involvement
- Eyelid Edema
- Intact Visual Acuity
VI. Diagnosis
- Predictors of Bacterial Infection
- Copious Eye Discharge
- Eyes glued shut in morning
- Especially if both eyes glued shut (Odds Ratio: 15)
- Predictors of Viral Infection
- Itching eyes (if moderate to severe, likely Allergic Conjunctivitis)
- Prior episodes of Conjunctivitis
- Efficacy
- References
VII. Complications
- Deeper eye involvement may occur in severe cases
-
Blepharitis ("Granulated Eyelids")
- Seen in chronic Bacterial Conjunctivitis
- Colonization of lid margins by Staphylococcus aureus
- External Hordeolum (stye)
VIII. Course: Self-Limited
- Resolves in 2 weeks without treatment (65% improve within 2-5 days)
- Clears in 48-72 hours with treatment
- Serious complications are rare
IX. Lab: Eye Culture Indications
- Severe cases
- Immune compromised state
- Contact Lens use
- Newborns
- Failed initial treatment
X. Management
- Conditions requiring urgent ophthalmology referral
- Gonococcal Conjunctivitis
- Chronic or recurrent Conjunctivitis
- Conjunctivitis not improving after 7 days of treatment
- Protocol
- Consider observing without Antibiotic therapy if no risk factors and have good follow-up
- Spontaneous resolution without treatment in most uncomplicated cases (See course above)
- Consider prescribing Antibiotics, and patient starts if not improving within 3 days
- Factors suggesting starting immediate Antibiotics
- Healthcare workers (can not return to work until discharge ceases)
- Patients residing in health care facility or hospital
- Children attending daycare or school who cannot return until treatment started
- Immune compromised patient
- Uncontrolled Diabetes Mellitus
- Contact Lens use
- Dry Eyes
- Recent ophthalmic surgery
- Consider observing without Antibiotic therapy if no risk factors and have good follow-up
- Medications
- See Topical Eye Antibiotic
- Course
- Typically 7 days has been used
- Short duration of 3-5 days is probably sufficient
- General Approach with First Line Agents (for low risk patients and infections)
- Daytime Agents
- Trimethoprim-Polymyxin B (Polytrim) solution 1 drop four times daily
- Avoid Sulfacetamide (low efficacy)
- Avoid Neomycin (Allergic Reaction is common in more than 25% after only 3 days of use)
- Nighttime agent (consider as soothing overnight management)
- Erythromycin 0.5% ointment nightly (or every 6 hours as single agent) for 7 days
- Daytime Agents
- Ocular Fluoroquinolones for serious (e.g. Contact Lens use) or refractory Bacterial Conjunctivitis
- Ciprofloxacin (Ciloxan) 0.3% ointment 0.5 inch every 8 hours for 2 days, then every 12 hours for 5 days
- Ciprofloxacin (Ciloxan) 0.3% solution 1 drop every 2 hours for 2 days, then every 4 hours while awake for 5 days
- Ofloxacin (Ocuflox) 0.3% solution 1 drop every 2 hours for 2 days, then every 6 hours while awake for 5 days
- Levofloxacin (Quixin) 0.5% solution 1 drop every 2 hours for 2 days, then every 4 hours while awake for 5 days
- Moxifloxacin (Vigamox) 0.5% solution 1 drop every 8 hours for 7 days
- Aminoglycosides alternatives for serious or refractory Bacterial Conjunctivitis
- Gentamicin (Gentak) 0.3% ointment 0.5 inch every 6 hours for 7 days
- Gentamicin (Gentak) 0.3% solution 1 drop every 4 hours for 7 days
- Tobramycin (Tobrex) 0.3% solution (ointment is not generic and is expensive)
- Direct treatment if specific Bacterial eye infection suspected
XI. Resources (Include Patient Education)
XII. References
- Williams (2017) Crit Dec Emerg Med 31(2): 3-12
- Cronau (2010) Am Fam Physician 81(2): 137-44 [PubMed]
- Hovding (2008) Acta Ophthalmol 86(1): 5-17 [PubMed]
- Sheikh (2005) Br J Gen Pract 55(521): 962-4 [PubMed]
- Wikstrom (2008) Acta Ophthalmol 86(1): 2-4 [PubMed]
- Winters (2024) Am Fam Physician 110(2):134-44 [PubMed]