Bacterial Conjunctivitis Clinical Presentation

The choice of questions to ask when eliciting a clinical history from the patient is influenced by such factors as age and social habits. It 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 below factors into consideration.

In the elderly patient, age is a consideration in determining whether the case may be related to defective host resistance. In such cases, 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 to the bacterial source.

Patients at a sexually active age should be considered for venereal diseases. Consider the following:

• If the conjunctivitis is associated with copious purulence, severe injection, and chemosis, then a discussion of possible exposure to Neisseria 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 may be desirable to have the nurse or other clinical personnel take the sexual history to avoid a sense of inappropriateness.
• It is better to ask the patient if they wish friends or family members to 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 whether the patient has recently experienced a viral upper respiratory tract infection or has any major known systemic illnesses, such as HIV disease 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.

The use of contact lens wear, especially extended-wear contact lens use and/or improper contact lens care, increases the risk of ocular infections, including those of bacterial conjunctivitis. When the cornea is involved, infections not properly treated can result in corneal scarring and permanent visual impairment.

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.

Bacterial conjunctivitis, as long as the cornea is not affected, 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.