Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Bacterial Conjunctivitis Workup

  • Author: Karen K Yeung, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Dec 04, 2015
 

Approach Considerations

A medical and detailed ocular history includes questions about the onset and duration of the red eye, the quality and quantity of discharge, presence or absence of pain, photophobia, trauma, blurry vision, foreign body sensation, ocular itch, contact lens use, and history of previous ocular infections. An eye evaluation should be performed with particular attention to reductions in best corrected vision in either eye, gross evaluation of lid margins and both bulbar and tarsal conjunctivae (presence or absence of a ciliary flush), any ocular discharge, pupillary reactions, any pain with eye movements, slit lamp biomicroscope evaluation of the cornea (with adjunctive fluorescein stain), intra-ocular pressures, and anterior chamber flare or cell. If only one eye has bacterial conjunctivitis, examine the unaffected eye first to prevent cross-infection.

Traditional teaching suggests that significant eye pain, loss of vision, and photophobia are indications of serious eye disease. Anisocoria and ocular pain during pupillary constriction (even during a pencil push-up test) can also indicate serious eye diseases.[5] However, note that the absence of photophobia and anisocoria does not rule out the possibility of such serious diseases. Conversely, complete redness of the conjunctiva obscuring the tarsal vessels, purulent discharge, matting of both eyes in the morning, and onset during winter or spring all increase the probability of bacterial conjunctivitis.[5] If the patient has symptoms of itchy eyes and recurrent conjunctivitis, bacterial conjunctivitis is unlikely.[20]

Conjunctival scrapings and cultures are frequently obtained in severe bacterial conjunctivitis, especially when the central corneal is affected or the corneal ulcer is 2 mm or larger or when antibacterial therapy is ineffective. Gram staining and cultures should be grown in blood agar, chocolate agar, Sabouraud dextrose agar, and thioglycollate broth.

Imaging studies do not play a significant role in the workup of bacterial conjunctivitis unless an underlying condition is suspected. For example, 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.

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.

Next

Conjunctival Scrapings and Cultures

Conjunctival scrapings can be performed with topical anesthetic and gentle use of a platinum spatula or similar blunt metallic object. This should precede antibiotic therapy. Gram stain is useful to identify bacterial characteristics. Giemsa stain is helpful to screen for intracellular inclusion bodies of Chlamydia.

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.

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.

Previous
 
 
Contributor Information and Disclosures
Author

Karen K Yeung, OD, FAAO Senior Optometrist, Arthur Ashe Student Health and Wellness Center, University of California, Los Angeles

Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry

Disclosure: Nothing to disclose.

Coauthor(s)

Barry A Weissman, OD, PhD, FAAO Professor of Optometry, Southern California College of Optometry; Professor Emeritus of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, International Society for Contact Lens Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Maria Elena De Shazer University of California at Los Angeles

Disclosure: Nothing to disclose.

Acknowledgements

Jerre Freeman, MD Founder, Chairman, Memphis Eye and Cataract Associates; Clinical Professor, Department of Ophthalmology, University of Tennessee Health Science Center College of Medicine

Jerre Freeman, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

References
  1. Shields T, Sloane PD. A comparison of eye problems in primary care and ophthalmology practices. Fam Med. 1991 Sep-Oct. 23 (7):544-6. [Medline].

  2. Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for adenoviral conjunctivitis. Am J Med Sci. 2008 Sep. 336 (3):254-64. [Medline].

  3. van Weert HC, Tellegen E, Ter Riet G. A new diagnostic index for bacterial conjunctivitis in primary care. A re-derivation study. Eur J Gen Pract. 2014 Sep. 20 (3):202-8. [Medline].

  4. Smith AF, Waycaster C. Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States. BMC Ophthalmol. 2009 Nov 25. 9:13. [Medline].

  5. Narayana S, McGee S. Bedside Diagnosis of the 'Red Eye': A Systematic Review. Am J Med. 2015 Nov. 128 (11):1220-1224.e1. [Medline].

  6. Jefferis J, Perera R, Everitt H, van Weert H, Rietveld R, Glasziou P, et al. Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Br J Gen Pract. 2011 Sep. 61 (590):e542-8. [Medline].

  7. Rietveld RP, ter Riet G, Bindels PJ, Schellevis FG, van Weert HC. Do general practitioners adhere to the guideline on infectious conjunctivitis? Results of the Second Dutch National Survey of General Practice. BMC Fam Pract. 2007 Sep 16. 8:54. [Medline].

  8. Isenberg SJ, Apt L, Valenton M, Del Signore M, Cubillan L, Labrador MA. A controlled trial of povidone-iodine to treat infectious conjunctivitis in children. Am J Ophthalmol. 2002 Nov. 134(5):681-8. [Medline].

  9. Jeng BH, Gritz DC, Kumar AB, Holsclaw DS, Porco TC, Smith SD, et al. Epidemiology of ulcerative keratitis in Northern California. Arch Ophthalmol. 2010 Aug. 128 (8):1022-8. [Medline].

  10. Høvding G. Acute bacterial conjunctivitis. Acta Ophthalmol. 2008 Feb. 86 (1):5-17. [Medline].

  11. Rapoza PA, Quinn TC, Kiessling LA, Taylor HR. Epidemiology of neonatal conjunctivitis. Ophthalmology. 1986 Apr. 93(4):456-61. [Medline].

  12. Bourne RR, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, et al. Causes of vision loss worldwide, 1990-2010: a systematic analysis. Lancet Glob Health. 2013 Dec. 1 (6):e339-49. [Medline].

  13. Laspina F, Samudio M, Cibils D, Ta CN, Fariña N, Sanabria R, et al. Epidemiological characteristics of microbiological results on patients with infectious corneal ulcers: a 13-year survey in Paraguay. Graefes Arch Clin Exp Ophthalmol. 2004 Mar. 242 (3):204-9. [Medline].

  14. Sirikul T, Prabriputaloong T, Smathivat A, Chuck RS, Vongthongsri A. Predisposing factors and etiologic diagnosis of ulcerative keratitis. Cornea. 2008 Apr. 27 (3):283-7. [Medline].

  15. Leck AK, Thomas PA, Hagan M, Kaliamurthy J, Ackuaku E, John M, et al. Aetiology of suppurative corneal ulcers in Ghana and south India, and epidemiology of fungal keratitis. Br J Ophthalmol. 2002 Nov. 86 (11):1211-5. [Medline].

  16. Lichtenstein SJ, Rinehart M, Levofloxacin Bacterial Conjunctivitis Study Group. Efficacy and safety of 0.5% levofloxacin ophthalmic solution for the treatment of bacterial conjunctivitis in pediatric patients. J AAPOS. 2003 Oct. 7 (5):317-24. [Medline].

  17. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD001211. [Medline].

  18. Ullman S, Roussel TJ, Culbertson WW, Forster RK, Alfonso E, Mendelsohn AD, et al. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. 1987 May. 94(5):525-31. [Medline].

  19. Schachter J, Lum L, Gooding CA, Ostler B. Pneumonitis following inclusion blennorrhea. J Pediatr. 1975 Nov. 87(5):779-80. [Medline].

  20. Rietveld RP, ter Riet G, Bindels PJ, Sloos JH, van Weert HC. Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms. BMJ. 2004 Jul 24. 329 (7459):206-10. [Medline].

  21. Borkar DS, Acharya NR, Leong C, Lalitha P, Srinivasan M, Oldenburg CE, et al. Cytotoxic clinical isolates of Pseudomonas aeruginosa identified during the Steroids for Corneal Ulcers Trial show elevated resistance to fluoroquinolones. BMC Ophthalmol. 2014 Apr 24. 14:54. [Medline].

  22. Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Lalitha P, O'Brien KS, et al. The steroids for corneal ulcers trial (SCUT): secondary 12-month clinical outcomes of a randomized controlled trial. Am J Ophthalmol. 2014 Feb. 157 (2):327-333.e3. [Medline].

  23. Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Lalitha P, Ray KJ, et al. Visual recovery in treated bacterial keratitis. Ophthalmology. 2014 Jun. 121 (6):1310-1. [Medline].

  24. 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. 1989 Mar 23. 320(12):769-72. [Medline].

  25. [Guideline] AAO Cornea/External Disease PPP Panel, Hoskins Center for Quality Eye Care. Conjunctivitis PPP. ONE Network. Available at http://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp--2013. 2013;

  26. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD001211. [Medline].

  27. O'Brien TP. Besifloxacin ophthalmic suspension, 0.6%: a novel topical fluoroquinolone for bacterial conjunctivitis. Adv Ther. 2012 Jun. 29(6):473-90. [Medline].

  28. Aoki R, Fukuda K, Ogawa M, Ikeno T, Kondo H, Tawara A, et al. Identification of Causative Pathogens in Eyes with Bacterial Conjunctivitis by Bacterial Cell Count and Microbiota Analysis. Ophthalmology. 2012 Dec 12. [Medline].

  29. Tabbara KF, Hyndiuk RA. Infections of the Eye. Boston, Mass: Little, Brown and Company; 1996.

  30. Deschênes J, Blondeau J. Besifloxacin in the management of bacterial infections of the ocular surface. Can J Ophthalmol. 2015 Jun. 50 (3):184-91. [Medline].

  31. Kitatani F, Fujimoto S, Asahi T, Konishiike J, Sera Y. [Clinical study on rifampicin applied every other day for severe cavitary pulmonary tuberculosis (author's transl)]. Kekkaku. 1974 May. 49 (5):133-8. [Medline].

  32. Deschênes J, Blondeau J. Besifloxacin in the management of bacterial infections of the ocular surface. Can J Ophthalmol. 2015 Jun. 50 (3):184-91. [Medline].

  33. Garnock-Jones KP. Azithromycin 1.5% ophthalmic solution: in purulent bacterial or trachomatous conjunctivitis. Drugs. 2012 Feb 12. 72 (3):361-73. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.