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Conjunctivitis (bacterial)—clinical management guidelines

Aetiology

  • Bacterial infection of the conjunctiva, typically by:
    • Staphylococcus species
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Moraxella catarrhalis

Predisposing factors

  • Children and the elderly have an increased risk of infective conjunctivitis (NB bacterial conjunctivitis in the first 28 days of life is a serious condition that must be referred urgently to the ophthalmologist.See Clinical Management Guideline on Ophthalmia Neonatorum )
  • Contamination of the conjunctival surface
  • Superficial trauma
  • Contact lens wear (NB infection may be Gram-negative)
  • Secondary to viral conjunctivitis
  • Recent cold, upper respiratory tract infection (NB refer also to Clinical Management Guideline on Conjunctivitis (viral, non-herpetic) or sinusitis)
  • Diabetes (or other disease compromising the immune system)
  • Steroids (systemic or topical, compromising ocular resistance to infection)
  • Blepharitis (or other chronic ocular inflammation)

Symptoms

  • Acute onset of:
    • redness
    • discomfort, usually described as burning or grittiness
    • discharge (may cause temporary blurring of vision)
    • crusting of lids (often stuck together after sleep and may have to be bathed open)
  • Usually bilateral—one eye may be affected before the other (by 1 or 2 days)

Signs

  • Lid crusting
  • Purulent or mucopurulent discharge
  • Conjunctival hyperaemia—maximal in fornices
  • Tarsal conjunctiva may show mild papillary reaction
  • Cornea: usually no involvement (occasionally superficial punctate keratitis (SPK)—mainly in lower third of cornea). If cornea significantly involved, consider possibility of gonococcal infection
  • Pre-auricular lymphadenopathy: usually absent

Differential diagnosis

  • Other forms of conjunctivitis:
    • epidemic keratoconjunctivitis (e.g. adenovirus)
    • herpes (simplex or zoster)
    • chlamydial infection
    • allergy
  • Other causes of acute red eye:
    • angle closure glaucoma
    • infective keratitis
    • anterior uveitis

Management by optometrist

  • Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

  • Often resolves in 5–7 days without treatment
  • Bathe/clean the eyelids with lint or cotton wool dipped in sterile saline or boiled (cooled) water to remove crusting
  • Advise patient that condition is contagious (e.g. do not share towels)

Pharmacological

  • Treatment with topical antibiotic may improve short-term outcome and render patient less infectious to others
  • Chloramphenicol 0.5% drops 2-hourly for 2 days, then four-times daily for 5 days
  • Chloramphenicol 1% ointment four-times daily for 2 days, then twice-daily for 5 days
  • Fusidic acid 1% eye drops twice-daily for 7 days
  • Contact lens wearers with a diagnosis of bacterial conjunctivitis should be treated with a topical antibiotic effective against Gram-negative organisms, e.g. gutt ofloxacin 0.3% q.d.s. for up to 10 days. Contact lenses should not be worn during the treatment period
  • Advise patient to return/seek further help if symptoms persist beyond 7 days

Management Category

  • Refer if condition fails to resolve, or if there is corneal involvement

Possible management by ophthalmologist

  • If resistant to treatment, or recurrent:
    • conjunctival swabs taken for microscopy and culture and/or PCR analysis
    • treatment with other antibiotics, based on culture results

full guideline available from…
The College of Optometrists, 42 Craven Street, London, WC2N 5NG
www.college-optometrists.org/en/utilities/document-summary.cfm/docid/E06259F6-CD07-4A31-B0919C06113CAACD

The College of Optometrists. Conjunctivitis (bacterial)—clinical management guidelines
First included: March 2016.