Bacterial Conjunctivitis
Subjective
A 56-year-old male presents with both eyes red and mattering.
Yesterday his eyes felt different and he woke up with the
lids of both eyes stuck together and had to take a warm
washcloth to get his eyes opened.
Objective
- VA: OU 6/7.5 (20/25)
- No preauricular lymphadenopathy
- Gross observation: shows moderate mucopurulent discharge
in the inferior fornix of each eye (Fig 1)
- Bulbar conjunctiva: grade 1 hyperemia OU, more pronounced
toward the fornices and less so near the limbus
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Fig. 1 This is a classic
expression of acute bacterial conjunctivitis
with mucopurulent discharge. Epidemiologically,
this is a relatively rare presentation in
adults .
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Assessment
- Bilateral bacterial conjunctivitis
Plan
- Tobramycin 1 gt. q.i.d. OU x 5 days
- Follow-up if not better in 4 to 5 days
Comments: Most topical antibiotic drops or ointments
would work here. Ointments generally are not very patient friendly,
leaving them a poor choice. Sodium sulfacetamide is contraindicated,
because it is inactivated by constituents within the mucopurulent
discharge. Trimethoprim with polymyxin B (Polytrim) is not
a good choice if a hyperacute mucopurulent discharge is present
because gonococcal bacteria has to be suspected. Also, trimethoprim
is bacteriostatic, not bactericidal. If the infection is ever
hyperacute (gonococcal or other highly pathogenic organism),
then a topical fluoroquinolone would be more appropriate along
with I.M. ceftriaxone (Rocephin).
If the bacterial conjunctivitis has been active for several
days, more secondary inflammation will be seen. In these cases
do not hesitate to use a combination antibiotic/steroid such
as dexamethasone/tobramycin (Tobradex) to treat the bacterial
conjunctivitis. This simultaneously treats both the infection
and the inflammation. When there is clinically significant
superficial punctate keratitis, stay away from the aminoglycosides
(tobramycin and gentamicin) because they tend to be more toxic
to the ocular surface. A better choice in these cases would
be trimethoprim/polymyxin or one of the fluoroquinolones.
General Observations
- Unilateral or bilateral red eye(s) with purulent or mucopurulent
discharge of varying degree.
- In subtle cases, carefully examine the lacrimal lake under
high magnification and look for micro-particulant debris
which can be evidence of bacterial infection
(Fig. 2)
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Fig. 2 In
early or mild expressions of bacterial infection,
there is no obvious mucopurulent discharge. However,
with high magnification in a darkened room, careful
examination of the lacrimal lake can reveal significant
micro-particulant debris in what is normally
an optically clear tear lake.
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- Preauricular lymphadenopathy is uncommon, but can be present
in hyperacute cases
- There can be some chemosis, depending upon the severity
of the infection
- Can occasionally have some superficial punctate keratitis,
especially if staphylococcal etiology. This is usually the
result of staphylococcal exotoxin chemotoxicity, and tends
to be seen mostly inferonasally because of tear film dynamics
- Concomitant staphyloccocal blepharitis can be causative
and, if not adequately treated, can lead to recurrences
- Common etiology — Adults: Staphylococcus aureus, Staphylococcus
epidermidis, Streptoccocus pneumoniae;
Children: Streptococcus pneumoniae, Haemophilus influenzae
- Therapy - Adults: polymyxin B/ trimethoprim, tobramycin,
or a fluoroquinolone; Children: trimethoprim/polymyxin B
solution or an ointment containing bacitracin and polymyxin
B (Polysporin)
- Treat for five to seven days as a rule
- The medical literature is starting to show that the fluoroquinolones
are developing a lot of resistance, particularly to staphylococcal
and pseudomonal species. As a result, it would be wise to
limit the use of the topical fluoroquinolones in treating " garden
variety" bacterial conjunctivitis.
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