Beruflich Dokumente
Kultur Dokumente
Overview
Presentation
DDx
Workup
Treatment
Medication
Updated:Mar27,2014
PracticeEssentials
Background
Pathophysiology
Etiology
Epidemiology
Prognosis
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References
PracticeEssentials
Commoncausesofbacterialconjunctivitis,aninflammationofthebulbarand/orpalpebral
conjunctivas,includestaphylococci,streptococci,gonococci,andChlamydia.Complicationsare
expectedtodeveloponlyincasescausedbyextremelypathogenicbacteria,suchasCtrachomatisor
Neisseriagonorrhoeae.
Signsandsymptoms
Signsandsymptomsofbacterialconjunctivitisincludethefollowing:
Folliclesorpapillaeontheinflamedconjunctiva
Discharge:Morepurulentthaninviralconjunctivitis,withmorematteringoftheeyelid
marginsandgreaterassociateddifficultypryingtheeyelidsopenfollowingsleep
Enlargedpreauricularlymphnode:Unusualinbacterialconjunctivitisbutfoundinsevere
conjunctivitiscausedbyNgonorrhoeae
Eyelidedema:Oftenpresentinbacterialconjunctivitis,butmildinmostcases;severeeyelid
edemainthepresenceofcopiouspurulentdischargeraisesthesuspicionofNgonorrhoeae
infection
SeeClinicalPresentationformoredetail.
Diagnosis
Theuseofconjunctivalscrapingsinthediagnosisofbacterialconjunctivitiscanproceedasfollows:
Conjunctivalscrapingscanbeperformedwithtopicalanestheticandgentleuseofaplatinum
spatulaorsimilarbluntmetallicobject
Gramstainisusefulforidentifyingbacterialcharacteristics
GiemsastainishelpfulinscreeningforintracellularinclusionbodiesofChlamydia
Culturescanbecompletedforchlamydialandotherbacterialorganisms,aswellasforviralagents.
Fungalculturewouldbeunusualexceptinthesettingofacornealulcerorinthecaseofknown
contaminationofacontactlenssolution.Thecellularresponseinconjunctivitisdiffersaccordingtothe
cause,asfollows:
Bacterialinfections:Neutrophilspredominate
Viralinfections:Lymphocytespredominate
Allergicreactions:Eosinophilspredominate
SeeWorkupformoredetail.
Management
Themainstayoftreatmentforbacterialconjunctivitisistopicalantibiotictherapy,althoughsystemic
antibioticsareindicatedforNgonorrhoeaeandchlamydialinfections.Firstlineantibiotics
(administeredaseyedropsorointments)commonlyusedtotreatbacterialconjunctivitisincludethe
following:
TrimethoprimwithpolymixinB
Gentamicin
Tobramycin
Neomycin
Ciprofloxacin
Ofloxacin
Gatifloxacin
Erythromycin
Povidoneiodinesolution1.25%ophthalmicsolutionmaybeasafeandviablealternativetotopical
antibioticsfortreatingbacterialconjunctivitis,[1]especiallyinresourcepoorcountries,whereantibiotics
maybehardtocomebyand/orexpensive.
Background
Inflammationofthebulbarand/orpalpebralconjunctiva,orconjunctivitis,canbecausedbyallergies,
viruses,orbacteria.Bacterialconjunctivitisiscommonlycausedbystaphylococci,streptococci,
chlamydialorganism,andgonococci.Mildconjunctivitisisusuallybenignandselflimitedandcanbe
easilytreatedwithantibiotics.Severeconjunctivitis,suchasthatcausedbygonococci,cancause
blindnessandcansignifyasevereunderlyingsystemicdisease.
Thepurposeofthisarticleisto(1)helpthepractitionerrecognizethecharacteristicsandsignificance
ofthecondition,(2)avoidpitfallsindiagnosis,and(3)conveyappropriatetreatmentmodalities.
Conjunctivalscrapingsandculturesarecommonlyusedtoconfirmthemicrobeinsevereandbacterial
conjunctivitisandthatresistanttoantibiotictreatment(seeWorkup).Themainstayoftreatmentof
bacterialconjunctivitisistopicalantibiotictherapy.SystemicantibioticsareindicatedforNeisseria
gonorrhoeaeandchlamydialinfections.Surgicalinterventionisrequiredonlyifthecorneaisinvolved
andresultsincornealopacification(seeTreatment).
Seethefollowingformoreinformation:
AcuteHemorrhagicConjunctivitis
AllergicConjunctivitis
AtopicKeratoconjunctivitis
EmergentTreatmentofAcuteConjunctivitis
EpidemicKeratoconjunctivitis
GiantPapillaryConjunctivitis
KeratoconjunctivitisSicca
NeonatalConjunctivitis
SuperiorLimbicKeratoconjunctivitis
ViralConjunctivitis
Pathophysiology
Thesurfacetissuesoftheeyeandtheocularadnexaarecolonizedbynormalflorasuchasstreptococci,
staphylococci,andCorynebacteriumstrains.Alterationsinthehostdefenseorinthespeciesofbacteria
canleadtoclinicalinfection.Alterationinthefloracanoccurbyexternalcontamination(eg,contact
lenswear,swimming)orspreadfromadjacentinfectioussites(eg,rubbingoftheeyes).
Theprimarydefenseagainstinfectionistheepitheliallayercoveringtheconjunctiva.Disruptionofthis
barriercanleadtoinfection.Secondarydefensesincludehematologicimmunemechanismscarriedby
theconjunctivalvasculature;tearfilmimmunoglobulinsandlysozyme;andtherinsingactionof
lacrimationandblinking.
Etiology
Bacterialconjunctivitismostoftenoccursinotherwisehealthyindividuals.Riskfactorsinclude
frequentexposuretoinfectedindividuals,contactlenswear,sinusitis,immunodeficiencystates,and
exposuretoagentsofsexuallytransmitteddiseaseatbirth.
Epidemiology
Bacterialconjunctivitisiscommonworldwide.Mostbenigncasesaretreatedwithtopicalantibioticsor
canresolvespontaneously.[2]Internationally,isolatedepidemicscanbedevastatinginareasaffectedby
blindinginfectionsofnewborns,especiallyinareasheavilyaffectedbyChlamydiatrachomatis.[3]
Racialandsexualdifferencesinincidence
Bacterialconjunctivitisoccursinpersonsofallraces,althoughdifferencesinfrequenciesmaybe
reflectedbygeographicalvariationsofpathogenprevalence.
Malesandfemaleshaveequalnaturalresistancetobacterialconjunctivitis.Differencesininfection
ratesmayreflectenvironmentalandbehavioralpatterns,suchastheexposureoffemaleelementary
schoolteacherstochildrenaffectedbythecondition.
Agerelateddifferencesinincidence
Ageisarelevantfactorinthesignificanceofbacterialconjunctivitis.Thepractitionermustbevigilant
inconsideringsexuallytransmitteddiseasescausedbyNeisseriagonorrhoeaeandChlamydiain
sexuallyactiveagegroupsandinnewbornswhomayhavebeenexposedduringbirth.Tactfuland
confidentialhistorytakingareanecessaryskillsoasnottoviolatingHIPPAregulations.Inanethical
ormedicolegalsituation,obtainingadvicefromadministrationand/orcolleaguesisrecommended.
Prognosis
Theprognosisforcompleterecoverywithoutsequelaeisexcellentinbacterialconjunctivitis,aslongas
thecorneaisnotinvolved.Complicationsareexpectedtodeveloponlyincasescausedbyextremely
pathogenicbacteria,suchasChlamydiatrachomatisorNgonorrhoeae.
Mortalityinthesettingofbacterialconjunctivitisisrelatedtothefailuretorecognizeandtreatthe
underlyingdisease.SepsisandmeningitiscausedbyNgonorrhoeaecanbelifethreatening.[4]
Chlamydialinfectioninthenewborncanleadtopneumoniaand/orotitismedia. [5]
Signsandsymptomsofdiscomfort,mucopurulentoculardischarge,andconjunctivalrednessare
commoninbenigncasesandoftenleadtoabsencefromworkandschooltominimizeinfectionto
others.Morbiditycanbeassociatedwithmisdiagnosis.Sincemanyeyediseasescausetheeyetobe
red,itisbeneficialtohaveasolidapproachtodiagnosis.