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 month 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 –ve)
• secondary to viral conjunctivitis
• recent cold, upper respiratory tract infection [NB refer also to Clinical Management Guideline on Conjunctivitis (viral, nonherpetic)] 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 one or two 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 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 Herpes 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 re ferthe patient elsewhere
Non pharmacological Often resolves in 5-7 days without treatment
Bathe/clean the eyelids with proprietary sterile wipes, lint or cotton wool dipped in sterile saline or boiled (cooled) water to remove crusting

Advise patient that condition is contagious (do not share towels, etc.)
(GRADE*: Level of evidence = low, Strength of recommendation = strong)
Pharmacological Treatment with topical antibiotic may improve short-term outcome and render patient less infectious to others
(GRADE*: Level of evidence = high, Strength of recommendation = strong).
Alternatives include: chloramphenicol 0.5% eye drops, chloramphenicol 1% ointment, azithromycin 1.5% eye drops, fusidic acid 1% viscous eye drops (NB high cost and narrower spectrum of activity than chloramphenicol)
This recommendation is based on the conclusions of a Cochrane Review (Sheikh and Hurwitz 2012) which included trials conducted in primary and secondary care. However, an individual patient meta-analysis of studies exclusively based in primary care (Jefferis et al 2011) found only a marginal benefit of antibiotics over placebo. Patients with purulent discharge or a mild severity of red eye were found to benefit most from treatment with antibiotics
Contact lens wearers with a diagnosis of bacterial conjunctivitis should be treated with a topical antibiotic effective against Gram –ve organisms, e.g. a quinolone such as levofloxacin or moxifloxacin. Contact lenses should not be worn during the treatment period (GRADE*: Level of evidence = low, Strength of recommendation = strong).
Advise patient to return/seek further help if symptoms persist beyond 7 days
Management Category B3: Management to resolution
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

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