There has occurred a relative decrease in the
incidence of bacterial conjunctivitis in general and
those caused by gonococcus and corynebacterium
diphtheriae in particular. However, in developing
countries it still continues to be the commonest type
of conjunctivitis. It can occur as sporadic cases and
as epidemics. Outbreaks of bacterial conjunctivitis
epidemics are quite frequent during monsoon season.
A. Predisposing factors for bacterial conjunctivitis,
especially epidemic forms, are flies, poor hygienic
conditions, hot dry climate, poor sanitation and dirty
habits. These factors help the infection to establish,
as the disease is highly contagious.
B. Causative organisms. It may be caused by a wide
range of organisms in the following approximate order
of frequency :
Staphylococcus aureus is the most common cause
of bacterial conjunctivitis and blepharoconjunctivitis.
Staphylococcus epidermidis is an innocuous flora
of lid and conjunctiva. It can also produce
Streptococcus pneumoniae (pneumococcus)
produces acute conjunctivitis usually associated
with petechial subconjunctival haemorrhages. The
disease has a self-limiting course of 9-10 days.
Streptococcus pyogenes (haemolyticus) is virulent
and usually produces pseudomembranous
Haemophilus influenzae (aegyptius, Koch- Weeks
bacillus). It classically causes epidemics of
mucopurulent conjunctivitis, known as ‘red-eye’
especially in semitropical countries.
Moraxella lacunate (Moraxella Axenfeld bacillus)
is most common cause of angular conjunctivitis
and angular blepharoconjunctivitis.
Pseudomonas pyocyanea is a virulent organism.
It readily invades the cornea.
Neisseria gonorrhoeae typically produces acute
purulent conjunctivitis in adults and ophthalmia
neonatorum in new born. It is capable of invading
intact corneal epithelium.
Neisseria meningitidis (meningococcus) may
produce mucopurulent conjunctivitis.
Corynebacterium diphtheriae causes acute
membranous conjunctivitis. Such infections are
rare now-a-days.
C. Mode of infection. Conjunctiva may get infected
from three sources, viz, exogenous, local surrounding
structures and endogenous, by following modes :
1. Exogenous infections may spread: (i) directly
through close contact, as air-borne infections or
as water-borne infections; (ii) through vector
transmission (e.g., flies); or (iii) through material
transfer such as infected fingers of doctors,
nurses, common towels, handkerchiefs, and
infected tonometers.
2. Local spread may occur from neighbouring
structures such as infected lacrimal sac, lids, and
nasopharynx. In addition to these, a change in
the character of relatively innocuous organisms
present in the conjunctival sac itself may cause
3. Endogenous infections may occur very rarely
through blood e.g., gonococcal and meningococcal
Pathological changes of bacterial conjunctivitis
consist of :
1. Vascular response. It is characterised by
congestion and increased permeability of the
conjunctival vessels associated with proliferation
of capillaries.
2. Cellular response. It is in the form of exudation
of polymorphonuclear cells and other
inflammatory cells into the substantia propria of
conjunctiva as well as in the conjunctival sac.
3. Conjunctival tissue repsonse. Conjunctiva
becomes oedematous. The superficial epithelial
cells degenerate, become loose and even
56 Comprehensive OPHTHALMOLOGY
desquamate. There occurs proliferation of basal
layers of conjunctival epithelium and increase in
the number of mucin secreting goblet cells.
4. Conjunctival discharge. It consists of tears,
mucus, inflammatory cells, desquamated epithelial
cells, fibrin and bacteria. If the inflammation is
very severe, diapedesis of red blood cells may
occur and discharge may become blood stained.
Severity of pathological changes varies depending
upon the severity of inflammation and the causative
organism. The changes are thus more marked in
purulent conjunctivitis than mucopurulent

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