CLINICAL TYPES OF BACTERIAL
CONJUNCTIVITIS
Depending upon the causative bacteria and the
severity of infection, bacterial conjunctivitis may
present in following clinical forms:
Acute catarrhal or mucopurulent conjunctivitis.
Acute purulent conjunctivitis
Acute membranous conjunctivitis
rialpseudomembranous conjunctivitis
Chronic bacterial conjunctivitis
Chronic angular conjunctivitis
ACUTE MUCOPURULENT CONJUNCTIVITIS
Acute mucopurulent conjunctivitis is the most
common type of acute bacterial conjunctivitis. It is
characterised by marked conjunctival hyperaemia and
mucopurulent discharge from the eye.
Common causative bacteria are: Staphylococcus
aureus, Koch-Weeks bacillus, Pneumococcus and
Streptococcus. Mucopurulent conjunctivitis
generally accompanies exanthemata such as measles
and scarlet fever.
Clinical picture
Symptoms
Discomfort and foreign body sensation due to
engorgement of vessels.
Mild photophobia, i.e., difficulty to tolerate light.
Mucopurulent discharge from the eyes.
Sticking together of lid margins with discharge
during sleep.
Slight blurring of vision due to mucous flakes in
front of cornea.
Sometimes patient may complain of coloured
halos due to prismatic effect of mucus present on
cornea.
Signs (Fig. 4.4)
Conjunctival congestion, which is more marked
in palpebral conjunctiva, fornices and peripheral
part of bulbar conjunctiva, giving the appearance
of ‘fiery red eye’. The congestion is typically less
marked in circumcorneal zone.
Chemosis i.e., swelling of conjunctiva.
Petechial haemorrhages are seen when the
causative organism is pneumococcus.
Flakes of mucopus are seen in the fornices,
canthi and lid margins.
Cilia are usually matted together with yellow
crusts.
Clinical course. Mucopurulent conjunctivitis
reaches its height in three to four days. If untreated,
in mild cases the infection may be overcome and the
condition is cured in 10-15 days; or it may pass to
less intense form, the ‘chronic catarrhal
conjunctivitis’.
Complications. Occasionally the disease may be
complicated by marginal corneal ulcer, superficial
keratitis, blepharitis or dacryocystitis.
Differential diagnosis
1. From other causes of acute red eye (see page
147).
2. From other types of conjunctivitis. It is made out
from the typical clinical picture of disease and is
confirmed by conjunctival cytology and
bacteriological examination of secretions and
scrapings (Table 4.1).
Fig. 4.4. Signs of acute mucopurulent conjunctivitis.
DISEASES OF THE CONJUNCTIVA 57
Table 4.1. Differentiating features of common types of conjunctivitis
Bacterial Viral Allergic Chlamydial (TRIC)
[A] CLINICAL SIGNS
1. Congestion Marked Moderate Mild to moderate Moderate
2. Chemosis ++ ± ++ ±
3. Subconjunctival ± ± – –
haemorrhages
4. Discharge Purulent or Watery Ropy/ Mucopurulent
mucopurulent watery
5. Papillae ± – ++ ±
6. Follicles – + – ++
7. Pseudomembrane ± ± – –
8. Pannus – – – (Except vernal) +
9. Pre-auricular + ++ – ±
lymph nodes
[B] CYTOLOGICAL FEATURES
1. Neutrophils + + (Early) – +
2. Eosinophils – – + –
3. Lymphocytes – + – +
4. Plasma cells – – – +
5. Multinuclear cells – + – –
6. Inclusion bodies :
Cytoplasmic – + (Pox) – +
Nuclear – + (Herpes) – –
7. Micro-organisms + – – –
advocated earlier) is however contraindicated as
it will wash away the lysozyme and other
protective proteins present in tears.
3. Dark goggles may be used to prevent photophobia.
4. No bandage should be applied in patients with
mucopurulent conjunctivitis. Exposure to air keeps
the temperature of conjunctival cul-de-sac low
which inhibits the bacterial growth; while after
bandaging, conjunctival sac is converted into an
incubator, and thus infection flares to a severe
degree within 24 hours. Further, bandaging of
eye will also prevent the escape of discharge.
5. No steroids should be applied, otherwise infection
will flare up and bacterial corneal ulcer may
develop.
6. Anti-inflammatory and analgesic drugs (e.g.
ibuprofen and paracetamol) may be given orally
for 2-3 days to provide symptomatic relief from
mild pain especially in sensitive patients.
Treatment
1. Topical antibiotics to control the infection
constitute the main treatment of acute
mucopurulent conjunctivitis. Ideally, the antibiotic
should be selected after culture and sensitivity
tests but in practice, it is difficult. However, in
routine, most of the patients respond well to
broad specturm antibiotics. Therefore, treatment
may be started with chloramphenicol (1%),
gentamycin (0.3%) or framycetin eye drops 3-4
hourly in day and ointment used at night will not
only provide antibiotic cover but also help to
reduce the early morning stickiness. If the patient
does not respond to these antibiotics, then the
newer antibiotic drops such as ciprofloxacin
(0.3%), ofloxacin (0.3%) or gatifloxacin (0.3%)
may be used.
2. Irrigation of conjunctival sac with sterile warm
saline once or twice a day will help by removing
the deleterious material. Frequent eyewash (as
58 Comprehensive OPHTHALMOLOGY
ACUTE PURULENT CONJUNCTIVITIS
Acute purulent conjunctivitis also known as acute
blenorrhea or hyperacute conjunctivitis is
characterised by a violent inflammatory response. It
occurs in two forms: (1) Adult purulent conjunctivitis
and (2) Ophthalmia neonatorum in newborn (see
page 71).
ACUTE PURULENT CONJUNCTIVITIS
OF ADULTS
Etiology
The disease affects adults, predominantly males.
Commonest causative organism is Gonococcus; but
rarely it may be Staphylococcus aureus or
Pneumococcus. Gonococcal infection directly
spreads from genitals to eye. Presently incidence of
gonococcal conjunctivitis has markedly decreased.
Clinical picture
It can be divided into three stages:
1. Stage of infiltraton. It lasts for 4-5 days and is
characterised by:
Considerably painful and tender eyeball.
Bright red velvety chemosed conjunctiva.
Lids are tense and swollen.
Discharge is watery or sanguinous.
Pre-auricular lymph nodes are enlarged.
2. Stage of blenorrhoea. It starts at about fifth day,
lasts for several days and is characterised by:
Frankly purulent, copious, thick discharge
trickling down the cheeks (Fig. 4.5).
Other symptoms are increased but tension in
the lids is decreased.
3. Stage of slow healing. During this stage, pain is
decreased and swelling of the lids subsides.
Conjunctiva remains red, thickened and velvety.
Discharge diminishes slowly and in the end
resolution is complete.
Associations. Gonococcal conjunctivitis is usually
associated with urethritis and arthritis.
Complications
1. Corneal involvement is quite frequent as the
gonococcus can invade the normal cornea through
an intact epithelium. It may occur in the form of
diffuse haze and oedema, central necrosis, corneal
ulceration or even perforation.
2. Iridocyclitis may also occur, but is not as
common as corneal involvement.
3. Systemic complications, though rare, include
gonorrhoea arthritis, endocarditis and septicaemia.
Treatment
1. Systemic therapy is far more critical than the
topical therapy for the infections caused by N.
gonorrhoeae and N. meningitidis. Because of
the resistant strains penicillin and tetracyline are
no longer adequate as first-line treatment. Any of
the following regimes can be adopted :
Norfloxacin 1.2 gm orally qid for 5 days
Cefoxitim 1.0 gm or cefotaxime 500 mg. IV qid
or ceftriaxone 1.0 gm IM qid, all for 5 days; or
Spectinomycin 2.0 gm IM for 3 days.
All of the above regimes should then be followed
by a one week course of either doxycycline 100
mg bid or erythromycin 250-500 mg orally qid.
2. Topical antibiotic therapy presently
recommended includes ofloxacin, ciprofloxacin or
tobramycin eye drops or bacitracin or
erythromycin eye ointment every 2 hours for the
first 2-3 days and then 5 times daily for 7 days.
Because of the resistant strains, intensive therapy
with penicillin drops is not reliable.
3. Irrigation of the eyes frequently with sterile
saline is very therapeutic in washing away
infected debris.
4. Other general measures are similar to acute
mucopurulent conjunctivitis.
5. Topical atropine 1 per cent eye drops should be
instilled once or twice a day if cornea is involved.
6. Patient and the sexual partner should be referred
for evaluation of other sexually transmitted dis-
Fig. 4.5. Acute purulent conjunctivitis. eases.
DISEASES OF THE CONJUNCTIVA 59
ACUTE MEMBRANOUS CONJUNCTIVITIS
It is an acute inflammation of the conjunctiva,
characterized by formation of a true membrane on the
conjunctiva. Now-a-days it is of very-very rare
occurrence, because of markedly decreased
incidence of diphtheria. It is because of the fact that
immunization against diptheria is very effective.
Etiology
The disease is typically caused by Corynebacterium
diphtheriae and occasionally by virulent type of
Streptococcus haemolyticus.
Pathology
Corynebacterium diphtheriae produces a violent
inflammation of the conjunctiva, associated with
deposition of fibrinous exudate on the surface as well
as in the substance of the conjunctiva resulting in
formation of a membrane. Usually membrane is formed
in the palpebral conjunctiva. There is associated
coagulative necrosis, resulting in sloughing of
membrane. Ultimately healing takes place by
granulation tissue.
Clinical features
The disease usually affects children between 2-8
years of age who are not immunised against
diphtheria. The disease may have a mild or very severe
course. The child is toxic and febrile. The clinical
picture of the disease can be divided into three stages:
1. Stage of infiltration is characterised by:
Scanty conjunctival discharge and severe pain
in the eye.
Lids are swollen and hard.
Conjunctiva is red, swollen and covered with
a thick grey-yellow membrane (Fig. 4.6). The
membrane is tough and firmly adherent to the
conjunctiva, which on removing bleeds and
leaves behind a raw area.
Pre-auricular lymph nodes are enlarged.
2. Stage of suppuration. In this stage, pain
decreases and the lids become soft. The
membrane is sloughed off leaving a raw surface.
There is copious outpouring of purulent
discharge.
3. Stage of cicatrisation. In this stage, the raw
surface covered with granulation tissue is
epithelised. Healing occurs by cicatrisation, which
may cause trichiasis and conjunctival xerosis.
Complications
1. Corneal ulceration is a frequent complication in
acute stage. The bacteria may even involve the
intact corneal epithelium.
2. Delayed complications due to cicatrization include
symblepharon, trichiasis, entropion and
conjunctival xerosis.
Diagnosis
Diagnosis is made from typical clinical features and
confirmed by bacteriological examination.
Treatment
A. Topical therapy
1. Penicillin eye drops (1:10000 units per ml) should
be instilled every half hourly.
2. Antidiphtheric serum (ADS) should be instilled
every one hour.
3. Atropine sulfate 1 percent ointment should be
added if cornea is ulcerated.
4. Broad spectrum antibiotic ointment should be
applied at bed time.
B. Systemic therapy
1. Crystalline penicillin 5 lac units should be
injected intramuscularly twice a day for 10 days.
2. Antidiphtheric serum (ADS) (50 thousand units)
should be given intramuscularly stat.
C. Prevention of symblepharon
Once the membrane is sloughed off, the healing of
raw surfaces will result in symblepharon, which should
be prevented by applying contact shell or sweeping
the fornices with a glass rod smeared with ointment.
Fig. 4.6. Acute membranous conjunctivitis.
60 Comprehensive OPHTHALMOLOGY
Prophylaxis
1. Isolation of patient will prevent family members
from being infected.
2. Proper immunization against diphtheria is very
effective and provides protection to the
community.
PSEUDOMEMBRANOUS CONJUNCTIVITIS
It is a type of acute conjunctivitis, characterised by
formation of a pseudomembrane (which can be easily
peeled off leaving behind intact conjunctival
epithelium) on the conjunctiva.
Etiology
It may be caused by following varied factors:
1. Bacterial infection. Common causative organisms
are Corynebacterium diphtheriae of low virulence,
staphylococci, streptococci, H. influenzae and N.
gonorrhoea.
2. Viral infections such as herpes simplex and
adenoviral epidemic keratoconjunctivitis may also
be sometimes associated with pseudomembrane
formation.
3. Chemical irritants such as acids, ammonia, lime,
silver nitrate and copper sulfate are also known
to cause formation of such membrane.
Pathology
The above agents produce inflammation of conjunctiva
associated with pouring of fibrinous exudate
on its surface which coagulates and leads to formation
of a pseudomembrane.
Clinical picture
Pseudomembranous conjunctivitis is characterized
by:
Acute mucopurulent conjunctivitis, like features
(see page 56) associated with.
Pseudomembrane formation which is thin
yellowish-white membrane seen in the fornices
and on the palpebral conjunctiva (Fig. 4.7).
Pseudomembrane can be peeled off easily and
does not bleed.
Treatment
It is similar to that of mucopurulent conjunctivitis.
CHRONIC CATARRHAL CONJUNCTIVITIS
‘Chronic catarrhal conjunctivitis’ also known as
‘simple chronic conjunctivitis’ is characterised by
mild catarrhal inflammation of the conjunctiva.
Etiology
A. Predisposing factors
1. Chronic exposure to dust, smoke, and chemical
irritants.
2. Local cause of irritation such as trichiasis,
concretions, foreign body and seborrhoeic scales.
3. Eye strain due to refractive errors, phorias or
convergence insufficiency.
4. Abuse of alcohol, insomnia and metabolic
disorders.
B. Causative organisms
Staphylococcus aureus is the commonest cause
of chronic bacterial conjunctivitis.
Gram negative rods such as Proteus mirabilis,
Klebsiella pneumoniae, Escherichia coli and
Moraxella lacunata are other rare causes.
C. Source and mode of infection. Chronic
conjunctivitis may occur:
1. As continuation of acute mucopurulent
conjunctivitis when untreated or partially treated.
2. As chronic infection from associated chronic
dacryocystitis, chronic rhinitis or chronic upper
respiratory catarrh.
3. As a mild exogenous infection which results from
direct contact, air-borne or material transfer of
Fig. 4.7. Pseudomembranous conjunctivitis. infection.
DISEASES OF THE CONJUNCTIVA 61
Clinical picture
Symptoms of simple chronic conjunctivitis include:
Burning and grittiness in the eyes, especially in
the evening.
Mild chronic redness in the eyes.
Feeling of heat and dryness on the lid margins.
Difficulty in keeping the eyes open.
Mild mucoid discharge especially in the canthi.
Off and on lacrimation.
Feeling of sleepiness and tiredness in the eyes.
Signs. Grossly the eyes look normal but careful
examination may reveal following signs:
Congestion of posterior conjunctival vessels.
Mild papillary hypertrophy of the palpebral
conjunctiva.
Surface of the conjunctiva looks sticky.
Lid margins may be congested.
Treatment
1. Predisposing factors when associated should be
treated and eliminated.
2. Topical antibiotics such as chloramphenicol or
gentamycin should be instilled 3-4 times a day for
about 2 weeks to eliminate the mild chronic
infection.
3. Astringent eye drops such as zinc-boric acid
drops provide symptomatic relief.
ANGULAR CONJUNCTIVITIS
It is a type of chronic conjunctivitis characterised by
mild grade inflammation confined to the conjunctiva
and lid margins near the angles (hence the name)
associated with maceration of the surrounding skin.
Etiology
1. Predisposing factors are same as for 'simple
chronic conjunctivitis'.
2. Causative organisms. Moraxella Axenfeld is the
commonest causative organism. MA bacilli are
placed end to end, so the disease is also called
'diplobacillary conjunctivitis'. Rarely, staphylococci
may also cause angular conjunctivitis.
3. Source of infection is usually nasal cavity.
4. Mode of infection. Infection is transmitted from
nasal cavity to the eyes by contaminated fingers
or handkerchief.
Pathology
The causative organism, i.e., MA bacillus produces a
proteolytic enzyme which acts by macerating the
epithelium. This proteolytic enzyme collects at the
angles by the action of tears and thus macerates the
epithelium of the conjunctiva, lid margin and the skin
the surrounding angles of eye. The maceration is
followed by vascular and cellular responses in the
form of mild grade chronic inflammation. Skin may
show eczematous changes.
Clinical picture
Symptoms
Irritation, smarting sensation and feeling of
discomfort in the eyes.
History of collection of dirty-white foamy
discharge at the angles.
Redness in the angles of eyes.
Signs (include:
Hyperaemia of bulbar conjunctiva near the canthi.
Hyperaemia of lid margins near the angles.
Excoriation of the skin around the angles.
Presence of foamy mucopurulent discharge at the
angles.
Complications include: blepharitis and shallow
marginal catarrhal corneal ulceration.
Fig. 4.8. Signs of angular conjunctivitis.
62 Comprehensive OPHTHALMOLOGY
Treatment
A. Prophylaxis includes treatment of associated
nasal infection and good personal hygiene.
B. Curative treatment consists of :
1. Oxytetracycline (1%) eye ointment 2-3 times a
day for 9-14 days will eradicate the infection.
2. Zinc lotion instilled in day time and zinc oxide
ointment at bed time inhibits the proteolytic
ferment and thus helps in reducing the
maceration.