What should be the focus of the history for suspected bacterial conjunctivitis (pink eye)?

Updated: Jan 03, 2019
  • Author: Karen K Yeung, OD, FAAO; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Answer

Most cases of bacterial conjunctivitis are bilateral, although the time of onset may vary. Most cases of bacterial conjunctivitis occur in otherwise healthy individuals. In these cases, the history should take the following factors into consideration:

  • A brief history to assess possible occupational exposure may be appropriate. A brief history of systemic illness should be obtained to determine whether the patient has recently experienced a viral upper respiratory tract infection, has any major known systemic illnesses (eg, HIV disease or diabetes), or has recently used antibiotics or immunosuppressive medications.
  • History of recent exposure to other cases is extremely helpful, especially to children. An exposure to a case that healed uneventfully would be comforting, whereas exposure to someone with known epidemic keratoconjunctivitis (viral) or severe herpes simplex dermatitis would raise concern.
  • A medication history is important to document what already has been tried and to rule out medicamentosa or other drug-related causes for the condition. Ocular redness and irritation may occur due to any eye drop solution or the preservatives in the solution. Systemic chemotherapeutic agents can cause an irritative conjunctivitis.
  • A history of allergies to medications should be established for avoidance purposes and recorded in the medical record prominently since this is often the only medical encounter with an otherwise healthy individual. Sulfonamides are particularly important because of their relatively high allergy incidence, the common practice of prescribing generic sulfacetamide for routine conjunctivitis, and the implied risk of severe allergic reactions such as Stevens-Johnson syndrome. An allergy history should document not only the medication or antigen but also the type of reaction. Stomach discomfort is of less concern than a diffuse rash, while respiratory distress is a major contraindication to any drug in that class, topical or systemic.
  • Contact lens wear, especially extended-wear contact lens use and/or improper contact lens care, increases the risk of ocular infections, including bacterial conjunctivitis. When the cornea is involved, infections not properly treated can result in corneal scarring and permanent visual impairment.
  • Patients with typical bacterial conjunctivitis do not complain of photophobia. Sensitivity to light is a symptom of intraocular inflammation, as in iritis, or disturbance of the corneal epithelium with lesions that test positive on fluorescein staining, such as those found in viral keratitis, retained corneal foreign body, or a metallic rust ring.
  • Duration of the disease and previous attempts at therapy should be documented. It is usual for symptoms to be present for several days or weeks at the time of presentation. An uncommonly long duration or a frequent recurrence suggests that other factors or conditions may be present. For instance, a molluscum lesion at the lid margin may be shedding virus into the eye. Chlamydial infection or viral keratoconjunctivitis may be present, with subsequent corneal complications. Compliance to antibiotic use can also help determine whether antibiotic resistant bacteria may be involved. A history of resistance to therapy may prompt the practitioner to obtain a culture, which can be effectively obtained with a standard red-cap culturette tube following swabbing of the lower lid margin and inferior cul-de-sac.
  • In the elderly patient, age is a consideration in determining whether the case may be related to defective host resistance. In such cases, it is appropriate to inquire about concomitant or recent increased susceptibility to other types of infections, for example, urinary tract or respiratory tract infections, which may hold clues to the bacterial source. Furthermore, MRSA and MRSE infections are far more prevalent in nursing home residents [20] and in patients who are chronically hospitalized.

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