Table 119-3 Differential Diagnosis of Ocular Infections—cont’d CONDITION ETIOLOGIC AGENTS SIGNS AND SYMPTOMS TREATMENT Episcleritis/scleritis Idiopathic autoimmune disease (e.g., SLE, Henoch-Schönlein purpura) Localized pain, intense erythema, unilateral; blood vessels bigger than in conjunctivitis; scleritis may cause globe perforation Episcleritis is self-limiting; topical steroids for fast relief
Foreign body Occupational or other exposure Unilateral, red, gritty feeling; Irrigation, removal; check for visible or microscopic size ulceration
CMV, Cytomegalovirus; EBV, Epstein-Barr virus; JIA, juvenile idiopathic arthritis; SLE, systemic lupus erythematosus.
gentle pressure on the nasolacrimal sac. Treatment usually requires probing of the nasolacrimal system to establish communication.
Endophthalmitis is an emergent, sight-threatening infection that usually follows trauma, surgery, or hematogenous spread from a distant focus. Causative organisms include coagulase-negative staphylococci, S. aureus, S. pneumoniae, Bacillus cereus, and Candida albicans. Examination is difficult because of severe blepharospasm and extreme photophobia. A hypopyon and haze may be visible on examination.
The lids should be treated as needed with warm compresses to remove accumulated discharge. Acute bacterial conjunctivitis is frequently self-limited, but topical antibiotics hasten resolution. Antibiotics are instilled between the eyelids four times a day until the discharge and chemosis subside. Recommended treatment includes topical trimethoprim-polymyxin B solution, sulfacetamide 5% solution, or erythromycin ointment. Ciprofloxacin solution should be restricted to corneal infections and resistant gram-negative infections in hospitalized patients. Gonococcal conjunctivitis in adults is treated with a single intramuscular (IM) dose of ceftriaxone (1 g) plus azithromycin (to treat possible concomitant chlamydial infection).
The treatment of ophthalmia neonatorum depends on the cause (see Table 119-2). Gonococcal ophthalmia neonatorum is treated with a single dose of ceftriaxone (25 to 50 mg/kg intravenous [IV] or IM; maximum dose 125 mg). These infants should be hospitalized. Antibiotic treatment also is recommended for newborns to mothers with untreated gonorrhea. Chlamydial conjunctivitis is treated with oral erythromycin for 14 days, partly to reduce the risk of subsequent chlamydial pneumonia.
The prognosis for bacterial and viral conjunctivitis is excellent. The major complication is keratitis, which can lead to ulcerations and perforation, and is uncommon except with N. gonorrhoeae and HSV infections. Chlamydial conjunctivitis may progress in infants to chlamydial pneumonia, which typically develops from 4 to 12 weeks of age (see Chapter 110).
Careful hand washing is important to prevent spread of conjunctivitis. Bacterial conjunctivitis is considered contagious for 24 hours after initiating effective treatment. Children may return to school, but treatment measures must be continued until there is complete clinical resolution.
All newborns, whether delivered vaginally or by cesarean section, should receive prophylaxis for gonococcal ophthalmia neonatorum as soon as possible after delivery. Silver nitrate 1% is used frequently but usually causes a chemical conjunctivitis. Alternative methods are equally effective and less irritating and include a single application of erythromycin 0.5% ointment or tetracycline 1% ointment.