Physical Examination of Bacterial Conjunctivitis
The physical examination for bacterial conjunctivitis should include visual acuity assessment, external examination, and slit-lamp biomicroscopy with particular attention to purulent discharge, conjunctival injection, and absence of corneal involvement. 1
Initial Assessment
Visual Acuity
- Document baseline visual acuity
- Note: Visual acuity may be compromised by patient discomfort, tearing, and inflammation 1
- Ensure consistency with anterior segment examination findings
External Examination
Eyelids and Adnexae
- Check for swelling, discoloration, malposition
- Assess for ulceration, nodules, ecchymosis
- Look for lateral flare and lash loss
Regional Lymphadenopathy
- Particularly examine for preauricular lymphadenopathy 1
Skin
- Evaluate for signs of associated conditions:
- Rosacea
- Eczema
- Seborrhea
Slit-Lamp Biomicroscopy
Conjunctival Findings
- Discharge: Purulent discharge is characteristic of bacterial conjunctivitis 1
- Inflammation: Assess distribution (diffuse vs. sectoral)
- Laterality: Unilateral or bilateral (often starts unilateral and becomes bilateral)
- Chemosis: Evaluate degree of conjunctival edema
- Hemorrhage: Note any subconjunctival hemorrhage
Eyelid Margins
- Inflammation and edema
- Meibomian gland dysfunction
- Discharge characteristics (purulent in bacterial cases)
- Ulceration, nodules, vesicles
Eyelashes
- Crusting
- Presence of scurf or mites (Demodex)
- Trichiasis
Cornea
- Critical: Rule out corneal involvement (epithelial defects, infiltrates) 2
- Apply fluorescein staining to detect epithelial defects
- Assess for stromal infiltrates which would suggest keratitis rather than simple conjunctivitis
Anterior Chamber
- Check for inflammatory reaction (cells and flare)
- Presence of hypopyon would indicate more severe infection
Distinguishing Features of Bacterial Conjunctivitis
- Discharge: Mucopurulent or purulent discharge (thicker than viral conjunctivitis)
- Conjunctival Reaction: Papillary rather than follicular reaction
- Eyelids: Often stuck together upon waking due to discharge
- Time Course: Typically acute onset
Red Flags Requiring Immediate Referral
- Moderate to severe pain (bacterial conjunctivitis typically causes irritation but not severe pain) 2
- Visual loss
- Corneal involvement (infiltrates or epithelial defects)
- Severe purulent discharge (may indicate hyperacute conjunctivitis from Neisseria)
- Lack of response to therapy within 48-72 hours
- Immunocompromised patient
Diagnostic Testing Considerations
- Cultures are not routinely needed for uncomplicated bacterial conjunctivitis 1
- Consider cultures for:
- Recurrent, severe, or chronic purulent conjunctivitis
- Cases not responding to initial treatment
- Suspected hyperacute conjunctivitis (Neisseria)
- All cases of neonatal conjunctivitis 1
Documentation Pearls
- Document laterality and onset pattern
- Note specific discharge characteristics (color, consistency, amount)
- Record presence or absence of corneal involvement
- Document response to lid eversion (to assess for foreign body or papillary reaction)
- Specify any associated systemic symptoms
By following this systematic approach to the physical examination of bacterial conjunctivitis, clinicians can accurately diagnose the condition, distinguish it from other causes of red eye, and identify cases requiring specialty referral or additional testing.