What are the signs and symptoms of bacterial conjunctivitis?

Signs and Symptoms of Bacterial Conjunctivitis

Bacterial conjunctivitis characteristically presents with purulent or mucopurulent discharge causing matted eyelids upon waking, conjunctival injection without significant itching, and typically lacks a history of recurrent conjunctivitis. 1, 2, 3

Key Clinical Features

Discharge Characteristics

• Purulent or mucopurulent discharge is the hallmark finding that distinguishes bacterial from viral conjunctivitis 1, 2
• Mattering and adherence of eyelids on waking is one of the strongest predictive factors for bacterial etiology 3
• The discharge is thick and yellow-green, unlike the watery discharge seen in viral conjunctivitis 4

Conjunctival Findings

• Papillary reaction of the conjunctiva rather than the follicular reaction typical of viral causes 1, 2
• Bulbar conjunctival injection (redness) that can be unilateral or bilateral 1, 2
• Chemosis (conjunctival swelling) may be present in more severe cases 1

Associated Symptoms

• Lack of itching is a key distinguishing feature from allergic conjunctivitis 3
• Irritation and foreign body sensation are common 1
• Pain is typically mild unless there is corneal involvement 1
• Photophobia suggests possible corneal complications 1
• Blurred vision may occur from discharge coating the cornea 1

Lymphadenopathy

• Preauricular lymphadenopathy is less common in bacterial conjunctivitis compared to viral causes, unless caused by hypervirulent organisms like Neisseria gonorrhoeae 2

Special Presentations Requiring Urgent Recognition

Hypervirulent Bacterial Conjunctivitis (Gonococcal)

• Marked eyelid edema with severe bulbar conjunctival injection 2
• Copious purulent discharge that is bilateral and severe 1, 5
• Rapid progression within 12-24 hours 2
• Risk of corneal infiltrate, ulceration, and perforation requiring aggressive systemic and topical therapy 2
• Suspect in sexually active adults or neonates 1-7 days postpartum 6, 5

Chlamydial Conjunctivitis

• Chronic presentation with follicular reaction (more prominent than typical bacterial) 1
• Mucoid rather than frankly purulent discharge 1
• Bulbar conjunctival injection with follicles on tarsal conjunctiva 1
• In neonates, manifests 5-19 days after birth (later than gonococcal) 1, 6
• May be associated with concurrent genitourinary symptoms in adults 1

Associated Systemic Findings

• Concurrent bacterial otitis media, sinusitis, or pharyngitis, particularly in children 2
• Absence of upper respiratory infection symptoms (which would suggest viral etiology) 1

Common Pitfalls to Avoid

Do not assume all red eyes with discharge are bacterial - viral conjunctivitis can have mild mucopurulent discharge, but the presence of follicles, preauricular nodes, and concurrent URI strongly favor viral etiology 1, 2

Do not miss hypervirulent organisms - any severe, rapidly progressive purulent conjunctivitis, especially in sexually active adults or neonates, requires immediate evaluation for Neisseria species and aggressive treatment to prevent corneal perforation 2, 5

Do not overlook chronic or recalcitrant cases - bacterial conjunctivitis that fails to respond to appropriate antibiotics within 5-7 days may indicate underlying blepharitis, meibomianitis, chlamydial infection, or rarely, malignancy such as sebaceous cell carcinoma 2, 5