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In classic presentations, patients complain of eyelids

sticking together on waking.
They may describe itching and burning or a gritty foreign body sensation. Pus floating across the eye may distort vision, though visual acuity is normal. Photophobia is minimal. Family members with similar complaints
typically are presenting conjunctivitis from an infectious cause. A history of a recent URI typically is associated with a viral cause.

  • Bacterial

    conjunctivitis is characterized by acute onset, minimal pain, occasional itch, and sometimes an exposure history.
    • Ocular surface disease (eg, keratitis sicca , trichiasis, chronic blepharitis) predisposes the patient to bacterial conjunctivitis.

    • Staphylococcus and Streptococcus species are the most common pathogens.

  • Viral conjunctivitis is characterized by acute or subacute onset, a minimal level of pain, and often with an exposure history.

    • Itching is common. A clear, watery discharge is the norm.

    • Occassionally, severe photophobia and foreign body sensation occurs, usually caused by adenovirus (epidemic keratoconjunctivitis), when associated with keratitis.

    • Check for preauricular adenopathy and a follicular conjunctival change, particularly on the palpebral conjunctiva. If present, the likely diagnosis is EKC.

    • Be aware that herpes simplex and chlamydia also cause follicular conjunctivitis and preauricular adenopathy.

  • Chlamydial conjunctivitis is characterized by chronic onset, a minimal level of pain, occasional itch, and a history of STD.

  • Allergic conjunctivitis is characterized by acute or subacute onset, no pain, and no exposure history.

    • Itch is extremely common. Clear, watery discharge is typical with or without a moderate amount of mucous production.

    • An aggressive form of allergic conjunctivitis is vernal conjunctivitis in children and atopic conjunctivitis in adults. Vernal disease is often associated with shield corneal ulcers. Perilimbal accumulation of eosinophils (Horner-Trantas dots) is typical of vernal disease. Vernal keratoconjunctivitis, usually affecting young boys, tends to be bilateral and occurs in warm weather. It is presumed to be a hypersensitivity to exogenous antigens and may be associated with or accompanied by keratoconus.

  • Giant papillary conjunctivitis resembles vernal disease.

    • It occurs mainly in contact lens wearers who develop a syndrome of excessive itch, mucous production, and increasing intolerance to contact use.

    • The giant papillae are predominantly on the upper palpebral conjunctiva and can only be seen on lid eversion.

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