Patients with ocular surface diseases such as conjunctivitis, blepharitis have greater potential for discomfort or further ocular damage. Early recognition of the signs of infection and prompt diagnosis minimize the potential for severe or chronic complications.
The evaluation for ocular surface disorders includes a carefully detailed patient history, assessment of associated risk factors, and examination of the anterior ocular structures and their functions.
There are several causes of conjunctivitis and it is important to make the correct diagnosis to avoid complications.
Evaluation of a patient exhibiting blepharitis, dry eye symptoms or signs consistent with blepharitis includes many of the elements of a comprehensive eye and vision examination and a more in-depth evaluation of the ocular surface and adnexa1,2.
External examination of the eye, including lid structure, skin texture, and eyelash appearance
Examining lid margins, bases of lashes, meibomian gland and its orifices
Comparison of the eyes helps determine the severity of the inflammation1
Onset and course of condition
Thorough medical history
Effects of previous treatments and the patient’s compliance in following recommendations1
Not every 'red eye' is 'bacterial conjunctivitis'. Be wary, particularly in cases that are sub-acute in onset, not responding to treatment or that are associated with other symptoms such as reduced vision, photophobia, double vision or significant eye pain2.
In patients who are contact lens wearers, be alert to the possibility of contact lens-related corneal infection.
This condition varies in severity from mild hyperaemia and tearing to a severe conjunctivitis with copious purulent discharge. Rarely conjunctivitis is sight threatening causing irreversible scarring.
Conjunctivitis has been described as clinically differentiated by symptoms and signs, i.e. discharge, conjunctival reaction, membranes and lymphadenopathy2.
Broad Differential Features
Associated Fever and Sore Throat
Papilliary with chemosis
Common in inclusion conjunctivitis
Chief Complaint of Bacterial Conjunctivitis
Foreign body sensation
Discharge: Purulent, mucopurulent, mixed1,3
Acute onset of:
Discomfort, usually described as burning or grittiness
Discharge (may cause temporary blurring of vision)
Crusting of lids (often stuck together after sleep and may have to be bathed open
Usually bilateral – one eye may be affected before the other (by one or two days)13
Purulent or mucopurulent discharge
Conjunctival hyperaemia (redness)
Tarsal conjunctiva may show mild papillary reaction
Cornea: usually no involvement. If cornea significantly involved, consider possibility of gonococcal infection
Lymphadenopathy usually absent13
Blepharitis is suspected when both the eyelids burn, itch and stick together, with the symptoms becoming worse in the
morning. Symptoms are often intermittent, with exacerbation and remissions occurring over long periods3.
Evaluation of a patient exhibiting dry eye symptoms or signs consistent with blepharitis includes many of the
elements of a comprehensive eye and vision examination and a more in-depth evaluation of the ocular surface and
Note: Cases of rapid onset of visual loss or an acutely painful red eye if present should be referred to the
ophthalmologist for same day evaluation.
Signs & Symptoms of Blepharitis
Foreign body sensation
Lids sticking together
Erythema (redness) of lid margins
Scaly collarets at base of lashes
Frequent loss of eyelashes
Mild forms often symptom free
Possible burning, stinging, itching
Oily skin scales and greasy crusting on the lashes
Hyperemia (redness) on anterior lid margins
Meibomian gland dysfunction
Blockage of the oil glands in the eyelids
Poor quality of tears
Redness of the lining of the eyelids
Combination of seborrheic Blepharitis and meibomian gland dysfunction
Dry eye symptoms
Blocked and inflamed meibomian glands
Lipid secretions of toothpaste consistency
Unstable tear film
Care of the Patient with Ocular Surface Disorders. OPTOMETRIC CLINICAL PRACTICE GUIDELINE. American Optometric Association. 2010. Download
Chen, J. Y. and Tey, A. GP guide to the diagnosis and management of conjunctivitis. Prescriber. 2014:25; 22–31. Download
NICE CKS. Blepharitis. October 2015. Download
American Optometric Association. Care of the Patient with Blepharitis. Quick Reference Guide. Download
Care of the Patients with Blepharitis. Quick Reference Guide. American Optometric Association. [Online]. Available at: https://www.aoa.org/documents/optometrists/QRG-10A.pdf. Last accessed on May 2019. Download