Eye Pain and Visual Change Answers 499Patientswith viral conjunctivitis typically have reddened conjunctivaand
watery discharge. Preauricular adenopathy is also associated with viral etiology.
Treatment includes cool compresses and an antihistamine/α-adrenergic com-
bination medication—naphazoline/pheniramine—for symptomatic care.
Patients with bacterial conjunctivitis (b)have thick mucopurulent dis-
charge and often wake-up with their eyelids stuck together. These patients are
treated with broad-spectrum antibiotics. Bacterial and viral conjunctivitis do
not always present classically and they can be difficult to distinguish clinically.
Many physicians will therefore treat conjunctivitis patients with antibiotic eye
drops until they can be reexamined by an ophthalmologist. Patients who wear
contact lenses are at risk for pseudomonal conjunctivitis (e).They should be
treated with an antibiotic that covers Pseudomonas,such as a fluoroquinolone
or aminoglycoside. It is very important to always consider gonococcal con-
junctivitis(a)in sexually active individuals, because this infection can cause
permanent visual loss if not rapidly identified and treated. Patients with gono-
coccal conjunctivitis have a severe conjunctivitis with copious mucopurulent
drainage and erythematous conjunctiva. Inpatient IV antibiotics should be
started while waiting for results of ocular Gram stain and culture. Allergic con-
junctivitis(d)presents with watery discharge and eye redness, but itching is
the most prominent symptom. Cyclical exacerbations associated with allergen
exposure may be clues to the diagnosis of allergic conjunctivitis.
449.The answer is b.(Tintinalli, p 1455.)This patient has a corneal abra-
sionfrom prolonged contact lens use. The abrasion lights upafter fluorescein
staining and cobalt blue illumination of the cornea. Contact lens wearers with
abrasions are at high risk for Pseudomonasinfection and should be treated with
an antipseudomonal agent (ie, tobramycin ophthalmic ointment) or fluoro-
quinolone drops. It is critical to distinguish an abrasion from a corneal ulcer.
Ulcers are deeper infections of the cornea that develop from corneal epithelial
defects (ie, abrasions). Contact lens wearers are also at high risk for corneal
ulcers. The hallmark of a corneal ulcer is a shaggy, white infiltrate within the
corneal epithelial defect.
(c)Uncomplicated corneal abrasions may be treated with erythromycin
ointment. Corneal ulcers are treated aggressively with antipseudomonal antibi-
otics and immediate ophthalmology consultation (a).Some ophthalmologists
will see the patient in the ED to perform corneal Gram stain and cultures; while
other ophthalmologists will examine the patient in 12 hours in the office set-
ting. Eye patches (d)are controversial, but should not be given to patients at
risk for fungal infections or pseudomonal infections asthey are at risk for