indistinct, feathery borders. Visual acuity is significantly decreased. Sometimes, satellite lesions surround the primary infiltrate. A purulent discharge in the lower part of the anterior cham- ber can also be found. Conjunctivitis in fungal infection is always secondary to keratitis.
1. When do your symptoms start? Bacterial conjunctivitis usually occurs in the hot, summer months. Viral infections can be associated with upper respiratory tract infections or pharyngitis and therefore occur more frequently in autumn.
Do they last more or less than three weeks? Chlamydial infections are chronic, recurrent with exacerbations and remissions and last more than three weeks. Viral infections usually take a less prolonged course of two to three weeks and bacterial infections very infrequently last longer than one week.
Has there been recent exposure to an infected individual? Adenoviral or picornaviral infec- tions are highly contagious and usually conjunctival infection can be diagnosed in other members of the family or coworkers.
Are symptoms constant or intermittent?
Chlamydial infections are usually chronic and recurrent lasting more than three weeks.
What are the main symptoms (sticky purulent, serous or mucopurulent discharge, blurring of vision)? Patients with bacterial conjunctivitis often present with a sticky purulent dischar- ge, viral infections are associated with a serous discharge and chlamydial infections with a mucopurulent discharge. Corneal involvement with blurring of vision occurs more fre- quently in viral infections (usually adenoviral or herpetic keratoconjunctivitis).
Do you have glued eye(s) in the morning?
Eyelids and/or lashes sticking in the morning upon waking due to a purulent discharge is a typical sign of bacterial conjunctivitis.
Does the patient complain of blurring of vision? Diminished visual acuity is usually a symptom of corneal involvement. Keratitis is a frequent complication of viral or chlamydial conjunctivitis. In bacterial conjunctivitis, keratitis is extremely rare. In Acanthamoeba and fungal keratoconjunctivitis, visual acuity is signifi- cantly decreased.
Are other members of the family/partners or likely contacts involved? Viral conjunctivitis (adenoviral and picornaviral) is highly contagious and occurs in epidemics. Chlamydial infections are typically found in sexually active adults and can be transmitted sexually, so examination of his/her sexual partner is necessary. Anterior segment infections caused by Chlamydia trachomatis occur in endemic areas.
Underlying general disease:
The conjunctiva can be affected during or after systemic infections:
bacterial conjunct viral conjunctivitis
no systemic manifestations,
sometimes has a history of recent upper respiratory tract in- fection or pharyngitis, chickenpox, zoster, lymphadenopathy
pneumonia and/or otitis (children), cervicitis and/or vaginitis (women), symptomatic or non-symptomatic urethritis (men), lymphadenopathy.
PHYSICAL EXAMINATION AND DIAGNOSTIC TESTS
ANTERIOR SEGMENT EXAMINATION Detailed examination of the anterior segment of the eye is the most important part of evalu- ation of patients with red eye. Ophthalmologists examine the anterior segment with the use of a slit lamp. GPs or GPPs can examine the conjunctiva and cornea with side illumination and a magnifier (see Chapter I on the differential diagnosis of the red eye). The type of discharge, changes in and on the surface of the palpebral or bulbar conjunctiva, and changes of the regu- larity and clearness of the cornea should be observed. If changes are seen in the cornea, the patient should be sent to an ophthalmologist for detailed diagnosis. Some features seen with a slit lamp or during examination with side illumination may be specific for various types of infectious conjunctivitis. The signs include: papillae, giant papillae, follicles, membranes or
pseudomembranes, corneal filaments, micro-pannus and gross-pannus. For GPs and GPPs it will be difficult to distinguish these changes but they should try to recognize conjunctival fol- licles during examination with side illumination and a magnifier. These are numerous, smooth, yellowish elevations of the conjunctiva, 2 – 5 mm in diameter, similar to a small grain of rice,
with no vessels inside them. Follicles represent hyperplasia of the subconjunctival lymphoid tis- sue. (Figure 4) They are a common presentation in viral (acute inflammation lasting less than three weeks), chlamydial conjunctivitis (chronic inflammation with exacerbation lasting more than three weeks) and toxic reactions.  They should be differentiated from papillae which are a non specific sign, occurring in any kind of inflammation (mainly in bacterial and allergic). They present as elevated, polygonal, hyperaemic areas separated by pale channels with cen- tral vessels erupting into a spoke-like pattern. The connective tissue septa that anchors the epi- thelium to the deeper collagenous tissue limits the size of papilla to less than 1 mm. (Figure 2)
ORDINARY BACTERIAL CONJUNCTIVITIS This type of conjunctivitis can be diagnosed on the basis of medical history and eye examina- tion. Usually slide stains, cultures or cytology are not necessary to prove the diagnosis. 
Diagnostic tests are indicated in neonatal bacterial conjunctivitis, difficult clinical cases, recur- rent conjunctivitis and in patients not responding to medication. It has to be remembered that in patients with bacterial conjunctivitis treated previously with antibiotics, the results of slide stains and cultures are very often negative. In hyper-acute and suspected neonatal conjuncti- vitis, it is mandatory to perform slide stains, cultures and antibiotic sensitivity as a matter of urgency.
Usually Gram stain is used for direct identification of causative bacteria. [9, 12] Conjunctival smears and corneal scrapings can be cultured on various media, the most popular is blood agar. In neonates and infants, it is necessary to exclude nasolacrimal duct obstruction as a cause of bacterial conjunctivitis.
VIRAL INFECTIONS Usually clinical diagnosis is used. Viral cultures and immunodiagnostic tests are not very help- ful and are infrequently used in clinical practice.  They are only performed in diagnostically difficult cases. Obtaining the results of viral cultures takes several weeks.