CHLAMYDIAL INFECTIONS If the diagnosis can not been made on a clinical basis performance of cytology with Giemsa stain (basophilic intracytoplasmic inclusion bodies in epithelial cells – Halberstaedter – von Provazek bodies), direct immunofluorescent antibody tests (DFA, IFA), ELISA and PCR tests of ocular specimens may be helpful. [1, 2, 3, 7] Doubtful clinical cases should be sent to an oph- thalmologist for detailed examination.
ACANTHAMOEBA AND FUNGAL CONJUNCTIVITIS Both conditions are severe and sight-threatening and therefore patients with suspected Acanthamoeba or fungal conjunctivitis should be send to an ophthalmologist for detailed exa- mination.
In many patients with different types of conjunctivitis cytology (performed with Giemsa stai- ning) allows more rapid diagnosis (not influenced by the previous treatment) than cultures, slide stains or immunological tests. [9, 12] (Table III)
MAIN TREATMENT GUIDELINES
ORDINARY BACTERIAL CONJUNCTIVITIS Neonatal bacterial conjunctivitis and difficult clinical cases should be sent to an ophthalmolo- gist for detailed diagnosis and treatment. In other cases, treatment is usually started with broad spectrum topical antibiotics. Since ordinary bacterial conjunctivitis is very often self- limiting, a less expensive option, like aminoglycosides, may be selected but fluoroquinolones
are used more and more frequently nowadays. [1, 9] If this therapy is not effective after seven days, the patient should be sent to an ophthalmologist for detailed diagnosis. Because anti- biotic resistance is becoming a growing problem, it is advisable to select bactericidal and not bacteriostatic antibiotics to diminish the probability of the development of antibiotic-resistant bacterial strains. It is also recommended that adequate dosing should be maintained (e.g. ami- noglycosides at least three times per day, fluoroquinolones four times per day) to decrease
the possibility of exposure of bacterial populations to repeated, sublethal doses of antibiotics which can stimulate development of mutations that are responsible for increased resistance. It is necessary to wash away any purulent discharge before initiating treatment.
HYPER-ACUTE BACTERIAL CONJUNCTIVITIS The patient should be sent to an ophthalmic center and admitted to hospital. Detailed exa- mination with slide stains, cultures and antibiotic sensitivity has to be performed. Treatment is started immediately with systemic antibiotics (basic therapy) – ceftraxione [adults 1 g IM, chil-
dren 125 mg IM, neonates 25 – 50 mg/kg (not to exceed 125 mg) IM or IV single dose]. Topical last-generation fluoroquinolones given hourly can also be administered.  Afterwards, the- rapy is adjusted according to the sensitivity of the cultured organism. Washing of discharge from the infected eyes should be considered.
VIRAL CONJUNCTIVITIS In adenoviral and picornaviral infections, treatment is only supportive. The recently introdu- ced ganciclovir 0.15 % ocular gel has antiviral activity against some serotypes of adenoviruses. Topical broad spectrum antibiotics can be used to prevent bacterial superinfection. If the patient is complaining of blurred vision, he/she should be sent to an ophthalmologist for detailed examination and exclusion of keratitis. Patients should be advised to wash their hands frequently, use separate towels and avoid close contact with other people.
In herpetic and varicella-zoster infections, topical acyclovir (3 % ointment four times per day for 3 weeks) is the treatment of choice. Ganciclovir (0.15 % gel four times per day for 3 weeks) is comparable in efficacy to acyclovir in the treatment of ocular herpetic infections.  Topical ido- xuridine (IDU), vidarabine and trifluridine are now less commonly used. Oral acyclovir 200 to 400 mg, given five times per day until the conjunctivitis resolves, is sometimes used in more seve- re cases. Cases of neonatal herpetic conjunctivitis should be sent to an ophthalmologist and tre- ated with oral acyclovir in conjunction with a paediatrician because they can be associated with systemic HSV infection, which is a life-threatening condition.  Zoster infection could be a sight- threatening disease so it should be treated by an ophthalmologist.
In molluscum contagiosum and papilloma, treatment is by surgical excision, incision, cauteri- zation, cryotherapy or curettage. The conjunctivitis and keratitis typically resolve after remo- val of the skin lesions. [1, 13] Spontaneous resolution is usually seen in 3 to 12 months in immu- nocompetent patients. Corticosteroids should be used with caution in viral conjunctivitis because they can worsen viral infections. It is important to wash and disinfect the hands carefully after contact with a patient with viral conjunctivitis because these infections are highly contagious.
CHLAMYDIAL INFECTIONS If diagnosis can not been made on a clinical basis or there is suspicion of corneal involvement, the patient should be sent to an ophthalmologist. Because of frequent concomitant systemic infections, oral azithromycin (one time single dose 1 gm p.o.) or clarithromycin, tetracycline,
doxycyline or erythromycin for two weeks, given to the patient and his or her sexual partner is basic therapy for chlamydial conjunctivitis. Therapy of both patient and his/her sexual partner is necessary. In some countries, only topical treatment is used as follows: topical sulphametacin eye drops 10 % – 30 % four times per day, together with erythromycin 0.5 % ointment or tetracy- cline 1 % ointment during the night for two weeks. The effectiveness of topical treatment added to systemic therapy is not proven. Trachoma is one of the leading causes of blindness in developing countries so GPs should always consider sending the patient to an ophthalmologist.
DIFFICULT CLINICAL DIAGNOSIS If the diagnosis is doubtful the patient should be sent to an ophthalmologist for detailed exa- mination and adequate treatment.