FLOWCHART II MAIN TREATMENT GUIDELINES
Ordinary bacterial conjunctivitis
Start treatment with aminoglycoside or flu- oroquinolone eye-drops. If conjunctivitis does not improve in 7 days send patient to an ophthalmologist for detailed examination.
Hyper-acute bacterial conjunctivitis
Send immediately to an ophthalmologist – risk of corneal perforation. Obligatory examination of patient’s sexual partner.
Treatment is supportive
Use antibiotic to prevent bacterial super-
infection Herpes simplex and varicella-zoster infection
Topical acyclovir or ganciclovir is the drug of choice
Use steroids with caution – may worsen viral infection
Send to an ophthalmologist for treatment if suspicions of corneal involvement (blurring of vision)
1. Systemic (basic therapy): azithromycin (one time dose 1 gm p.o.) or clarithromy- cin, tetracycline, doxycyline or erythro- mycin for 2 weeks for the patient and his or her sexual partner 2. Topical erythromycin or tetracycline oint- ment 3. In some countries only topical treatment is used as follows: topical sulphametacin eye drops 10 % – 30 % 4 times per day, together with erythromycin 0.5 % oint- ment or tetracycline 1 % ointment during night for 2 weeks.
Difficult clinical diagnosis
Send to an ophthalmologist for detailed diagnosis and treatment.
ADDENDUM – SPECIAL CASES OF CONJUNCTIVITIS
I. HYPER-ACUTE CONJUNCTIVITIS A very rare but sight threatening form of bacterial conjunctivitis is hyper-acute conjunctivitis caused by Neisseria species (N. gonorrhoeae or meningitides) or less often Pseudomonas aeru- g i n o s a i n f e c t i o n s . T h e d i s e a s e i s u s u a l l y b i l a t e r a l a n d i s c h a r a c t e r i z e d b y s u d d e n , r a p i d o n s e t ,
fulminating conjunctivitis with marked eyelid swelling, severe hyperaemia, chemosis and pro-
fuse, thick, yellow-green purulent discharge. Typically, the purulent discharge is copious and quickly recurs when wiped or washed away. There is a high risk of corneal infiltration and cor- neal necrosis and perforation within hours which can lead to blindness. Gonococcal conjuncti- vitis usually develops in the newborn and less often in the adult patient. In neonates, septi- caemia with arthritis and meningitis may develop. [1, 9] In adults, septicaemia with arthritis and pelvic inflammatory disease may rarely occur.  Neisseria gonorrhoeae infections are transmitted sexually and therefore it is mandatory to examine and treat not only the patient but also his/her sexual partner.
II. NEONATAL CONJUNCTIVITIS Neonatal conjunctivitis requires special diagnosis and therapy because of frequent corneal and systemic involvement. Therefore, treatment should be performed in cooperation with a pae- diatrician because of the possibility of life-threatening systemic manifestations of the infec- tion. Most cases of neonatal conjunctivitis develop as a result of vaginal delivery by an infected mother and are indicative of inadequate prenatal care. The conjunctivitis can be prevented by prophylaxis of the neonate at birth. It includes the use of topical 1 % silver nitrate solution or 1 % silver acetate in single-dose ampoules (a long-term standard prophylactic agent that is no longer available in many countries), 0.5 % erythromycin or 1.0 % tetracycline ointment or 2.5 % povidone-iodine solution. [5, 6] Silver nitrate solution is not active against chlamydia. Slide stains and cultures of conjunctival smears or scrapings are indicated in all cases of suspec- ted neonatal conjunctivitis. 
III. BLEPHAROCONJUNCTIVITIS Blepharoconjunctivitis (inflammation of the eyelid margin and conjunctiva) is a common ophthalmological disorder as well as one of the most difficult conditions to treat. It can be related to skin or lid diseases (Figure 8). 
Figure 8 – Crustings, oedema, hyperaemia and small ulcerations of the lid margin in a girl with staphylococcal blepharoconjunc- tivitis.