**3. Conjunctival infections**

Conjunctival infections manifested as conjunctival hyperemia [7, 8] (**Figure 2**). Lower eyelid follicles may accompany conjunctivitis. Discharge and preauricular lymphadenopathy may accompany be also present.

Acute conjunctivitis is less than 4 weeks, otherwise it is considered as chronic. Several entities should be mentioned. When conjunctivitis is accompanied by throat pain, fever and malaise, it is suggested as hay fever. When papillae and follicles in both upper and lower eyelids accompany conjunctivitis, adult inclusion conjunctivitis should be suspected. This is a sexually transmitted disease and both mates should be treated. Gonorrhea conjunctivitis is character‐ ized by copious purulent discharge while other agents cause mucopurulent, mucoid or serous discharge. A form of viral conjunctivitis is hemorrhagic conjunctivitis in which conjunctival hyperemia is accompanied by subconjunctival hemorrhages.

**Figure 2.** Viral conjunctivitis. Note the conjunctival congestion without corneal or intraocular involvement.

Conjunctival myiasis is conjunctival infestation by larvae of different types of flies depending on the habitat [9]. The larvae are tiny white and move quickly. They cause conjunctival hyperemia and the patient complains of unilateral ocular irritation. Rarely, the larva may migrate into the lacrimal drainage system and cause obstruction.

Infectious agents include bacteria, virus and chlamydia. Most microorganisms cannot invade intact epithelium. The only exceptions are *Neisseria gonorrhoeae*, *Corynebacterium diphtheria*, *Haemophilus aegyptius* and Listeria.

Infectious conjunctivitis should be differentiated from noninfectious agents such as allergic conjunctivitis and dry eyes. In neonates occurring in the first month of life, ophthalmia neonatorum is an entity that may be caused by various microorganisms such as chlamydia and less commonly by *Neisseria gonorrhoeae*. Tetracycline 1% or erythromycin 0.5% ointment qid for 3 weeks is effective for prevention and treatment.

Most of the acute viral conjunctivitis forms are self‐limited and treatment is aimed to decrease discomfort and prevent secondary infection. Topical antibiotic such as sulfacetamide 10% (Sulfacid®) qid may be applied. In G6PD and sulfa‐sensitive patients, other antibiotics such as Gatifloxacin (Zymar®) bid, a quinolon, may be prescribed. It is best to defer topical corticoste‐ roid for a week to ascertain that the conjunctivitis is not herpetic or adenoviral. If no improve‐ ment is observed after a week, topical corticosteroid such as fluorometholone (FML®) 0.1% qid may be used for 1–2 weeks in tapered dosage. Patients should be instructed to prevent eye‐ finger‐eye contact (and other contact means) especially with adenoconjunctivitis. The disease is infective between 7 and 10 days. Hay fever is treated by mild topical corticosteroids such as fluorometholone (FML®) 0.1% qid or loteprednol (Lotemax®) 0.5% and nasal decongestant. Adult inclusion conjunctivitis is treated by topical and systemic tetracycline (e.g. doxycycline hyclate 100 mg once a day or tetracycline 250 mg qid). The mate should be treated as well. Myiasis is treated by removal of all the larvae from the conjunctival sac. Instillation of topical cocaine 4% may be added before removing the larvae to decrease their movement.
