Correspondence
The Red Eye
N Engl J Med 2000; 343:1577November 23, 2000
- Article
To the Editor:
In his review of the red eye (Aug. 3 issue),1 Leibowitz makes one point that I would like to challenge. He states that the discharge that characterizes viral conjunctivitis is watery and that the discharge that characterizes bacterial conjunctivitis is purulent or mucopurulent (what is the difference?) and mats the lid on awakening. It seems to me that Leibowitz perpetuates a well-entrenched myth that has little, if any, scientific basis.
It is hard to imagine why a viral inflammatory process should differ in character from a bacterial inflammatory process. Certainly, in cases of pharyngitis or cases of bronchitis or pneumonia, it is not possible to examine either a pharynx or gross bronchial secretions and make the distinction between viral and bacterial causes. Why should the conjunctiva have this special property? It seems to me that the primary care practitioner cannot — and should not — rely on the gross appearance of conjunctival secretions to decide whether to prescribe antibacterial treatment, either topical or systemic.
1 ReferencesMichael K. Rees, M.D.
1415 Beacon St., Brookline, MA 024461
Leibowitz HM . The red eye. N Engl J Med 2000;343:345-351
Full Text | Web of Science | Medline
To the Editor:
An infrequent but potentially lethal cause of subconjunctival hemorrhage is near-asphyxia. Too often I have seen this diagnosis missed by primary care physicians and have later performed the autopsy, after there was repeated injury.
George R. Nichols, II, M.D.
2307 Greene Way, Louisville, KY 40220To the Editor:
The excellent review by Leibowitz on the red eye might have included another treatment for inclusion conjunctivitis (or trachoma). Azithromycin, taken in a single dose, has the advantage of high compliance as well as rates of clinical cure similar to those of tetracycline and erythromycin.
Sheila West, Ph.D.
Johns Hopkins University, Baltimore, MD 21287-9019Author/Editor Response
Dr. Leibowitz replies:
To the Editor: Strangulation, as a cause of sudden, severe venous congestion of the head, can certainly cause subconjunctival hemorrhage, but I did not cover any of the many forms of asphyxia in my review, since it is not generally encountered by ophthalmologists. I am surprised by the diagnostic importance that Nichols attributes to this sign.
West's suggestion is an important one. Because of space limitations, I did not discuss azithromycin for the treatment of ocular chlamydial infection in my article. Though a relatively new therapeutic approach, a single oral dose of azithromycin does appear to be effective in children with trachoma in areas where this disease is hyperendemic. However, I know of no studies that have demonstrated the effectiveness of this regimen for the treatment of chlamydial inclusion conjunctivitis in adolescents and adults. Since a single dose of azithromycin eradicates Chlamydia trachomatis from the urogenital tract, one might anticipate that it would be effective against the ocular infection. If it is effective, its use would indeed be advantageous and would reduce poor compliance.
With regard to Rees's challenge, I stand by my statement that “a purulent discharge generally suggests a bacterial infection, but otherwise, the nature of the discharge is not clinically useful in determining the cause.” In my article I also describe the discharge that generally accompanies acute bacterial conjunctivitis as purulent or mucopurulent (the difference is in the amount of mucus mixed with the collection of leukocytes and cellular debris) and the discharge that generally accompanies acute viral conjunctivitis as watery. These are accurate and useful characterizations. The primary care practitioner can choose to ignore the appearance of conjunctival secretions as myth, but would do so at potential peril to the patient.
Howard M. Leibowitz, M.D.
Boston University School of Medicine, Boston, MA 02118-2394- Citing Articles (2)
