Eye discharge

Eye discharge is any fluid or material from the eye or lids, from watery tears to mucus, pus, blood or crusts. It reflects conjunctival, corneal, lid or lacrimal disease.

Classification by character.

• Watery: viral conjunctivitis, allergy, irritation, nasolacrimal obstruction.
• Mucoid or ropy: allergic conjunctivitis (vernal), dry eye.
• Purulent: bacterial conjunctivitis, gonococcal, keratitis, dacryocystitis, canaliculitis.
• Mucopurulent: bacterial and chlamydial conjunctivitis.
• Bloody: trauma, haemorrhagic conjunctivitis, tumour.
• Crusting at the lid margin: blepharitis.

Key distinctions. Hyperacute copious purulent discharge within hours suggests gonococcal infection. Discharge with a red, painful, photophobic eye suggests keratitis. Discharge with a swollen tender medial canthus suggests dacryocystitis. A neonate with discharge in the first 28 days needs same day assessment.

History. Onset, duration, character, one or both eyes, eyes stuck shut in the morning, pain, redness, itch, grittiness, photophobia, vision change. Contact lens use, trauma, recent surgery, sexual history, contact with infected people, upper respiratory symptoms. Immunosuppression, topical drops, systemic disease, neonatal history (maternal infection, prolonged rupture of membranes), and previous episodes.

Drug history. Topical drops (preservatives), antibiotics, steroids, and drugs causing dryness.

Examination. Visual acuity, lids (swelling, crusts, ectropion, entropion, trichiasis), conjunctival injection, papillae or follicles, membrane or pseudomembrane, cornea (fluorescein staining, infiltrate, ulcer), anterior chamber (hypopyon), pupils, preauricular node, lacrimal sac (pressure with reflux of pus), nasal examination, and general examination for infection (fever, rash, genital symptoms).

Red flags

• Reduced vision, severe pain, photophobia, corneal infiltrate or hypopyon
• Hyperacute purulent discharge (gonococcal) or pseudomembrane
• Neonate with discharge in the first 28 days
• Contact lens wearer with discharge
• Chemical or penetrating injury
• Immunosuppression, diabetes or recent eye surgery
• Swollen painful lid or canthus with fever (orbital or preseptal cellulitis, dacryocystitis)
• Vesicular rash on the forehead or tip of the nose
• Proptosis or restricted eye movements

Special groups. Neonates: ophthalmia neonatorum. Children: bacterial and viral conjunctivitis, nasolacrimal obstruction. Pregnancy: avoid tetracyclines and fluoroquinolones systemically. Older adults: dry eye, lid malposition, and dacryocystitis. Region specific: trachoma, onchocerciasis, and gonococcal infection.

Conjunctival infection

• Bacterial (Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella), gonococcal, chlamydial inclusion conjunctivitis, trachoma
• Viral: adenovirus, epidemic keratoconjunctivitis, herpes simplex, varicella zoster, enterovirus, molluscum contagiosum
• Ophthalmia neonatorum (gonococcal, chlamydial, herpes simplex, chemical, bacterial)
• Parinaud oculoglandular syndrome

Corneal and intraocular

• Bacterial, fungal, acanthamoeba and herpetic keratitis, corneal ulcer, contact lens related infection
• Endophthalmitis, uveitis, dacryocystitis, canaliculitis

Lid and adnexal

• Anterior and posterior blepharitis, meibomian gland dysfunction, chalazion, hordeolum (stye), trichiasis, entropion and ectropion
• Preseptal and orbital cellulitis, lid and conjunctival tumours (sebaceous carcinoma masquerade)

Non-infectious

• Allergic, vernal, atopic and giant papillary conjunctivitis, contact dermatoconjunctivitis
• Dry eye with mucus filaments, nasolacrimal duct obstruction, floppy eyelid
• Foreign body, chemical injury, medication toxicity, Stevens Johnson syndrome, ocular cicatricial pemphigoid

Reasoning. Characterise the discharge, examine the cornea and lid margins, and treat clear cases of mild conjunctivitis. Swab and refer for severe, atypical, neonatal, contact lens related, recurrent or non-responding disease.

First line. Visual acuity, fluorescein staining, slit lamp or penlight examination, eversion of the upper lid, and palpation of the lacrimal sac.

Targeted tests.

• Conjunctival swab for Gram stain and culture in severe purulent disease, neonates, contact lens wearers, immunosuppression, recurrent disease, and treatment failure.
• Nucleic acid amplification test for chlamydia and gonorrhoea.
• Viral polymerase chain reaction or antigen test for herpes simplex and adenovirus when the diagnosis is unclear.
• Corneal scraping for Gram stain, culture and fungal stains in keratitis.
• Conjunctival scraping for Giemsa stain (eosinophils in allergy, inclusion bodies in chlamydia).
• Culture of expressed pus from dacryocystitis; CT orbit with contrast for suspected orbital cellulitis.
• Biopsy of chronic unilateral blepharoconjunctivitis not responding to treatment (sebaceous carcinoma).
• Sexual health screen, HIV test and syphilis serology when sexually transmitted infection is suspected.

Limitations. Cultures are often negative in viral and chlamydial disease. Clinical separation of bacterial from viral conjunctivitis is imperfect.

Hygiene (all patients). Clean discharge with cooled boiled water or saline and clean cotton wool or tissue, wiping from the inner to outer canthus. Use a fresh piece for each wipe. Wash hands and do not share towels or pillows. Stop contact lens wear and cosmetics until resolved. Stay away from work or school until discharge settles (infective cases).

Bacterial conjunctivitis (mild). Self limiting in 5 to 7 days. When treated: chloramphenicol 0.5 percent drops 1 drop every 2 hours for 48 hours (while awake) then 4 times daily to complete 5 days. Or fusidic acid 1 percent gel 1 drop twice daily for 7 days. Alternatives: ofloxacin 0.3 percent 1 drop four times daily for 5 days, or azithromycin 1.5 percent 1 drop twice daily for 3 days. Avoid steroid drops.

Contact lens wearers and suspected corneal involvement. Stop lens use, send lenses and case for culture, ofloxacin 0.3 percent or ciprofloxacin 0.3 percent 1 drop every 1 to 2 hours initially after scraping, and same day ophthalmology.

Gonococcal conjunctivitis. Ceftriaxone 1 g IM as a single dose (1 g IV daily for 3 days when keratitis is present), with frequent saline irrigation, same day ophthalmology, test of cure, partner treatment and sexual health care. Add doxycycline 100 mg orally twice daily for 7 days when chlamydia is not excluded.

Chlamydial conjunctivitis and trachoma. Azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days), with partner treatment; trachoma: azithromycin 20 mg/kg orally as a single dose (maximum 1 g), face washing and environmental measures, with surgery for trichiasis.

Ophthalmia neonatorum. Same day paediatric and ophthalmology care. Ceftriaxone 25 to 50 mg/kg IV or IM as a single dose (maximum 125 mg) for gonococcal infection. Azithromycin 20 mg/kg orally daily for 3 days for chlamydia. Aciclovir 20 mg/kg IV every 8 hours for suspected herpes simplex. Saline irrigation. Treatment of mother and partner.

Viral conjunctivitis. Supportive: cold compresses and lubricants (hypromellose 0.3 percent, 1 drop every 1 to 2 hours), hygiene to prevent spread.

Herpes simplex and zoster: aciclovir 3 percent ointment 5 times daily or ganciclovir 0.15 percent gel 5 times daily until healed (ophthalmology care). Valaciclovir 1 g orally three times daily for 7 days for zoster ophthalmicus.

Adjust valaciclovir for kidney function: creatinine clearance 30 to 49 mL/min, 1 g every 12 hours; 15 to 29 mL/min, 1 g daily; under 15 mL/min, 500 mg daily.

Allergic conjunctivitis. Olopatadine 0.1 percent 1 drop twice daily, cold compresses and allergen avoidance.

Blepharitis. Lid hygiene (warm compress then lid scrub twice daily), azithromycin 1 percent drops 1 drop twice daily for 3 days then once daily for 4 weeks. Doxycycline 100 mg orally daily for 6 to 12 weeks (avoid in pregnancy and children under 12 years) for meibomian gland disease. Chalazion: warm compresses, incision and curettage for persistent lesions. Stye: warm compresses and removal of the lash.

Dacryocystitis and canaliculitis. Warm compresses, amoxicillin with clavulanic acid 625 mg orally three times daily for 7 days, ENT or ophthalmology referral for drainage; IV ceftriaxone for cellulitis or systemic illness.

Preseptal and orbital cellulitis. Preseptal: amoxicillin with clavulanic acid 625 mg orally three times daily for 7 days, review at 24 to 48 hours; orbital: admit, ceftriaxone 2 g IV every 12 hours plus metronidazole 500 mg IV every 8 hours, urgent CT, and ophthalmology and ENT.

Keratitis and endophthalmitis. Emergency ophthalmology (fortified or fluoroquinolone drops after scraping; intravitreal antibiotics for endophthalmitis).

Nasolacrimal duct obstruction. Massage and observation in infants (resolves in most by 12 months), dacryocystorhinostomy in adults.

Dry eye with mucus. Lubricants, lid hygiene and ciclosporin 0.05 percent drops twice daily for moderate to severe disease.

Chemical injury and foreign body. Immediate irrigation with at least 1 to 2 L of saline or water until pH is 7.0 to 7.4, and same day ophthalmology.

Monitoring. Review at 48 to 72 hours when not improving, and at 1 to 2 weeks. Check visual acuity at each review.

Referral and escalation. Same day ophthalmology for red flags. Sexual health service for suspected gonococcal or chlamydial infection. ENT or oculoplastic surgery for lacrimal obstruction. Public health for outbreaks.

Admission criteria. Orbital cellulitis, endophthalmitis, neonatal gonococcal or herpetic infection, severe keratitis, or immunosuppressed patients with severe infection.

Discharge and safety netting. Return for pain, light sensitivity, reduced vision, swelling of the lids or face, fever, increasing discharge, or no improvement within 48 to 72 hours.