When should I consider referring a patient with bacterial conjunctivitis to an ophthalmologist?

You should consider referring a patient with bacterial conjunctivitis to an ophthalmologist in several specific situations, particularly if there are signs of severe disease or complications ¹,².

• Ophthalmia Neonatorum: All cases of neonatal sticky eye with redness require urgent referral to ophthalmology to prevent serious systemic and local complications ¹,². Management often involves input from paediatrics ¹,².
• Suspected Herpes Infection: Ocular infection with herpes simplex or herpes zoster requires urgent specialist assessment and treatment with oral antivirals ¹,².
• Contact Lens Use: If the conjunctivitis is associated with contact lens use and topical fluorescein reveals corneal staining (epithelial defect), urgent referral is required as this can be a sight-threatening condition ¹,². Bacterial keratitis can also occur in contact lens wearers ¹. Do not give antibiotics in the interim as this may interfere with corneal culture ¹,².
• Recurrent and Persistent Conjunctivitis: If symptoms persist after 10 days, it is recommended to stop all drops and refer to ophthalmology ¹. Discussion with ophthalmology is also recommended for recurrent or persistent conjunctivitis ¹.
• Red Flags for Serious Causes: Arrange urgent assessment by ophthalmology if the person has any red flag indicating a serious cause of red eye, maintaining a low threshold for referral to avoid missing sight-threatening conditions ¹,².
• Suspected Gonococcal or Chlamydial Conjunctivitis: Consider this possibility in sexually active individuals or children of any age where sexual abuse is suspected ¹.
• Suspected Periorbital or Orbital Cellulitis: This requires urgent assessment by ophthalmology ¹,².
• Severe Disease: Refer urgently if there is corneal ulceration, significant keratitis, or the presence of a pseudomembrane ¹,².
• Recent Intraocular Surgery: Patients with recent intraocular surgery presenting with conjunctivitis should be referred ¹,².
• Associated Systemic Conditions or Immunocompromise: Refer if the conjunctivitis is associated with a severe systemic condition such as rheumatoid arthritis or if the patient is immunocompromised ¹,².
• Diagnostic Uncertainty: Discuss with or refer to ophthalmology if there is diagnostic uncertainty or if appropriate diagnostic equipment is not available ¹,².
• Molluscum Contagiosum: Consider referral if conjunctivitis is thought to be due to molluscum contagiosum ¹.