History

Fact Explanation
Asymptomatic Some patients with chronic conjunctivitis can be asymptomatic. Patients with Chlamydia conjunctivitis can have a latent phase, where clinical signs and symptoms do not manifest even in the presence of infection. [6]
Red eye Patients complain of red eye which lasts for weeks (usually more than 3 weeks). [1,2]
Purulent discharge Symptoms of chronic conjunctivitis usually last for many weeks. Chronic bacterial conjunctivitis causes purulent discharge. [1,2]
Sticky eye lids Sticky eye lids is commonly encountered with bacterial conjunctivitis. Patients often complain of inability to open their eyes in waking up in the mornings.
Burning sensation This is a complain of chronic bacterial conjunctivitis. [4]
History of frequent styes Styes or external hordeola refers to the acute and focal infection of the glands of Zeis, which is commonly caused by staphylococci. Due to the close proximity these two conditions can be associated with each other. [4]
Sensation of a foreign body Patients often complain of a sensation of foreign body in the eye. Chlamydia infection can cause in-turning of the eyelids which in turn rubs against the conjunctiva. This may contribute to the development of a foreign body sensation. [4,6]
Impaired vision Patients with chronic conjunctivitis can have reduced visual acuity, finally leading to blindness after many years of disease. [6]
History of recurrent conjunctivitis Some adults are colonized by Staphylococcus aureus. These patients are at risk of recurrent conjunctivitis and chronic conjunctivitis. [1,2]
History of dacryocystitis Dacryocystitis refers to the inflammation of the lacrimal glands. Infected lacrimal glands act as foci for spreading the organism to the conjunctiva causing chronic conjunctivitis. Chlamydia trachomatis is the organism commonly causing dacryocystitis. [1]
History of blepharitis Blepharitis refers to the inflammation of the eyelids. It is commonly caused by infections like Staphylococcus aureus. Patients with blepharitis are at risk of chronic conjunctivitis. [3]
Risk factors Conjunctivitis is commoner among contact lens users. Chronic dry eye and lagophthalmos (inability to close the eyes completely) are predisposing factors for recurrent conjunctivitis. People who live in crowded areas under unhygienic circumstances are at increased risk of chlamydia infection. Immunodeficiency syndromes, chemotherapy and systemic immunosuppression are other predisposing factors for bacterial conjunctivitis. [1,5,6]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 23 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. HøVDING GUNNAR. Acute bacterial conjunctivitis. [online] 2008 June, 86(1):5-17 [viewed 23 August 2014] Available from: doi:10.1111/j.1600-0420.2007.01006.x
  3. BEZDETKO PA, SERGIENKO N, DYOMIN Y, KOROL A, NIKITIN N, MERZBACHER M, GROß D, KOHNEN R. Successful treatment of blepharitis with bibrocathol (Posiformin® 2 %) Graefes Arch Clin Exp Ophthalmol [online] 2012 Dec, 250(12):1869-1875 [viewed 23 August 2014] Available from: doi:10.1007/s00417-012-2001-0
  4. MORROW GL, ABBOTT RL. Conjunctivitis. Am Fam Physician [online] 1998 Feb 15, 57(4):735-46 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9490996
  5. BAUTISTA MARNELLI A., QUAN WALTER D. Y., WANG JUN. A Case of Chronic Conjunctivitis following Rituximab Therapy. Advances in Hematology [online] 2009 December, 2009:1-4 [viewed 23 August 2014] Available from: doi:10.1155/2009/272495
  6. HU VH, HOLLAND MJ, BURTON MJ. Trachoma: Protective and Pathogenic Ocular Immune Responses to Chlamydia trachomatis PLoS Negl Trop Dis [online] , 7(2):e2020 [viewed 23 August 2014] Available from: doi:10.1371/journal.pntd.0002020

Examination

Fact Explanation
Examination of conjunctiva Conjunctival follicles and papillae can be seen in chronic conjunctivitis caused by Chalamydia. Follicles are caused by subepithelial collections of lymphoid cells. These appear as small, yellow-white elevations over the conjunctiva. Engorged small vessels are seen as papillae. Conjunctival edema (chemosis) can be detected due to the presence of inflammation. This occurs with dilatation and increased permeability of the vessels in the conjunctiva. [1]
Entropion Entropion is the in-turning of the eyelids which causes continuous rubbing over the conjunctiva causing conjunctival scarring subsequently. [1]
Corneal opacification Corneal opacifications can be observed in patients with chronic conjunctivitis due to chlamydia infection. This is a sinister sign and it may threaten the vision. [1]
Discharge Purulent discharge can be seen in bacterial conjunctivitis. [2]
Erythema Erythema of the conjunctiva can be seen due to inflammation. [2,3]
Visual acuity Visual acuity should be checked in every patient. It can be reduced due to excessive purulent discharge. Patients with chronic chlamydial conjunctivitis may have reduced visual acuity. [1]
References
  1. HU VH, HOLLAND MJ, BURTON MJ. Trachoma: Protective and Pathogenic Ocular Immune Responses to Chlamydia trachomatis PLoS Negl Trop Dis [online] , 7(2):e2020 [viewed 23 August 2014] Available from: doi:10.1371/journal.pntd.0002020
  2. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 23 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  3. MORROW GL, ABBOTT RL. Conjunctivitis. Am Fam Physician [online] 1998 Feb 15, 57(4):735-46 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9490996

Investigations - for Diagnosis

Fact Explanation
Culture Microbial culture is useful in isolating the infectious organism in chronic conjunctivitis. [2,3]
Conjunctival biopsy Histological examination of the conjunctival biopsy shows mild to moderate epithelial hyperplasia. Inflammatory reaction causes aggregates of macrophages, T cells and polymorphonuclear leucocytes. Presence of lymphoid follicles indicates the presence of active trachoma, [1]
Investigations used to isolate Chlamydia Enzyme immuno-assays, cell cultures, direct fluorescent monoclonal antibody staining, DNA hybridization assays, polymerase chain reaction tests are useful investigations in isolating chlamydia trachomatis which is responsible for chronic conjunctivitis. [3,4]
References
  1. HU VH, HOLLAND MJ, BURTON MJ. Trachoma: Protective and Pathogenic Ocular Immune Responses to Chlamydia trachomatis PLoS Negl Trop Dis [online] , 7(2):e2020 [viewed 23 August 2014] Available from: doi:10.1371/journal.pntd.0002020
  2. ARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 23 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  3. MORROW GL, ABBOTT RL. Conjunctivitis. Am Fam Physician [online] 1998 Feb 15, 57(4):735-46 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9490996
  4. LIETMAN TOM, BROOKS DAVID, MONCADA JEANNE, SCHACHTER JULIUS, DAWSON CHANDLER, DEAN DEBORAH. Chronic Follicular Conjunctivitis Associated with or . CLIN INFECT DIS [online] 1998 June, 26(6):1335-1340 [viewed 23 August 2014] Available from: doi:10.1086/516373

Management - General Measures

Fact Explanation
Health education Patients with chronic conjunctivitis should be advised to maintain proper facial hygiene by regularly washing ocular and nasal secretions and to keep their eyes clean with minimal touching. Infected persons should use a handkerchief and should wash their hands before touching the eyes. Patients who had gonococcal or chlamydial conjunctivitis should be educated about the barrier methods of contraception and their sexual partners should be traced and treated as well. Patients should refrain form using contact lenses until the infection settles. Disposable lenses should replaced with new ones. They should adhere to proper cleaning of the lenses as recommended. [1,2]
References
  1. HU VH, HOLLAND MJ, BURTON MJ. Trachoma: Protective and Pathogenic Ocular Immune Responses to Chlamydia trachomatis PLoS Negl Trop Dis [online] , 7(2):e2020 [viewed 23 August 2014] Available from: doi:10.1371/journal.pntd.0002020
  2. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 23 August 2014] Available from: doi:10.3949/ccjm.75.7.507

Management - Specific Treatments

Fact Explanation
Antibiotics Most of the infective organisms causing conjunctivitis can be treated with topical antibiotics, however some patients may require systemic antibiotics. Antibiotic treatment should be guided by the antibiotic sensitivity of the organism. Azithromycin is proven to be highly effective in treatment of trachoma, which also effective in reducing the incidence of trachoma among untreated individuals. [1,2,3,4]
References
  1. VAN WINKELHOFF AJ, ABBAS F, PAVICIC MJ, DE GRAAFF J. Chronic conjunctivitis caused by oral anaerobes and effectively treated with systemic metronidazole plus amoxicillin. J Clin Microbiol [online] 1991 Apr, 29(4):723-725 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC269860
  2. SULIS G, URBINATI L, FRANZONI A, GARGIULO F, CARVALHO AC, MATTEELLI A. Chlamydia trachomatis conjunctivitis in a male teenager: a case report. Infez Med [online] 2014 Jun, 22(2):140-3 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24955802
  3. CHIDAMBARAM J. D., MELESE M., ALEMAYEHU W., YI E., PRABRIPUTALOONG T., LEE D. C., CEVALLOS V., ZHOU Z., WHITCHER J. P., GAYNOR B. D., LIETMAN T. M.. Mass Antibiotic Treatment and Community Protection in Trachoma Control Programs. Clinical Infectious Diseases [online] 2004 November, 39(9):e95-e97 [viewed 23 August 2014] Available from: doi:10.1086/424747
  4. TAYLOR K. I, TAYLOR H. R. Distribution of azithromycin for the treatment of trachoma. British Journal of Ophthalmology [online] 1999 February, 83(2):134-135 [viewed 23 August 2014] Available from: doi:10.1136/bjo.83.2.134