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Inclusion conjunctivitis in adults

Inclusion conjunctivitis in adults usually presents with a history of several weeks or months of a red, irritable eye with a sticky discharge. Often the symptoms are in one eye only. Clinical signs include large lymphoid follicles and papillary hyperplasia of the palpebral conjunctiva, with or without conjunctivitis. On close questioning a large proportion of female patients, more than male patients, admit to some genito-urinary symptoms. The differential clinical diagnosis includes adenovirus, herpes simplex virus, vernal conjunctivitis and staphylococcal conjunctivitis. Otitis media is a relatively common complication. An excellent and reasonably accessible account of the clinical features is given in Viswalingam et al., 1983.

Chlamydial inclusion conjunctivitis is caused by genital tract serovars D to K of C. trachomatis. Many, but by no means all cases, will be found to have a concomitant chlamydial genital tract infection, usually asymptomatic, [an association noted by Mordhorst 1967]. Analysis of the nucleic acid [PCR-genotyping] or the serovar of the ocular and genital infecting strains shows that they are essentially identical [Garland et al., 1995; Isobe et al., 1996]. It is usually considered, albeit with little or no direct evidence, that the infection is caused by infected genital tract secretion transferred to the eye by the hands. While this seems entirely likely, one study of persons with just one eye infected found no relationship between the eye infected and whether the individual was left or right handed [Postema et al., 1996]. Approximately 1 in 300 cases of chlamydial genital tract infection were found to have associated chlamydial adult inclusion conjunctivitis, but this is almost certainly an underestimate due to the relatively insensitive methods then available [Tullo et al., 1981].


The trachoma serovars of C. trachomatis (serovars A, B, Ba & C) and the oculo-genital serovars D to K associated with adult inclusion conjunctivitis do not appear to differ greatly in their virulence. In trachoma, the complications arise from the fact that, where the disease is endemic, repeated infection is common and leads to increased severity [see: *Immunopathogenesis.RepeatedInfections*]. In adult inclusion conjunctivitis secondary to genital tract infection, there is not the same likelihood of re-infection. Furthermore, in developed countries there is a greater likelihood that the infection will be treated promptly. Thus conjunctival scarring is rarely a complication of adult inclusion conjunctivitis, although micro-pannus, and micro ulceration of the cornea following punctate keratitis do, rarely, occur [Darougar & Viswalingam, 1988].


Laboratory testing is usually required to establish, with any certainty, the cause of follicular conjunctivitis in the adult. This is because other agents, most notably adenovirus, may cause a similar clinical appearance. Very occasionally, adenoviral and chlamydial co-infection occur together. This should be considered in patients with prolonged follicular keratoconjunctivitis [Mellman-Rubin et al., 1995].

Table 1: Clinical comparisons of different causes of adult conjunctivitis. (After Viswalingam et al., 1983).

Causative agent / condition Remarks
Adenovirus Acute papillary and follicular conjunctivitis. Initially unilateral, usually becomes bilateral in 5 – 7 days. Tearing, puffy lids, preauricular lymphadenopathy more pronounced than in chlamydial disease. Ecchymosesof bulbar conjunctiva and petaechial hameorrhages of the palpebral conjunctiva are common. Follicles smaller, less florid than chlamydial. Keratitis involving pupillary area gives rise to symptoms of severe photophobia and blurring of vision
Herpes simplex virus Occasionally presents as acute follicular conjunctivitis without lid vesicles or corneal ulcers, when usually misdiagnosed as adenovirus conjunctivitis. 7 – 14 days after onset of conjunctivitis a punctate keratitisleading to erosions or to dendritic corneal ulcers may occur. Often a history of recurrence indicates HSV.
Staphylococci Usually bilateral and associated with blepharitis, meibomitis & / or chalazia. Marginal infiltrates usually dense and yellowish. Superficial vascularization of upper & / or lower zones of cornea. Conjunctival swabs Gram stained or cultured show S. aureus.
Rosacea Blepharoconjunctivitis associated with M. furfur. Similar to Staphylococcal disease but characteristic telangiectasia of vessels of lids, face and especially nose.
Vernal or atopic ‘Allergic’ conjunctivitis is associated with atopy or use of certain drugs. Limbal & bulbar follicles common in atopic form. Whitish, large, cobblestone papillae in vernal conjunctivitis. Cytology smear shows eosinophils. Personal history of allergy.
Molluscum contagiosum Chronic keratoconjunctivitis similar to chlamydial. Initial nodule easily over-looked. Umbilicated appearance of nodule and presence of characteristic eosinophilic inclusion bodies in a cytology smear is diagnostic.
Chlamydia A chronic follicular conjunctivitis, usually unilateral, sub-acute onset. Symptoms: foreign-body sensation, tearing, mucoid discharge, redness, photophobia, swelling of lids. Incubation usually 1 – 3 weeks. Palpebral conjunctiva show follicles, predominantly in upper and lower fornices but also around the caruncle and on the plica. Usually pronounced papillae on tarsal conjunctiva. Cornea usually not affected but occasionally a fine punctate keratitis which resolves spontaneously.

Conjunctival chlamydial infection is best demonstrated either by staining a conjunctival smear with C. trachomatis-specific fluorescent monoclonal antibody, or by the use of commercial nucleic acid-based diagnostic kits. Interestingly, the addition of per nasal swabbing led, in one study, to a 53% increase in the isolation of chlamydia by culture and a 27% increase for adenovirus [Morton et al., 1990].


It is essential that all patients with chlamydial conjunctivitis and their sexual partners are examined and treated for concomitant chlamydial genital tract infection [Garland et al., 1995]. Inclusion conjunctivitis generally responds well to the kind of regimens of macrolide or doxycycline used for treating chlamydial genital tract infection [Stenberg & Mardh, 1993; Viswalingam et al., 1986]. In the case of doxycycline, treatment with a weekly dose of 300 mg for three weeks or a daily dose of 1.5 mg/kg of body weight (100 mg) for one week produced a clinical and microbiological cure in 100% of 93 patients with adult chlamydial conjunctivitis. However, mild to moderate papillary responses persisted in some patients up to six months from completion of their treatment. The best results were obtained with a daily dose of 100 mg for two weeks, which produced rapid clinical and microbiological cure in all patients [Viswalingam et al., 1986]. The use of azithromycin for the treatment of trachoma suggests that it is likely to be a convenient and effective drug for use in treating adult chlamydial inclusion conjunctivitis.

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Darougar, S. & Viswalingam, N. D. (1988). Marginal corneal abscess associated with adult chlamydial ophthalmia. British Journal of Ophthalmology 72, 774 – 777.

Garland, S. M., Malatt, A., Tabrizi, S., Grando, D., Lees, M. I., Andrew, J. H. & Taylor, H. R. (1995). Chlamydia trachomatis_ conjunctivitis. Prevalence and association with genital tract infection. Medical Journal of Australia 162, 363 – 866.

Isobe, K., Aoki, K., Itoh, N., Ohno, S., Takashima, I. & Hashimoto, N. (1996). Serotyping of Chlamydia trachomatis from inclusion conjunctivitis by polymerase chain reaction and restriction fragment length polymorphism analysis. Japanese Journal of Ophthalmology 40, 279 – 285.

Mellman-Rubin, T. L., Kowalski, R. P., Uhrin, M. & Gordon, Y. J. (1995). Incidence of adenoviral and chlamydial coinfection in acute follicular conjunctivitis. American Journal of Ophthalmology 119, 652 – 554.

Mordhorst, C. H. (1967). Studies on oculogenital TRIC agents isolated in Denmark. American Journal of Ophthalmology 63, Suppl:1282 – 1288.

Morton, C. E., Mallinson, H., Clearkin, L. G., Ansons, A. M., Kaye, L. C. & Mutton, K. J. (1990). Per-nasal swabbing as an aid to the diagnosis of chlamydial and adenovirus conjunctivitis. Eye 4, 510 – 513.

Postema, E. J., Remeijer, L. & van der Meijden, W. I. (1996). Epidemiology of genital chlamydial infections in patients with chlamydial conjunctivitis; a retrospective study. Genitourinary Medicine 72, 203 – 205.

Stenberg, K. & Mardh, P. A. (1993). Treatment of concomitant eye and genital chlamydial infection with erythromycin and roxithromycin. Acta Ophthalmology (Copenhagen) 71, 332 – 335.

Tullo, A. B., Richmond, S. J. & Easty, D. L. (1981). The presentation and incidence of paratrachoma in adults. Journal of Hygiene (London) 87, 63 – 69.

Viswalingam, N. D., Darougar, S. & Yearsley, P. (1986). Oral doxycycline in the treatment of adult chlamydial ophthalmia. British Journal of Ophthalmology 70, 301 – 304.

Viswalingam, N. D., Wishart, M. S. & Woodland, R. M. (1983). Adult chlamydial ophthalmia. British Medical Bulletin 39, 123 – 127. [Old review, but there is still much relevant clinical information in this BMB devoted entirely to chlamydia and their infections].