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Chronic Conjunctivitis

ROUTINE — Conjunctiva

Symptoms

  • Persistent red eye (conjunctival hyperemia) lasting >4 weeks.
  • Conjunctival discharge and foreign body sensation.
  • Eyelids sticking together upon awakening.

Clinical Findings

General characteristics

  • Persistent follicular or papillary conjunctival reaction (>3–4 weeks).
  • Possible superior corneal pannus, palpable preauricular nodes, or peripheral subepithelial infiltrates.

Adult inclusion conjunctivitis (chlamydial)

  • Unilateral chronic follicular reaction with stringy mucoid discharge.
  • Presence of a palpable preauricular node in a sexually active adult.
  • Often misdiagnosed as refractory bacterial or viral conjunctivitis.

Molluscum contagiosum

  • Small, dome-shaped, pearly-white umbilicated nodules on the lid margin.
  • Causes a secondary toxic follicular conjunctivitis due to viral shedding.

Trachoma (c. trachomatis serotypes a–c)

  • Leading infectious cause of blindness; endemic in regions with low sanitation.
  • Superior tarsal follicles lead to cicatricial scarring, entropion, and trichiasis.
  • Pathognomonic Herbert pits: Scarred follicles at the limbus.

Parinaud oculoglandular syndrome

  • Unilateral granulomatous/follicular conjunctivitis with prominent ipsilateral lymphadenopathy.
  • Most common trigger: Cat-scratch disease (Bartonella henselae).

Masquerade syndromes

  • Sebaceous gland carcinoma: Chronic unilateral blepharoconjunctivitis in elderly patients (requires biopsy).
  • Conjunctival lymphoma: Characterized by "salmon-patch" lesions.

Etiology

Infectious

  • Chlamydia (Adult Inclusion D–K or Trachoma A–C).
  • Molluscum contagiosum, Microsporidia, or Bartonella.

Non-infectious / toxic

  • Drug-Induced: Chronic use of drops with BAK, brimonidine, or antivirals (especially trifluridine).
  • Mechanical: Trichiasis, floppy eyelid syndrome, or retained foreign bodies.

Allergic & atopic

  • Vernal keratoconjunctivitis (VKC): Giant "cobblestone" papillae and Horner-Trantas dots.
  • Atopic keratoconjunctivitis (AKC): Associated with atopic dermatitis; high risk for fibrosis.

Masquerade

  • Sebaceous carcinoma, OSSN/CIN, or ocular cicatricial pemphigoid (MMP).

Red Flags

  • Unilateral conjunctivitis >3 weeks: Must rule out molluscum, chlamydia, or sebaceous gland carcinoma.
  • New symblepharon formation: High suspicion for mucous membrane pemphigoid (MMP).
  • Blood-stained discharge: Suggests potential granulomatous disease or tumor.
  • Extensive molluscum lesions in an adult: Mandatory HIV testing.

Investigations

Clinical exam

  • Evert eyelids to inspect tarsal conjunctiva for follicles, papillae, and scarring.
  • Check for lid-margin nodules (molluscum) and meibomian gland health.

Laboratory testing

  • Chlamydia: PCR/NAAT of a conjunctival swab (most sensitive).
  • Giemsa stain: Look for basophilic intracytoplasmic inclusion bodies.
  • Microsporidia: Confocal microscopy or conjunctival scrapings.

Biopsy

  • Mandatory for suspicious unilateral upper-lid disease to rule out sebaceous gland carcinoma.
  • Indicated for suspected lymphoma or pemphigoid (with DIF).

Treatment

Chlamydial (adult inclusion)

  • Oral Azithromycin (1 g single dose) or Doxycycline (100 mg BID × 7 days).
  • Treat sexual partners simultaneously to prevent reinfection.

Trachoma

  • WHO SAFE strategy: Surgery (for trichiasis), Antibiotics (Azithromycin), Facial cleanliness, Environmental improvement.

Molluscum contagiosum

  • Surgical excision or cryotherapy of the lid-margin lesion; conjunctivitis resolves post-removal.

Toxic / drug-induced

  • Discontinue the offending topical agent; resolution typically occurs within 2–4 weeks.

Microsporidia

  • Topical fumagillin or PHMB; coordinate care with an infectious disease specialist if HIV+.

Clinical Pearl

Chronic follicular conjunctivitis in a sexually active adult is adult inclusion conjunctivitis until proven otherwise. Success requires oral antibiotics for both the patient and their partners, not just topical drops.

Differential Diagnosis

  • Parinaud oculoglandular syndrome
  • Superior limbic keratoconjunctivitis (SLK)
  • Toxic follicular conjunctivitis
  • Ocular rosacea

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