• Home
• Glaucoma Updates
• Literature Updates
• Drugs
  • Antibiotics
  • Antiviral Drugs
  • Corticosteroids
  • Glaucoma Medications
  • Ocular Allergy Drugs
  • Steroid Antibiotic
  • NSAIDS
  • Oral Medications
  • Dry Eye Intervention
• Plaquenil Updates
• Diabetes Updates
• Diabetes A1C Test
• GDx-VCC/HRT/OCT
• Exam Room Essentials
• Contact Us

Chlamydial Conjunctivitis in the Adult
(Adult Inclusion Conjunctivitis)

Subjective
A 30-year-old male presented with a history of a mildly red right eye with mild, mucoid discharge for a month. He had already been treated with tobramycin by one doctor and naphazoline hydrochloride/pheniramine maleate by another. In desperation he sought a third opinion.

Objective

• Mild conjunctival hyperemia
• Scant mucoid excess in inferior cul-de-sac
• 3+ giant follicles in the inferior conjunctival fornix (Fig. 1)
• 2+ papillary hypertrophy and injection to superior tarsal conjunctiva
• OS was entirely normal

Fig. 1 These "giant" follicles in the inferior conjunctival fornix are virtually pathognomonic of adult inclusion (chlamydial) conjunctivitis

Assessment

• Chlamydial conjunctivitis (adult inclusion conjunctivitis)

Plan

• Oral azithromycin (Zithromax) 4 - 250 mg tablets for one day
• Re-evaluate in one week

Comments: Chlamydial infections are venereal, and sexual partners merit proper care as well. This infection responds rapidly to proper systemic therapy; there is little or no need to use topical medicines, other than artificial tears. In newborn prophylaxis, however, topically applied erythromycin ophthalmic ointment is sound therapy because conjunctival mucosal infection from infected vaginal mucosa represents direct tissue inoculation (as opposed to the ocular manifestation of systemic disease seen in the adult).

General Observations

• Generally this red eye is observed unilaterally in sexually active adults. They usually present with follicular conjunctivitis, occasional swollen lids, and possible preauricular lymphadenopathy .
• Numerous giant follicles in the inferior conjunctival fornix are a classic finding and virtually pathognomonic.
• Often, the history will reveal that this condition has been going on for several weeks. Bacterial infections usually run a much shorter clinical course of one to two weeks (similar to adenoviral infections).
• A scant mucoid discharge, similar to that seen in ocular allergy is the rule. Mucopurulent discharge would be more typical with bacterial infections.
• This condition does not respond to topical antibiotics. It must be remembered that this conjunctivitis is usually an ocular manifestation of a sexually transmitted urogenital infection.
• The combined features of this disease, both historically and clinically, point to the right diagnosis. Keep a high index of suspicion in dealing with any red eye out of the usual. While hoofbeats are usually associated with horses, remember there are zebras out there, too.
• This is an excellent opportunity to work with your patient's family doctor. In fact, most of these patients we have seen over the years have been treated by other doctors with anti-bacterial eye drops to which they did not respond, and in desperation they seek a second or third opinion until they are appropriately treated.

Medical Treatment
Traditional therapy has been 1 gm of either tetracycline or erythromycin p.o. in four divided doses (250 mg q.i.d.) for three weeks. Now that doxycycline (Vibramycin) is available generically, it is much preferred over tetracycline or erythromycin. There are four reasons for this:

Doxycycline is relatively inexpensive, can be taken without regard to meals or dairy products, is taken only twice daily, and is effective with only 10 days of therapy. It is prescribed as 2 - 100 mg capsules, taken daily for 10 days.

An even newer therapy, which has become standard of care, is azithromycin, a macrolide antibiotic of which erythromycin is the prototype. For most indicated infectious processes (respiratory or soft tissue) it is used as: 500 mg the first day, followed by 250 mg for four more days. (With the new "Tri-Pack" the dosage is simply one 500 mg tablet taken over three days.) However, it has been shown to be effective against chlamydial infections as: 4 - 250 mg capsules, or two 500 mg capsules (1 gram) for only one day or a single dose of a 1000 mg suspension. Azithromycin has become our usual therapy for adult inclusion conjunctivitis.