**9. Adult inclusion conjunctivitis**

Chlamydia sexually transmitted diseases account for more than 500 million cases world‐ wide; but the exact prevalence of adult inclusion conjunctivitis is unknown because infec‐ tion is usually self-limited and does not always reach medical attention. The primary source of infection is from cervicitis in females and urethritis in males. The spread is from "hand -to genital tract -to eye" (during sexual activity). The incubation period is considered to be ap‐ proximately 5 to 19 days. Persons between the ages of 15 and 30 years are at highest risk for adult inclusion conjunctivitis.

#### **9.1. Clinical features**

Symptoms include:

Foreign body sensation.

Mild photophobia and

Mucopurulent discharges from the eyes.

Signs are:

Transmission of trachoma is closely associated with personal hygiene and environmental sanitation. Facial cleanliness and environmental improvements the F&E components of the SAFE strategy are primarily targeting the transmission of C. trachomatis between individu‐ als. Numerous epidemiological studies have found an association between dirty faces and

Eye-seeking flies are a common feature of many trachoma endemic communities and have long been considered a potential vector. Chlamydia trachomatis was found (by PCR) on 15%

Many trachoma control programmes actively advocate for general improvements in water supply (for face washing) and sanitation (to suppress fly populations). This drive has fortu‐ nately coincided with the setting of the United Nations' Millennium Development Goals (MDG). The target for the seventh MDG is to halve the number of people without safe water

Every case of conjunctivitis should be treated as early as possible to reduce transmission of

WHO has recommended this regime to be carried out in endemic areas to minimize the in‐ tensity and severity of trachoma. The regime is to apply 1 percent tetracycline eye ointment

In previously endemic countries in Europe and elsewhere, trachoma declined in the face of general improvements in living conditions and health. Such changes are beginning to hap‐ pen in some parts of currently endemic countries. However, for many communities it may take many decades for general improvements in living standards to happen and to have an impact on trachoma. Therefore, it is necessary to pro-actively implement the SAFE strategy as the best validated approach to control this blinding disease. The limited published data on the impact of implementing the SAFE strategy indicate that even in some of the most highly endemic regions, such as South Sudan, significant reductions in the prevalence of ac‐

Vaccine for C. trachomatis that would prevent and resolve infection has been slow largely because of the intracellular nature of Chlamydia and lack of ability to genetically transform the organism. However, recent advances in the field have identified some requirements for vaccine design. It is now generally accepted that MOMP, possibly with other antigens, would be important for a vaccine. However, because of the diversity of MOMP sequences that define different C. trachomatis strains, more than one MOMP would be required. The immune response that must be induced comprises mucosal sIgA antibody and systemic an‐ tigen-specific CD 4 TH1 lymphocyte responses. Protection of mice against challenge with

of flies caught leaving faces of children in a study from Ethiopia.

**3.** Blanket antibiotic therapy (intermittent treatment).

twice daily for 5 days in a month for 6 months.

**4.** The development of an efficacious vaccine:

active trachoma in children

242 Common Eye Infections

and basic sanitation by 2015

The future of trachoma control

tive disease can be achieved.

disease.

**2.** Early treatment of conjunctivitis:

Conjunctival hyperaemia more marked in the fornices.

Acute follicular hypertrophy predominantly in the lower palpebral conjunctiva

Superficial keratitis in upper hemisphere of the cornea.

Superior micropannus may also occur.

Pre-auricular lymphadenopathy is common finding.

Clinical course: the course of the disease is benign; but often evolves into the chronic follicu‐ lar conjunctivitis.

#### **9.2. Differential diagnosis**

Adults develop a follicular conjunctivitis that can be indistinguishable from that of tracho‐ ma. The follicles may be present on both the lower conjunctiva and upper tarsus. The onset is usually acute with preauricular lymphadenopathy on the involved side and a serosangui‐ neous to mucopurulent discharge. After 2 weeks of infection, corneal involvement is more prominent and includes keratitis, subepithelial opacities, and infiltrates that are marginal and/or central. Occasionally there is mild scarring and corneal vascularization referred to as micropannus, but these are late findings, usually among cases that have not been treated.

Otitis media is a common complication of chlamydial conjunctivitis. Although there can be prompt resolution of the disease, In addition there can be a genital tract disease (which fail‐ ure to treat) resulting in the recurrence of the conjunctivitis.

Inclusion conjunctivitis is caused by serotypes D to K of Chlamydia tachomatis. The LGV strains (L1, L2, and L3) of C. trachomatis are responsible for a much more severe ocular dis‐ ease referred to as Parinaud's oculoglandular syndrome. This syndrome is comprised of an inflammatory conjunctival response with severe lymphadenopathy involving the preauricu‐ lar, cervical, and submandibular nodes. The LGV serovars are uncommon in developed countries with few reports in the literature but are very common in tropical and subtropical developing countries. Occasionally keratoconjunctivitis resulting from L2 has been reported as a consequence of laboratory accidents.

#### **9.3. Treatment**

The best form of treatment for adult inclusion conjunctivitis is to prevent chlamydial sexual‐ ly transmitted diseases (STDs). Unfortunately, most chlamydial STDs are asymptomatic for males (approximately 40%) and females (approximately 70%) and usually go undetected be‐ cause routine diagnostic screening for C. trachomatis is not performed. Thus, it is important to recognize adult inclusion conjunctivitis that is caused by C. trachomatis and treat both the ocular and genital tract disease. Because chlamydial STDs cannot be resolved by topical ocu‐ lar antibiotics, systemic therapy is recommended. Most cases infected with non-LGV sero‐ vars will respond to oral tetracycline250mg four times a day for 3-4 weeks; Doxycycline100mg twice a day for 1-2 weeks or 200mg weekly for 3 weeks, or erythromycin 250mg four times a day for 3-4 weeks; when tetracycline is contraindicated as in pregnant and lactating females.

For LGV, the best treatment regimen for inclusion conjunctivitis caused by C. psittaci and C. pneumoniae is unknown, although 6 weeks of oral antibiotics has been successful in some cases for complete eradication.

#### **9.4. Prophylaxis**

Patient's sexual partner should be examined and treated.

Improvement in personal hygiene and regular chlorination of swimming pool decrease the spread of disease.
