Follicular Conjunctivitis

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What is Follicular Conjunctivitis

Follicular conjunctivitis is the swelling or inflammation of the conjunctiva in the eye. The conjunctiva is a fine, transparent layer of tissue. It borders the inner eyelid and spans the sclera (the white ocular surface). 

Eye Anatomy

There are many causes of follicular conjunctivitis including viruses, atypical bacteria, and toxins. Some of these toxins include topical medications, such as brimonidine (a type of glaucoma drug). 

Follicular conjunctivitis looks like “pink eye.” Some cases are acute (such as viral conjunctivitis), while others may be chronic (such as toxic conjunctivitis). 

What makes follicular conjunctivitis unique is the rounded nodules of grey-white follicles that appear in the conjunctiva. Follicles will turn pale on the surface and red at the base. This is due to an accumulation of lymphocytes (white blood cells in the immune system).

Follicular Conjunctivitis

If an individual does not receive proper treatment for follicular conjunctivitis, there is a risk of recurrence of infection, scarring, and blindness

Types of Follicular Conjunctivitis

Follicular conjunctivitis can be acute or chronic. The cause of your disease will determine its classification. Discussion about causes is presented in the following section. 

There are several types of chronic follicular conjunctivitis:

  • Toxic follicular conjunctivitis. This is a toxic reaction to a specific topical medication. An eye doctor will perform laboratory tests to rule out chlamydial infection. Then you'll stop using the drug in question to see if there is an improvement.  
  • Trachoma. This eye disease is an infection caused by the bacterium Chlamydia trachomatis. It is more common in developing countries, with the fly being the primary form of transmission. 
  • Inclusion conjunctivitis. This is a chlamydial infection in your eye. It is common in the developed world. It is a sexually transmitted infection, usually spread through genital-eye contact. Follicles in such infections will appear much larger than those observed in viral conjunctivitis.
  • Follicular conjunctivitis due to molluscum lesions. This type of eye condition appears in response to the molluscum contagiosum virus. This virus causes lesions to form on and around the eyelid margins. These infect the conjunctiva, causing a follicular reaction. In individuals living with HIV, lesions can be more prevalent and widespread.

Trachoma is the leading cause of corneal blindness globally. 

What Causes Follicular Conjunctivitis? 

In acute follicular conjunctivitis, the most common cause is viral.

Here is a list of viral infections associated with acute cases of the eye condition:

  • Epidemic keratoconjunctivitis 
  • Herpes zoster keratoconjunctivitis 
  • Infectious mononucleosis 
  • Epstein-Barr virus

Bacterial infections (like chlamydia) may also cause acute follicular conjunctivitis. In such instances, an eye doctor will use the term “inclusion conjunctivitis” to describe the infection.

As discussed in the previous section, chronic follicular conjunctivitis can be caused by:

  • Reactions to topical medications
  • Bacterial infections
  • Viral infections

A common cause of chronic follicular conjunctivitis is the bacteria Chlamydiae trachomatis. This type of infection can have two clinical forms: trachoma and inclusion conjunctivitis. If inclusion conjunctivitis is not treated properly, infections can remain for more than three weeks. If trachoma is not treated, it can lead to blindness.

Symptoms of Follicular Conjunctivitis

Symptoms of follicular conjunctivitis include the following:

  • Hyperemia (an excess of blood in the eye vessels, causing the reddish-pink eye)
  • Chemosis (fluid accumulation in the eye that causes swelling and gives a “big blister” appearance)
  • Watery discharge 
  • Pus discharge
  • Photophobia (exposure to light causes pain or discomfort in the eye)
  • Periorbital pain (individuals feel pain in, around, or behind the eye)

How is Follicular Conjunctivitis Diagnosed?

If you have any symptoms mentioned above, call your eye doctor immediately. An optometrist or ophthalmologist can perform a differential diagnosis to rule out all possible causes, such as:

  • Uveitis (inflammation of the uveal tract)
  • Keratitis (an inflammatory eye condition that affects the cornea)
  • Foreign body (items such as dirt, eyelashes, or debris stuck in your eye)

If none of the above are the cause, they will move on to other tests. This helps determine what type of conjunctivitis it is.

In follicular conjunctivitis cases, the follicles are most noticeable in the inferior palpebral and forniceal conjunctiva (specific areas of the transparent membrane). Your preauricular lymph node (in front of your ear) will often be swollen. 

Conjunctiva Anatomy

An eye doctor will perform an eye examination and laboratory testing. They may look for molluscum lesions to determine if those are the cause for recurrence. 

If eye care clinicians do not find anything, they may request a detailed history of a topical medication. In these cases, you will discontinue using the medication to see if it is genuinely the cause of infection. 

If these causes are not likely, eye care clinicians may suspect a chlamydial infection (by C. trachomatis). They will send samples to the lab for confirmation.

Treatment For Follicular Conjunctivitis 

Treatment for follicular conjunctivitis will be based on the cause of infection. 

In chlamydial infections, eye care clinicians may prescribe an oral antichlamydial antibiotic. The most effective antibiotics of this type include azithromycin or doxycycline. However, the antibiotic regimen may also include tetracycline or erythromycin. All regular sexual partners should be treated as well to prevent the infection from reappearing. 

In cases due to molluscum lesions, an eye surgeon will remove the lesion either by excision or curettage (scooping or scraping tissue). Topical medications do not work in such cases. 

For viral follicular conjunctivitis, eye care clinicians will recommend patients to stop wearing contacts. Most cases self-resolve within two weeks. Other advisable treatments include:

  • Frequent hand washing and disinfection
  • No use of cosmetic products 
  • Cold compress
  • Artificial tear eye drops

Eye care clinicians may prescribe topical corticosteroids in special cases with photophobia and decreased vision

Common Questions and Answers

Can you go blind from conjunctivitis?

Follicular conjunctivitis (trachoma) has the potential to cause blindness. These infections are recurrent and can cause conjunctival scarring, leading to blindness. However, the prevalence of this type of conjunctivitis is not high in developed countries like the United States. 

Other types of follicular conjunctivitis do not cause blindness. However, individuals should seek treatment, as an eye infection may indicate a more serious, underlying disease. 

What is the prognosis for follicular conjunctivitis?

The prognosis for follicular conjunctivitis is generally good if individuals visit an eye clinic and seek proper treatment. 

If not treated, the infection may reappear at a later time. This is the case for untreated chlamydial infection. In trachoma cases, the prognosis could be worse (scarring and corneal blindness) if treatment is not received. 

Is acute follicular conjunctivitis pink eye?

Acute follicular conjunctivitis can be pink eye due to the reddening of the eyes. However, it is important to understand that not all pink eye cases will be acute follicular conjunctivitis. Pink eye can also be a case of papillary conjunctivitis, and the cause may be different.

Is follicular conjunctivitis contagious?

Follicular conjunctivitis can be contagious in some cases. An example of this is inclusion conjunctivitis, which is caused by the bacteria Chlamydiae trachomatis. An individual with this type of infection can spread the bacteria to other individuals via sexual transmission or genital-ocular transmission. Epidemic keratoconjunctivitis is quite contagious. It can be passed through tears or discharge from the eye of an infected individual and touching your own eye.

Resources
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“Chronic Follicular Conjunctivitis.” Chronic Conjunctivitis, Part 1: Chronic Follicular Conjunctivitis, www.aao.org/focalpointssnippetdetail.aspx?id=9980fabb-4860-46fb-b49d-b804ec97d557.

“Follicular Conjunctivitis.” Follicular Conjunctivitis | Columbia Ophthalmology, www.columbiaeye.org/education/digital-reference-of-ophthalmology/cornea-external-diseases/infectious/follicular-conjunctivitis.

“Papillary Versus Follicular Conjunctivitis.” Clinical Education - Book Excerpts, American Academy of Ophthalmology, www.aao.org/bcscsnippetdetail.aspx?id=9d2ac3f7-43cb-4096-9c26-3c7b6d052e20.

Solano, Daniel. “Viral Conjunctivitis.” StatPearls [Internet]., U.S. National Library of Medicine, 30 Oct. 2020, www.ncbi.nlm.nih.gov/books/NBK470271/.

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