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What is Follicular Conjunctivitis

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

Icon of a pink/red eyeball

Different causes may give rise to the eye conduction, including viruses, atypical bacteria, and toxins. Some of these toxins include topical medications, such as brimonidine (a type of glaucoma drug). 

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

What makes follicular conjunctivitis unique is the round-to-oval nodules of grey-white follicles in the conjunctiva. Follicles will appear pale on the surface and red at its base, with an accumulation of lymphocytes (white blood cells in the immune system).


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In some cases, when an individual does not receive proper treatment for follicular conjunctivitis, there is the risk of recurrence of infection, scarring, and blindness. 

Types of Follicular Conjunctivitis

Follicular conjunctivitis can be acute or chronic. However, causes for the eye disease can vary and lead to different classifications. Discussion about causes is presented in the following section. 

Specifically, with chronic follicular conjunctivitis, there are different types:

  • Toxic follicular conjunctivitis. This occurs when a toxic reaction occurs to a specific topical medication. To classify it, an eye doctor will perform laboratory tests to rule out chlamydial infection and discontinue 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 vector of transmission. 
  • Inclusion conjunctivitis. This ocular chlamydial infection is common in the developed world. It is a sexually transmitted infection, usually spread through genital-eye contact. Follicles in such infections will appear remarkably 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, which then go on to 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

However, bacterial infections like chlamydia may also cause an acute case of follicular conjunctivitis. In such instances, an eye doctor will use the term “inclusion conjunctivitis” to describe the infection.

The earlier section mentioned that a frequent cause of chronic follicular conjunctivitis is infection due to Chlamydiae trachomatis, a bacterial organism. This type of infection, however, can have two clinical forms: trachoma and inclusion conjunctivitis. In the latter case, non-treated or poorly treated infections can remain for more than three weeks. 

Symptoms of Follicular Conjunctivitis

Symptoms of follicular conjunctivitis include the following:

  • Hyperemia (when there is an excess of blood in the eye vessels, causing the reddish-pink eye)
  • Chemosis (when fluid accumulates in the eye to cause swelling and give 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 an individual presents with some of the symptoms mentioned above, it is best to visit the nearest eye clinic. 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 (an individual may or may not report a foreign body sensation in the eye)

If none of the above are the cause, then other diagnostic methods are applied. This helps determine what type of conjunctivitis it is, namely follicular or papillary (more prominent appearance of papillae). 

In follicular conjunctivitis cases, the follicles are often most easily seen in the inferior palpebral and forniceal conjunctiva (specific areas of the transparent membrane). Similarly, a preauricular (before the ear) lymph node is often palpable in some cases of follicular conjunctivitis. 

If eye care clinicians come across chronic follicular conjunctivitis cases, a further eye examination and laboratory testing will occur. 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. Certain medications of this kind can cause a toxic effect that results in this type of conjunctivitis. In these cases, a high level of suspicion and discontinuation of medication may be recommended to see if it is genuinely the cause of the eye problem. 

Lastly, if neither of these two causes is plausible, eye care clinicians may suspect a chlamydial infection (by C. trachomatis) and send samples to the lab for confirmation.

Treatment For Follicular Conjunctivitis 

Treatment for follicular conjunctivitis will be based on the causative agent, that is, the pathogen or topical medication that causes the eye condition. 

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. Eye care clinicians will also recommend having regular sexual partners treated to prevent the infection from reappearing. 

In follicular conjunctivitis 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. 

If individuals are considered to have viral follicular conjunctivitis, eye care clinicians will recommend that they not wear contact lenses unless symptoms have gone away. 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

Finally, 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?

If an individual presents with follicular conjunctivitis (trachoma), there is the risk of corneal blindness due to recurrent infection and conjunctival scarring. 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 and may be passed on by coming into contact with tears or discharge from the eye of an infected individual and touching your own eye.

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Author: Anthony Armenta | UPDATED January 20, 2021
Medical reviewer: Dr. Melody Huang, O.D.
Resources

“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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