Clinical Pearl

With Chlamydia conjunctivitis, find out if the patient has been exposed to domesticated birds, particularly parakeets. A sizeable number of U.S. parakeets carry the Chlamydia organism in their bodies as Chlamydia psittacosis, which causes a clinically identical picture to sexually transmitted disease. Treatment is the same: one 1000-mg dose of oral azithromycin.

ampicillin (various), amoxicillin, amoxicillin/clavulanate potassium (Augmentin, GlaxoSmithKline) or a second-generation cephalosporin such as cefuroxime (Ceftin, GlaxoSmithKline).

\section{Adult Inclusion Conjunctivitis (Chlamydia): Diagnosis}

Adult inclusion conjunctivitis, caused by Chlamydia, often manifests as a lingering, low-grade red eye with scant mucous discharge. The patient may have been self-treating for some time. Often, these cases are seen on referral from a general practitioner who treated the patient unsuccessfully with a topical eye drop that did not resolve the condition.

In reviewing the signs and symptoms, this patient may seem to have both a viral and a bacterial infection at the same time. A key point in the differential diagnosis is the asymmetry of the follicles between the two eyes. With fluorescein staining, one eye may have giant inferior follicles, while the other eye has a limited follicular response, if any. One may also see a very inflamed upper tarsal conjunctiva with papillary hypertrophy once the upper lid is everted.

If Chlamydia is suspected, it is important to ask if the patient has changed sex partners or had a new sex partner in the last few months. The patient may also have noticed burning on urination, although as many as 50\% of those with Chlamydia are asymptomatic.

Many optometrists are uncomfortable asking such personal questions, but there is no need to be embarrassed about clinically relevant details. One approach is to tell the patient that you suspect he or she has a sexually transmitted disease, so the questions do not seem out of the ordinary. Another approach is to thoroughly review systems, starting at the top with headaches, moving on to upper respiratory and breathing problems, gastrointestinal issues, and sexual partners/urination.

\begin{figure}
\centering
\includegraphics{figure_1.pdf}
\caption{Giant follicles to the inferior palpebral conjunctiva classic for chlamydial conjunctivitis.}
\label{figure_1}
\end{figure}

\section{Adult Inclusion Conjunctivitis (Chlamydia): Management}

Adult inclusion conjunctivitis is the ocular manifestation of a systemic condition; it must be addressed with systemic medication. There is no need for topical therapy, other than artificial tears if desired.

Key to successful management of Chlamydia conjunctivitis is concurrent treatment of both sexual partners so that they do not re-infect one another. For compliance and efficacy, the ideal treatment is a single 1000-mg dose of oral azithromycin\cite{34}, although 3- and 5-day courses of azithromycin have also been shown clinically to be effective\cite{35}.

It is incumbent upon us to coordinate the management of this condition with the patient's gynecologist or personal physician. Chlamydia is one of the leading causes of female infertility. Our patients---and their sexual partners---need medical care and counseling for the non-ocular aspects of this sexually transmitted disease. Chlamydia should also be reported to the local health department, which can be done online on a state-by-state basis.