The document discusses chlamydial conjunctivitis, particularly caused by Chlamydia trachomatis, highlighting its transmission, diagnosis, and treatment methods. It details the disease's progression, immune response, and complications, including trachoma, which can lead to preventable blindness due to repeated infections. Management strategies include antibiotics, hygiene improvements, and surgical interventions for severe cases.

1. CHLAMYDIAL CONJUNCTIVITIS

2. Infiltration
Scarring

3. CHLAMYDIA
Family: Chlamydiaceae
Genus: Chlamydia, Chlamydophila
C. trachomatis
• Urogenital infections, Trachoma,
• Conjunctivitis, Pneumonia,
• Lymphogranuloma venerium (LGV)
C. psittaci
• Pneumonia (Psittacosis)
C. pneumoniae
• Bronchitis, sinusitis,
• Pneumonia

4. Small obligate intracellular parasites
Contains DNA, RNA and ribosomes
Gram Negative cell wall
• Cell wall not well characterized
• Inner and outer membrane
• LPS but no peptidoglycan
Dependant on energy molecules
• Can’t make ATP
MICROBIOLOGY
Left- Cluster of spore-like, C. trachomatis
elementary bodies located intracellularly,
inside one of the larger epithelial cells. Right-
Under a magnification of 200X, Chlamydia
trachomatis bacteria, and intracellular C.
trachomatis inclusion bodies.

5. Two morphological forms
• Elementary body
• Reticulate body
Elementary bodies (EB)
• Small (0.3 - 0.4 µm), Extracellular
• Rigid outer membrane, Resistant
• Non-replicating, non-metabolically active
• Infectious
• Bind to columnar epithelial cells / Macrophages
PHYSIOLOGY AND STRUCTURE

6. Reticulate bodies (RB)
• Larger (0.8 - 1 µm)
• Intracellular
• Fragile membrane
• Metabolically active
• Replicating
• Non-infectious
EB
R
B
↓
↓
←

7. DEVELOPMENTAL CYCLE OF CHLAMYDIA
EB bind to host cells
• Epithelial cell
• Macrophage
Internalization
• Endocytosis
• Phagocytosis
Inhibition of phagosome-lysosome
fusion
Reorganization into RB
Growth of RB by binary fission
Reorganization into EB
Inclusion bodies
Release of EB
• Lysis -C.psittaci
• Extrusion - C.trachoma and
C.pneumoniae

9. PATHOGENESIS AND IMMUNITY
(C.TRACHOMATIS)
• Infects epithelial cells / Macrophages
• Down regulation of Class I MHC
• Infiltration of PMNs and lymphocytes
• Lymphoid follicle formation
• Fibrosis
• Disease results from destruction of cells and host immune response
• No long lasting immunity; reinfection results in inflammatory response

10. CHLAMYDIA TRACHOMATIS
• Adult Inclusion conjunctivitis
• Trachoma
• Pneumonia in infants
• Urogenital infections
• Reiter’s Syndrome
• Lymphogranuloma venerium (LGV)

11. ADULT INCLUSION CONJUNCTIVITIS
• Oculogenital infection usually caused by serovars (serological
variants) D–K of C. trachomatis
• Affects 5–20% of sexually active young adults in Western
countries.
• Transmission is by autoinoculation from genital secretions.
• The incubation period is approximately a week.

12. DIAGNOSIS
Symptoms:
• Subacute onset of unilateral or bilateral redness, watering and discharge.
• Untreated, becomes chronic and though self-limiting may persist for several months.
Signs:
• Watery or mucopurulent discharge.
• Tender preauricular lymphadenopathy.
• Large follicles prominent in the inferior fornix and also in the upper tarsal
conjunctiva.
• Superficial punctate keratitis.
• Perilimbal subepithelial corneal infiltrates may appear after 2–3 weeks.
• Chronic cases have less prominent follicles and commonly develop papillae.
• Mild conjunctival scarring and superior corneal pannus.

13. Adult chlamydial conjunctivitis. (A) Large forniceal follicles; (B)
superior tarsal follicles; (C) peripheral corneal infiltrates; (D)
superior pannus

14. TREATMENT
Start with Empirical treatment.
Referral to a genitourinary specialist is mandatory in confirmed cases.
Systemic therapy involves one of the following:
• Azithromycin 1 g repeated after 1 week is the treatment of choice. Some
guidelines advocate only a single 1 g dose.
• Doxycycline 100 mg twice daily for 10 days (tetracyclines are relatively
contraindicated in pregnancy/breastfeeding and in children under 12
years of age).
• Erythromycin, amoxicillin and ciprofloxacin are alternatives.

15. TREATMENT ….. CONT’D
Topical antibiotics such as erythromycin or tetracycline ointment used to achieve
rapid relief of ocular symptoms, but are insufficient alone.
Reduction of transmission risk involves abstinence from sexual contact until
completion of treatment (1 week after azithromycin).
Re-testing for persistent infection to be done 6–12 weeks after treatment.
Symptoms take weeks to settle and follicles and corneal infiltrates can take months to
resolve due to a prolonged hypersensitivity response to chlamydial antigen.

16. TRACHOMA
PATHOGENESIS
• World’s leading cause of preventable irreversible blindness
• Related to poverty, overcrowding and poor hygiene
• The morbidity is the result of the establishment of re-infection cycles within
communities
• Whereas an isolated episode of trachomatous conjunctivitis may be
relatively innocuous
• Recurrent infection elicits a chronic immune response consisting of a cell-
mediated delayed hypersensitivity (Type IV) reaction to the intermittent
presence of chlamydial antigen and can lead to loss of sight

17. • Prior contact with the organism confers short-term partial immunity but also
leads to a heightened inflammatory reaction upon re-infection
• Vaccination is not helpful.
• The fly is an important vector, but there may be direct transmission from
eye or nasal discharge
• Associated principally with infection by serovars A, B, Ba and C of
Chlamydia trachomatis
• Serovars D–K conventionally associated with adult inclusion conjunctivitis
and other species of the Chlamydiaceae family such as Chlamydophila
psittaci and Chlamydophila pneumoniae have also been implicated.

18. Diagnosis
Features are divided into an ‘active’ inflammatory stage and a
‘cicatricial’ chronic stage, with considerable overlap
WHO Grading of Trachoma
Tf = Trachomatous Inflammation (Follicular): five or more follicles (>0.5
mm) on the superior tarsal plate
TI = trachomatous inflammation (intense): diffuse involvement of the
tarsal conjunctiva, obscuring 50% or more of the normal deep tarsal vessels;
papillae are present
TS = trachomatous conjunctival scarring: easily visible fibrous white tarsal
bands
TT = trachomatous trichiasis: at least one lash touching the globe
CO = corneal opacity sufficient to blur details of at least part of the pupillary
margin

19. MACALLAN CLASSIFICATION
Stage 1: Superior tarsal follicles, mild superior SPK, and pannus,
often preceded by purulent discharge and tender preauricular node.
Stage 2: Florid superior tarsal follicular reaction (2a) or papillary
hypertrophy (2b) associated with superior corneal SEIs, pannus,
and limbal follicles.
Stage 3: Follicles and scarring of superior tarsal conjunctiva.
Stage 4: No follicles, extensive conjunctival scarring.
Late complications: Severe dry eyes, trichiasis, entropion,
keratitis, corneal scarring, superficial fibrovascular pannus,
Herbert pits (scarred limbal follicles), corneal bacterial
superinfection, and ulceration.

20. Trachoma. (A) Typical white subtarsal follicles; (B) marked
pannus; (C) stellate conjunctival scarring (arrow); (D) Arlt line
and conjunctival follicles; (E) Herbert pit (arrow); (F) cicatricial

21. Active trachoma is most common in pre-school children and is characterized by the
following:
• Mixed follicular/papillary conjunctivitis associated with a mucopurulent discharge
• Superior epithelial keratitis and pannus formation
Cicatricial trachoma is prevalent in middle age.
• Linear or stellate conjunctival scars in mild cases, or broad confluent scars (Arlt
line) in severe disease.
• Although the entire conjunctiva is involved, the effects are most prominent on the
upper tarsal plate.
• Superior limbal follicles may resolve to leave a row of shallow depressions
(Herbert pits).
Trichiasis, distichiasis, corneal vascularization and cicatricial entropion
• Severe corneal opacification.
• Dry eye caused by destruction of goblet cells and the ductules of the lacrimal
gland.

22. The SAFE strategy supported by the WHO encompasses Surgery for trichiasis,
Antibiotics for active disease, Facial hygiene and Environmental improvement.
1. Antibiotics should be administered to those affected and to all family
members. A single antibiotic course is not always effective in eliminating
infection in an individual and communities may need to receive annual
treatment to suppress infection.
• A single dose of azithromycin (20 mg/kg up to 1 g) is the treatment of choice.
• Erythromycin 500 mg twice daily for 14 days or doxycycline 100 mg twice
daily for 10 days (tetracyclines are relatively contraindicated in
pregnancy/breastfeeding and in children under 12).
• Topical 1% tetracycline ointment is less effective than oral treatment.
Management

23. 2. Facial cleanliness is a critical preventative measure.
3. Environmental improvement, such as access to adequate water and
sanitation, as well as control of flies, is important.
4. Surgery is aimed at relieving entropion and trichiasis and
maintaining complete lid closure, principally with bilamellar tarsal
rotation.