What are the causes of recurrent conjunctivitis?

Causes of Recurrent Conjunctivitis

Recurrent conjunctivitis is most commonly caused by allergies, chronic infections, underlying ocular surface disorders, and mechanical irritation, with each requiring specific identification and targeted treatment to prevent complications and improve quality of life. 1

Infectious Causes

Viral

• Adenovirus - Most common viral cause (80% of viral conjunctivitis cases) 2

  • Presents with watery discharge, follicular reaction, preauricular lymphadenopathy
  • Can cause subepithelial corneal infiltrates leading to long-term visual impairment
  • Highly contagious with potential for epidemic outbreaks

• Herpes Simplex Virus (HSV)

  • Usually unilateral but can be bilateral in atopic or immunocompromised patients
  • May recur with stress, fever, UV exposure, or immunosuppression
  • Risk of corneal involvement with potential for scarring and vision loss
  • Distinguished by vesicular eyelid lesions or dendritic epithelial keratitis 1

• Varicella Zoster Virus (VZV)

  • Associated with dermatomal rash in herpes zoster ophthalmicus
  • Can cause recurrent inflammation with risk of corneal scarring and anesthesia 1

Bacterial

• Chlamydia trachomatis

  • Serotypes D-K cause inclusion conjunctivitis
  • Serotypes A-C cause trachoma (leading infectious cause of global blindness)
  • Presents with follicular conjunctivitis and can persist for months if untreated
  • Associated with systemic manifestations (urethritis, cervicitis) 1

• Chronic bacterial infections

  • Often associated with blepharitis or meibomian gland dysfunction
  • Common organisms: Staphylococcus aureus, Staphylococcus epidermidis
  • Recurrent episodes without proper lid hygiene 3

• Parinaud oculoglandular syndrome

  • Caused by Bartonella henselae (cat scratch disease), Francisella tularensis (tularemia)
  • Unilateral granulomatous follicular conjunctivitis with regional lymphadenopathy 1

Non-Infectious Causes

Allergic

• Seasonal/perennial allergic conjunctivitis

  • Environmental allergens (pollens, grasses)
  • Characterized by intense itching, bilateral involvement
  • Recurrent with allergen exposure 1

• Vernal keratoconjunctivitis

  • Chronic, recurrent, bilateral inflammation
  • More common in young males in warm climates
  • Giant papillae on upper tarsal conjunctiva
  • Risk of corneal complications 1

• Atopic keratoconjunctivitis

  • Associated with atopic dermatitis
  • Chronic, bilateral inflammation
  • Can lead to corneal scarring and vision loss 1

Mechanical/Irritative

• Contact lens-related

  • Giant papillary conjunctivitis
  • Poor lens hygiene or protein deposits on lenses
  • Improper fit causing mechanical irritation 1

• Mucus fishing syndrome

  • Cyclical, chronic inflammation caused by repetitive mechanical removal of mucus
  • Perpetuates inflammation through trauma 1

• Floppy eyelid syndrome

  • Associated with obesity and sleep apnea
  • Mechanical irritation during sleep 1

Deficiency Diseases

• Keratoconjunctivitis sicca (Dry eye)

  • Tear film instability leading to chronic inflammation
  • Underlying cause for many recurrent conjunctivitis cases 1

• Ligneous conjunctivitis

  • Rare genetic disorder with plasminogen deficiency
  • Characterized by recurrent pseudomembrane formation
  • Can lead to significant corneal complications 1

Other Causes

• Blepharoconjunctivitis

  • Inflammation of both eyelid and conjunctiva
  • Often associated with rosacea or seborrheic dermatitis 1

• Medication-induced/preservative-induced

  • Chronic use of preserved eye drops
  • Topical medications causing allergic or toxic reactions 1

• Systemic diseases

  • Rheumatologic conditions (Sjögren's syndrome, rheumatoid arthritis)
  • Immunodeficiency disorders 4

Diagnostic Approach

1. Detailed history:

   • Duration and frequency of episodes
   • Character of discharge (watery, mucoid, purulent)
   • Associated symptoms (itching, burning, foreign body sensation)
   • Unilateral vs. bilateral presentation
   • Contact lens use and hygiene practices
   • Exposure to allergens or infected individuals

2. Key examination findings:

   • Pattern of conjunctival reaction (follicular vs. papillary)
   • Type of discharge
   • Presence of preauricular lymphadenopathy
   • Eyelid abnormalities (blepharitis, meibomian gland dysfunction)
   • Corneal involvement

Management Considerations

• Identify and treat underlying causes rather than just symptoms
• Allergic conjunctivitis: Topical antihistamines with mast cell-stabilizing activity 4
• Viral conjunctivitis: Supportive care, strict hygiene to prevent spread 4
• Bacterial conjunctivitis: Consider targeted antibiotics based on culture in recurrent cases 5
• Chlamydial conjunctivitis: Requires systemic antibiotics in addition to topical therapy 5
• Dry eye/blepharitis: Requires ongoing lid hygiene and ocular surface management 3

Pitfalls to Avoid

• Treating all cases as infectious without identifying underlying causes
• Prolonged use of topical antibiotics without clear indication
• Failure to recognize vision-threatening complications requiring specialist referral
• Missing systemic associations of recurrent conjunctivitis
• Overlooking contact lens-related issues in recurrent cases

Remember that recurrent conjunctivitis often indicates an underlying condition that requires specific diagnosis and management to prevent long-term complications affecting vision and quality of life.