Can chlamydial conjunctivitis result from direct ejaculation into the eye?

The majority of cases of chlamydial conjunctivitis are thought to result from autoinoculation by the patient of infected genital secretions from themselves or their sexual partners. We noted that some patients had developed symptoms following direct ejaculation into the affected eye. We describe four cases of chlamydial conjunctivitis following ejaculation of semen directly into the eye, which have not been previously described. In only one case was chlamydia detected in the genital tract. In three cases, there was no evidence of genital chlamydial infection; the sources of the eye infection being either from infected genital material of their sexual partners transferred by hands to the eyes, or more likely from direct ejaculate inoculation. It is likely that this mode of transmission is underestimated as a history of ejaculation into the conjunctiva is not normally asked for.

Otitis media in adults with chlamydial conjunctivitis.

The aim of this study was to assess the prevalence of otological symptoms in patients with chlamydial conjunctivitis. We report four cases of chlamydial conjunctivitis, in association with otitis media, that were investigated by an otologist.

Interpretation of Chlamydia trachomatis antibody response in chlamydial oculogenital infection.

OBJECTIVE: To study: (a) the chlamydial antibody response (to the D-K serovars) using the micro-immunofluorescence (micro-IF) test in the following groups: (I) chlamydial genital infection only, (II) chlamydial ocular infection only, (III) combined chlamydial ocular and genital infection (oculo-genital infection), (IV) chlamydial ocular infection with chlamydia-negative non-gonococcal urethritis, (V) adenovirus conjunctivitis (control group 1), (VI) male partners of group I-IV with no chlamydial oculogenital infection or non-gonococcal urethritis (control group 2) (b) the cross reactivity of antibodies in patients' sera between the three chlamydial species and within the serovars of C trachomatis in those with culture-positive chlamydial oculo-genital infection. SETTING: oculogenital (diagnostic) clinic at Moorfields Eye Hospital, London, UK. SUBJECTS: 209 consecutive patients attending the clinic with Chlamydia trachomatis oculogenital infection and 86 patients with adenovirus conjunctivitis (control group 1) and 55 male partners with no evidence of chlamydial oculogenital infection or non-gonococcal urethritis (control group 2). RESULTS: Of all the patients with proven chlamydial oculogenital infection, 10.5% (22/209) and 94% (197/209) had IgM and IgG antibodies respectively. The geometric mean IgG antibody titres (GMT) were 1:98, 1:123, 1:245 and 1:101 in groups I to IV respectively. The IgG GMT values seen in control groups 1 and 2 were 1:45 and 1:36 respectively. Only 2/86(2%) patients in group V (control group 1) had IgG chlamydial antibodies of 1:32 and 1:64, whilst only 1/55(1.8%) and 4/55(7.3%) of patients in group VI(control group 2) had chlamydial IgG antibody titres of > or = 1:256 and > or = 1:128 respectively. A four-fold rise or fall in IgG antibody titre occurred in 56%(107/192) of patient groups I-IV over 2-6 weeks. Low titre cross-reactive antibody responses against different chlamydial species and serovars were commonly seen; 71%(148/209) of all patients showed cross-reactivity with Chlamydia pneumoniae or psittaci species or both, whilst 92% (193/209) of patients showed some level of cross reactivity to other pooled serovars of C trachomatis (A-C and L 1-3). CONCLUSIONS: Serological diagnosis of chlamydial infection as evidenced by a positive IgM antibody response, high IgG titre (> or = 1:256) or > or = 4-fold rise or fall in IgG antibody titre was seen in 78%(163/209) of patients with culture-positive chlamydial oculogenital infection. Chlamydial IgG antibody titres of > or = 1:256 had a sensitivity of 42.6%, specificity of 98.2%, positive predictive value of 98.8% and a negative predictive value of 31% for chlamydial infection at any site, when considering groups I-IV and control group 2. In this study of 216 patients with conjunctivitis, a positive IgG antibody response (titre > or = 1:16) had a sensitivity of 98.5%, specificity of 97.7%, positive predictive value of 98.5% and a negative predictive value of 97.7%, for chlamydial conjunctivitis. Patients with dual chlamydial infection of conjunctiva and genital tract had a higher IgG GMT titre than those with ocular or genital infection alone: infection at a second site may produce an anamnestic response. Although the micro-IF test is a useful adjunct for the diagnosis of chlamydial infection, cross-reactivity between different chlamydial species and serovars is common. Chlamydial seroepidemiological studies should be interpreted with caution, as studies may attribute a serological response to a particular species or serovar in a setting where two or more are prevalent.

Chlamydial ocular infection: efficacy of partner notification by patient referral.

Records on 254 patients with chlamydial ocular infection observed over a period of 67 months at the Moorfield's Eye Hospital were reviewed retrospectively in relation to sexual partners in the 6 months prior to diagnosis. Contactable partners were given an appointment through index patients to attend our clinic. Those unable to attend were issued contact slips, as used by the sexually transmitted disease (STD) clinics in the United Kingdom, to attend elsewhere: 175/328 (53%) of all partners were seen in our clinic: 161/218 (74%) of current regular partners compared to only 7/57 (12%) of ex-regular and 7/53 (13%) of casual partners. However, of those given appointments 175/201 (87%) attended: 161/179 (90%) of current regular, 7/14 (50%) of ex-regular and 7/8 (88%) of casual partners. Seventy of 328 (21%) of all partners were issued contact slips, of whom 47/70 (67%) were reported to have attended elsewhere. No contact slips were returned by other clinics, indicating a failure in the contact slip system. Thirty-five of 53 (66%) of casual, 22/57 (39%) of ex-regular and none of the current regular partners were untraceable. One hundred and five of 196 (54%) female partners were examined, of whom 59/105 (56%) had chlamydial genital infection, 45/105 (43%) had other genital infections and 35/105 (33%) had multiple genital infections. Seventy of 132 (53%) male partners were examined, of whom 58/70 (83%) had chlamydial or non-specific urethritis, 5/70 (7%) had other genital infections and 4/70 (6%) had multiple genital infections. Partner notification is important to interrupt chlamydia transmission.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenovirus keratoconjunctivitis: an enigma.

'Adenovirus keratoconjunctivitis' is a diagnosis commonly made in Eye Casualty Departments. There are no clinical features that allow identification of the serotype causing the infection. The changeable patterns of presentation and manifestation of the different serotypes and the capacity of adenovirus to mimic other viral or bacterial infections is an enigma. Adenovirus infections are usually self-limiting; permanent visual loss is very rare. The use of corticosteroids is generally limited to cases with severe symptoms such as glare and incapacitating blurring of vision. Corticosteroids will not alter the basic pathogenesis of the disease but will suppress inflammatory signs. The sub-epithelial lesions are an immunopathological phenomenon resulting from the interaction of viral antigen and antibody in the anterior stroma with the cornea acting as a 'blotter'. An effective antiviral remains elusive.

Lymphocyte proliferative responses to chlamydial antigens in human chlamydial eye infections.

In order to study the relationship between cell-mediated immune responses to Chlamydia trachomatis and the pathogenesis of human chlamydial eye disease, we have measured the peripheral blood lymphocyte proliferative responses to whole chlamydial elementary bodies in 40 subjects with oculogenital chlamydial infection of varying severity, 13 subjects with genital chlamydial infections and 12 healthy seronegative controls. The mean stimulation index was significantly higher in those with oculogenital infections than in controls. There was a strong correlation between the response to C. trachomatis serotypes B and L1. We studied the relationship between proliferative responses and four clinical parameters: follicular conjunctivitis, papillary hypertrophy, corneal pannus and epithelial punctate keratitis, but were unable to show a significant association with any of these. Nor was there any association between proliferative response and serum antibody titre to C. trachomatis (pooled serotypes D-K), duration of disease or quantitative isolation of chlamydia from the conjunctiva. The depletion of CD8+ cells had no consistent effect on proliferative responses to serotype L1 in 13 subjects.

Marginal corneal abscess associated with adult chlamydial ophthalmia.

In four patients with an adult chlamydial ophthalmia small, marginal corneal abscesses were detected. These corneal abscesses were associated with unilateral papillary and follicular conjunctivitis and punctate keratitis. In these patients no bacteria was isolated from the abscesses, but Chlamydia trachomatis was isolated from materials collected from the abscesses and from the conjunctival swabbings. In addition all patients had microbiologically proved concomitant chlamydial genital infections. The clinical signs resolved after topical treatment with rifampicin or tetracycline eye ointment for six weeks or systemic treatment with tetracycline for two weeks. Because of concomitant chlamydial genital infection it is advisable to treat patients with adult chlamydial ophthalmia with systemic tetracycline and to refer these patients and their consorts for investigation and treatment of their genital infection.

Treatment of trachoma in the West Bank.

A double-blind stratified treatment trial was carried out on 368 patients with moderate to severe trachoma in two West Bank villages to assess the efficacy of family based therapy using tetracycline eye ointment, oral doxycycline or oral sulphametopyrazine. Treatment with tetracycline eye ointment twice daily for five days each month for six months, or a weekly dose of oral doxycycline, 5 mg/kg body weight for three weeks, or a weekly dose of oral sulphametopyrazine, 35 mg/kg body weight for three weeks was given to the patients and the members of their respective families. Clinical cure rates of 73% for tetracycline eye ointment, 74% for doxycycline and 72% for sulphametopyrazine were achieved three months after treatment, improving to 79, 80 and 82% respectively at one year. There were no statistically significant differences between the three groups treated.

Recurrent herpes simplex virus ocular infection: epidemiological and clinical features.

The epidemiological and clinical features of recurrent herpes simplex virus ocular infection (RHSV) were studied. Of 108 patients with primary herpes simplex virus ocular infection (PHSV) who were followed up for two to 15 years 35 (32%) suffered one or more recurrent attacks. The recurrence rate was significantly higher in patients under 20 years of age, but there was no significant difference between recurrence rates in males and females. Of 35 patients with RHSV 17 (49%) had one recurrent attack, 14 (40%) had between two and five, and four (11%) had between six and 15 attacks. The mean time interval between PHSV and the first four RHSV attacks was 10 months, and was shorter in subsequent attacks. The duration and severity of RHSV were reduced in successive recurrences. Patients with more severe conjunctivitis and lid lesions during PHSV ocular infection had a higher incidence of recurrent infection. The severity of the corneal signs in PHSV had no influence on the incidence of recurrent infection. Several clinical forms of RHSV were observed. Conjunctivitis associated with lid lesions was observed in 29 (83%) patients. In six (17%) patients the disease presented as an acute follicular conjunctivitis without characteristic lid or corneal lesions. Dendritic ulcer was found in three (9%) patients, and in one of them it was associated with a disciform keratitis. A chronic blepharoconjunctivitis developed in eight (23%) patients. The epidemiological and clinical features of RHSV were compared with those of PHSV.

Oral doxycycline in the treatment of adult chlamydial ophthalmia.

Ninety-three consecutive patients with adult chlamydial ophthalmia were treated with four different regimens of oral doxycycline. In patients treated with a single dose of 5 mg/kg of body weight (300 mg) of doxycycline the severity of clinical signs was reduced, and in half of the patients shedding of the infective agent was stopped. Treatment with a weekly dose of 300 mg of doxycycline for three weeks or a daily dose of 1.5 mg/kg of body weight (100 mg) for one week produced a clinical and microbiological cure in 100% of patients. However, in some of these patients mild to moderate papillary responses were present up to six months from completion of the treatment. The best results were obtained with a daily dose of 100 mg for two weeks, which produced rapid clinical and microbiological cure in all patients.

Epidemiological and clinical features of primary herpes simplex virus ocular infection.

The epidemiological and clinical features of primary herpes simplex virus ocular infection in 108 patients were studied. Of these, 69 (64%) were aged 15 or over and only eight (7%) were under the age of 5. Associated upper respiratory tract infection was found in 38 (35%) patients and systemic disorders such as mild malaise, fever, and aching in 34 (31%) patients. Common symptoms were redness, watering, discharge, itching, irritation, and lid swelling, whereas pain, photophobia, lid vesicles and ulcers, and blurred vision were less frequent. The major signs consisted of vesicles and ulcers on the lids, papillary responses which were more severe in the upper lid conjunctiva, follicles which were more common in the lower lid conjunctiva, fine and coarse epithelial punctate keratitis, and subepithelial punctate keratitis. Dendritic ulcers and disciform keratitis were found in 16 (15%) and two (2%) patients respectively. The clinical forms of primary herpes simplex virus ocular infection varied. Moderate or severe disease was observed in 41 (38%) and 16 (15%) patients respectively. In eight (7%) patients the disease presented as an acute follicular conjunctivitis without characteristic lid or corneal lesions. A chronic blepharoconjunctivitis which lasted for months developed in 16 (15%) patients. The epidemiological and clinical features in our patients were compared with features of the disease reported previously.