Conjunctivitis refers to the inflammation of the conjunctiva. It is chronic when it lasts for four or more weeks. The conjunctiva is a, thin, clear membrane lining. It covers the eye’s outer surface. It secretes mucus that wets and lubricates the eye. 

Chronic conjunctivitis does not seriously affect vision. It also does not cause severe morbidity (illness). Nevertheless, it can be extremely frustrating to both the patient and the physician. This is because it may not respond to commonly used topical antibiotics. It may also not respond to topical steroids, artificial tears, and other treatments. 

Also Known As



Chronic conjunctivitis is majorly classified as bilateral, unilateral papillary and follicular. 

  • Bilateral may be due to bacterial, tuberculosis and virus. It may also be due to trachoma, allergies and Vitamin A deficiency. Bilateral affects both eyes.
  • The following may cause unilateral chronic papillary conjunctivitis:
  1. Lacrimal drainage infections which include chronic dacryocystitis (recurrent bacterial conjunctivitis limited to one eye). It also includes canaliculitis (caused by an infection in the canaliculus). Canaliculus is a small canal or tubular passage.
  2. The giant fornix syndrome
  3. Masquerade syndrome
  4. Factitious conjunctivitis
  • Chronic follicular conjunctivitis is caused by chlamydial infection, toxic conjunctivitis from tropical medications, and molluscum contagiosum. 
  • Vernal keratoconjunctivitis

Other types include:

  • Chronic bacterial conjunctivitis
  • Meibomitis
  • Chronic keratoconjunctivitis
  • Ligneous conjunctivitis
  • Giant papillary conjunctivitis

Causes and Risk Factors

The following may cause the disease:

  • Giant fornix syndrome causes unilateral chronic papillary conjunctivitis. It occurs among the elderly in their 80s and 90s. 
  • Sebaceous carcinoma of the eyelid causes masquerade syndrome. Masquerade syndrome is a malignant tumor involving the conjunctiva. It is more common in women between the ages of 50 and 80 and is found in the upper eyelid.
  • Factitious conjunctivitis is self-inflicted. A soldier may, for example, place scraped dental plaque in his or her eye to avoid dangerous duty. Mucus fishing syndrome is another type of factitious conjunctivitis. A patient may try to remove discharge from the eye using fingers or a cotton applicator. In the process, the patient may cause conjunctival trauma and damage the eye. 
  • An infection causes chronic follicular conjunctivitis in the orgasm chlamydia trachomatis. The infection is divided into two clinical forms: trachoma and inclusion conjunctivitis. Trachoma is a prevalent disease in developing countries. It is caused by poor sanitation. The sexual transmission of chlamydia trachomatis causes inclusion conjunctivitis. A toxic reaction to topical medication can cause chronic follicular conjunctivitis. Molluscum contagiosum causes molluscum lesions found on or near the eyelid. These are prevalent among HIV-infected patients. Toxic follicular conjunctivitis results from a toxic reaction to topical medication. 
  • Staphylococcus bacterial species cause chronic bacterial conjunctivitis. It is often associated with blepharitis (inflammation of the eyelids).
  • Inflammation of the meibomian oil glands causes meibomitis. Meibomitis can lead to dry eyes.
  • The buildup of fibrin (a protein) causes ligneous conjunctivitis. It can lead to dry eyes.
  • A trachoma infection can cause chronic keratoconjunctivitis. Trachoma is the leading cause of preventable blindness globally. It affects both the cornea and conjunctiva. 
  • A foreign body in the eye can cause giant papillary conjunctivitis. It is a type of allergic conjunctivitis. Those likely to develop giant papillary conjunctivitis include wearers of hard contact lenses. It may also affect those who don’t replace soft contact lenses regularly. An exposed suture on the surface of the eye or a prosthetic eye also increases the likelihood of this disease.
  • Vernal keratoconjunctivitis is a severe, chronic allergy that affects the surface of the eye. It is prevalent in warm dry climates and commonly occurs in boys.

Signs & Symptoms

Symptoms may vary from disease to disease. For example:

  • Symptoms of chronic bacterial conjunctivitis include redness of the conjunctiva and burning. They may also include morning eyelash crusting, a feeling of something in the eye and regular styes.
  • Skin disorder acne rosacea could be an indication of meibomitis and blepharitis. 
  • Symptoms of inclusion conjunctivitis include red eyes and a discharge.
  • Ligneous conjunctivitis may show symptoms of chronic tearing and mild discomfort. Symptoms may also include redness in the eye, pain, and photophobia. The disease can hamper daily activities.

Generally, other symptoms include:

  • Swelling of the region overlying the lacrimal sac
  • Blocked tear ducts/stagnation of tears
  • Insidious/watery discharge
  • Hyperemia (a large amount of blood in any part of the body)
  • Chemosis (swelling of the conjunctiva)


Careful diagnosis should be made due to the many types of chronic conjunctivitis. The following procedures or methods lead to a proper diagnosis:

  • Conjunctival scrapings and culture or biopsy
  • Expressing the canaliculus after applying anesthesia to the eye 
  • Factitious conjunctivitis requires a very high level of suspicion. This is because the patient may not admit to the real cause. The ophthalmologist looks out for red flags. such as an unrealistic history and indifference to the severity of the disease. Also, an unusual pattern of conjunctival staining and non compliance with medication regimens. Failure to respond to what should be an effective treatment should raise red flags. 
  • A laboratory test can confirm chlamydia infection in case of chronic follicular conjunctivitis. The physician may examine the eyelids for molluscum lesions. He/she will take a detailed history of topical drug use. This is to determine the presence of chronic follicular conjunctivitis.  
  • To diagnose toxic follicular conjunctivitis, the ophthalmologist must maintain suspicion which strives to determine the likely cause. The ophthalmologist may also observe the resolution of conjunctivitis after discontinuing the medication.


Treatment for chronic conjunctivitis aims to eliminate the inflammation.

Medical Treatment

The options available for treating chronic conjunctivitis include:

  • Antibiotics 
  • Artificial tears
  • Topical medicines
  • In the case of factitious conjunctivitis, the treatment may be psychiatric. It involves identifying the nature of the problem. The physician then confronts the patient with the diagnosis. 
  • Inclusion conjunctivitis requires treating the genital infection using an oral antibiotic. 
  • Anti-staphylococcal antibiotics can treat giant fornix conjunctivitis. Intensive topical antibiotics and corticosteroids can also treat it.
  • Forceps can remove the ligneous lesion. It is likely to bleed upon removal.

Surgical Treatment

There are minimal situations that may warrant surgical treatment. In treating recalcitrant canalicular cases, the diverticulum (tubular sac) must be removed. This action leaves the normal canalicular drainage intact. 
Surgery or radiation can treat a malignant lesion in molluscum contagiosum.  
Curettage (surgical scraping) can remove all the particles in molluscum contagiosum. 
Surgery can correct ptosis (a drooping of the upper eyelid). Ptosis corrects giant fornix conjunctivitis.

Prognosis/Long-term outlook

The mucus fishing syndrome can turn out to be a vicious cycle. Patients are thus admonished against manipulating their eyes.

Follow Up

The problem with giant fornix syndrome is that diagnosis can delay for up to two years. This may lead to corneal complications, scarring, chronic corneal ulceration and perforation. 

Trachoma is a form of chronic conjunctivitis. It can cause scarring of the conjunctiva and painful inturned (growing inward) eyelashes. It can also cause corneal scarring with blindness.


Periodic mass administration of antichlamydial antibiotics can reduce cases of trachoma.