Follicular Conjunctivitis

Overview

Follicular conjunctivitis is a type of eye inflammation. The conjunctiva is the thin, clear skin that covers the white of your eye and lines the inside of your eyelids. When it gets irritated, it turns red and sore. In follicular conjunctivitis, tiny round bumps called follicles also form on the inside of the eyelid. Follicles are small gatherings of immune cells, the body's defence cells, that appear when the eye is irritated. They look like little grains of rice or tiny blisters under the lid. Follicular conjunctivitis is not one single illness. It is a pattern the eye makes in response to several different triggers, such as a virus, an allergy, contact lenses or eye drops.

Yes. Red, inflamed eyes are one of the most common reasons people see a pharmacist, GP or eye specialist, and the follicular pattern is seen very often, especially in children, teenagers and young adults and in people who wear contact lenses.

Anyone can get it. It is seen most often in children and young adults, people with allergies, asthma or eczema, contact lens wearers, and people who use eye drops regularly. Some types spread easily from person to person, so it can appear in families, schools and shared living spaces.

Symptoms

Common symptoms

• Redness in one or both eyes
• Watery discharge rather than thick pus
• Itching, or a gritty, sandy feeling in the eye
• The feeling that something is stuck in your eye
• Mild sensitivity to light
• A swollen or tender gland in front of the ear on the same side as the red eye
• Eyelids stuck together in the morning, usually only mildly
• Small bumps (follicles) seen under the eyelid when a doctor looks closely
• Slightly blurred vision that clears when you blink

Symptoms in children

• Rubbing the eyes a lot, or being clingy and unsettled
• Watery eyes along with a cold, sore throat or mild fever, which is typical of a viral cause
• Puffy eyelids on waking
• Itchy eyes with hay fever or other allergies, sometimes with dark circles under the eyes
• Sticky eyes in a newborn baby, which should always be checked quickly

Symptoms in older adults

• Symptoms that overlap with dry eye and eyelid inflammation, which are more common with age
• Red eyes linked to long-term use of eye drops, including ones bought over the counter
• Vision changes that are noticed more easily and feel more worrying
• Difficulty putting in eye drops, which can make treatment harder to keep up

Causes

Main causes

• Viral infections, often the same viruses that cause colds and sore throats
• Some viral infections such as herpes viruses, which need specialist care
• Bacterial infections, including some that are passed during sex, such as chlamydia
• Allergies, such as hay fever, dust or pet allergies
• Irritation from contact lenses, lens solutions or poor lens hygiene
• Reaction to eye drops or ointments, including preservatives inside them
• Small skin bumps on the eyelid (molluscum contagiosum)
• Other inflammatory eye conditions, and sometimes no clear cause is found

Risk factors

• Close contact with someone who has a red, watery eye
• Wearing contact lenses, especially with poor hand or lens hygiene
• Allergies, eczema or asthma
• Using eye drops often, particularly ones that contain preservatives
• Sharing towels, pillows or eye makeup, or not washing hands regularly
• Attending school or childcare, or living in crowded housing
• A recent cold or chest infection
• Being sexually active without protection, which raises the chance of a chlamydial infection
• A health condition or treatment that weakens the immune system

When to see a doctor

See a doctor urgently if:

• You have eye pain, light sensitivity, or your vision has changed
• You wear contact lenses and your eye is red and painful
• There is thick pus, or the eye keeps producing a lot of discharge
• You have recently had eye surgery or an eye injury
• A baby or newborn has red or sticky eyes
• You feel generally unwell with fever and a swollen, red eye

Book a routine appointment if:

• Red, itchy or watery eyes that last more than a week
• Red eyes that keep coming back
• You think an allergy, a contact lens or an eye drop might be the trigger
• You want advice on which over-the-counter eye product is safe for you
• Someone in your household also has red eyes and you want to stop it spreading

Diagnosis

A doctor, optometrist or pharmacist can usually work out what is going on by asking about your symptoms and looking closely at your eyes. They may gently pull down your lower lid and turn up your upper lid to look for follicles, using a small torch and magnifier. This takes seconds. They will also ask about contact lenses, allergies, recent colds, eye drops you use, and whether anyone close to you has red eyes.

Tests that may be done

• A vision check
• A closer look with an eye microscope (slit lamp), which magnifies the eye and eyelid
• A swab of the discharge, sometimes, to look for bacteria or a sexually transmitted infection
• Checks for dry eye or eyelid problems that can cause similar symptoms
• Allergy testing, in some recurring cases
• A review of your contact lens routine and lens solutions

What to expect at your appointment

The appointment is quick and does not hurt, although the light can feel bright and having your eyelid gently held open can be a little uncomfortable for a moment. You may be asked to leave your contact lenses out for a while. Most people do not need blood tests or scans. If a sexually transmitted infection is possible, you may be offered a simple swab or urine test and a referral to a sexual health service, which is confidential and routine.

Treatment

Treatment depends on the cause. Many cases settle on their own with simple home care. The goals are to ease soreness, stop any spread and check that nothing more serious is going on. Because follicular conjunctivitis has several possible causes, a treatment that helps one cause will not help another. That is why a proper look at your eye is worth it before you buy anything.

Self-care at home

• Use a cool, clean compress over closed eyes for a few minutes several times a day to ease soreness and itching
• Try not to rub your eyes, as this makes irritation worse and can spread infection
• Wash your hands often with soap and water, and dry them with your own towel
• Do not share towels, flannels, pillows or eye makeup with anyone
• Stop wearing contact lenses until your eyes are fully better, and throw away the lenses and case you were using
• Clean your eyelids gently with cooled boiled water and a fresh cotton pad, wiping once and then throwing the pad away
• Avoid eye makeup until the redness has gone
• Ask your pharmacist about soothing lubricating eye drops, and check they are suitable for you, especially if you wear lenses
• Wear sunglasses if bright light is uncomfortable
• Keep children off school while their eyes are red and sticky, following your school's advice

Medical treatments

If a bacterial cause seems likely, a doctor may prescribe antibacterial eye drops or ointment. If a sexually transmitted infection is found or suspected, both partners need treatment, and this is usually arranged through a confidential sexual health service. Antiviral treatment is occasionally needed for certain viral causes and is managed by an eye specialist. When allergy is the trigger, the focus is on avoiding the trigger plus anti-allergy eye drops or tablets recommended by a pharmacist or doctor. If an eye drop or its preservative seems to be the cause, stopping it with your doctor's advice usually settles things. Steroid eye drops are sometimes used for particular inflammatory causes, but only under specialist supervision, because they can cause harm if used for the wrong reason. Never use leftover eye drops or someone else's drops.

When is surgery considered?

Surgery is almost never needed for follicular conjunctivitis. Rarely, long-standing infection can scar the inside of the eyelid and make the lashes turn inward. This is seen mainly with trachoma in some low-income regions. If that happened, a small operation can correct the eyelid, and your eye specialist would discuss it with you.

Living with this condition

Most people can carry on with normal life. Expect some gritty discomfort, watery eyes and a bit of stickiness in the mornings for a week or two. Keep a small supply of clean cotton pads and a separate towel, wash your hands before touching your eyes, and give yourself a break from screens if your eyes feel tired. If you wear contact lenses, plan to use glasses until your eyes have been clear for a few days.

Lifestyle tips

• Build hand washing into your routine, especially after touching your eyes and before handling lenses
• Follow your contact lens cleaning and replacement schedule exactly, and never use tap water on lenses
• Keep a note of when symptoms flare, to help spot allergy triggers such as pollen, pets or dust
• Replace eye makeup and brushes after an infection
• Keep rooms well ventilated and reduce dust where you can if allergies are a trigger
• Get regular eye check-ups if you wear contact lenses

Diet and exercise

No special diet is needed for follicular conjunctivitis. Eating well and staying active support your general health and immune system. Exercise is fine. If your eyes are red and sticky and the cause may be infectious, it is sensible to avoid swimming pools until they clear, and to wash your hands after using shared gym equipment.

Mental health and emotional wellbeing

Red, watery, itchy eyes can be uncomfortable, tiring and make you feel self-conscious, especially at work or school. Poor sleep from sore eyes can affect your mood. Most people feel better quickly, but if you are feeling anxious, low or overwhelmed, please talk to your doctor. If you ever feel unable to cope or have thoughts of harming yourself, contact your local crisis helpline or your local emergency number straight away. You deserve support.

Prevention

Partly. The infectious types spread through hands, towels, pillows and close contact, so regular hand washing and not sharing personal items makes a real difference. Allergy-related and lens-related types can be reduced by avoiding triggers and following contact lens care instructions carefully. If a particular eye drop seems to irritate your eyes, tell your doctor or pharmacist so a different option can be found.

Vaccines

There is no vaccine for follicular conjunctivitis itself. Some infections that can affect the eyes can be prevented by routine vaccines, depending on where you live, and trachoma control programmes in some regions use public health measures. Ask your local health service what applies in your area.

Screening programmes

There is no routine screening test for follicular conjunctivitis. In some parts of the world, public health programmes screen communities for trachoma. If you wear contact lenses, regular eye check-ups are a sensible way to catch problems early.

Complications

If left untreated

• Spread to the other eye, or to people close to you
• Symptoms that drag on for weeks, with ongoing discomfort and gritty eyes
• Scarring of the inside of the eyelid in rare, long-standing cases, which can lead to dry eye
• Involvement of the clear front surface of the eye (the cornea) with some viral causes, which can affect vision
• A corneal infection in contact lens wearers, which needs urgent care to protect sight
• For chlamydia, an infection that continues and can be passed to partners
• In some low-income regions, trachoma can lead to the eyelid turning inward and, over many years, to vision loss

Long-term outlook

The outlook is good for most people. The great majority recover fully within one to three weeks, and vision usually returns to normal. Some cases take a little longer, and allergic types can come back with the seasons. If your eyes are not settling, or you are worried at any point, see your doctor or optometrist. Getting the right advice early is the simplest way to protect your sight.

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