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This 23-year-old man presented with a long history of itching, redness, discharge, and watering of both eyes since childhood. He has been treated with antibiotics, antihistamines, and a steroid subconjunctival injection on one occasion. “Cobblestones” were noted on both upper lids, the conjunctiva was noted to be hyperemic and the corneas were vascularized with the pupillary axis obstructed in the right eye. Vision was right eye 20/400 and left eye 20/40.

1.	This patient could be suffering from:
	d -- (a) or (b) This case has already undergone a long active state and is presenting late.  He comes from a region where trachoma is common making this diagnosis likely.  Note the scarring of the upper tarsus.  This could be Alt’s line that is a band of scar tissue in tarsal conjunctiva just above and parallel to the lid margin.  Allergic conjunctivitis can occur anywhere, and it can also result in severe scarring of the upper tarsus.
2.	The most important thing to do now is:
	d -- attempt to confirm the cause as infectious or allergic Before proceeding with treatment, it is important to decide whether this is caused from allergy or infection.
3.	A sensible way to proceed is as follows:
	d -- (a) and (b) The patient can be treated with azithromycin to see if the condition improves.  This would indicate that the condition is infectious and this course should be continued along with frequent lubrication.  If the antibiotic has no effect, then treatment for allergy using steroid could be carried out.