Trachoma

Dr. Brenda W’mosi

Outline
• Introduction
• Epidemiology
• Clinical features
• Grading of trachoma
• Management of trachoma
• Prevention and control
Introduction
• In ancient Greek ‘trachoma’ means ‘roughness’
• Causes irreversible blindness
• Leading cause of infectious blindness in the world
• Infections become less frequent and last a shorter duration with
increasing age
Epidemiology
• Responsible for visual impairment or blindness of 1.9 million people
worldwide as per WHO
• Responsible for 1.4% of blindness cases worldwide as per WHO
• It was reported in June 2021 , that 136 million people living in
Trachoma endemic areas were at risk of trachoma blindness
• Hyperendemic in the poorest and rural regions of Africa, Central and
South America, Asia, Australia and Middle East
• In trachoma endemic areas, it occurs more in pre-school aged
children with a prevalence of 60-90%
Epidemiology -Kenya
• A study done by Karimurio et al
showed that trachoma is
endemic in 6 areas( Samburu,
Narok, West Pokot, Kajiado,
Baringo, Meru North)
• About 53,000 people are
currently affected by the disease
• Around 7 million people who live
in the trachoma endemic
counties are at risk of trachoma
Trachoma
• It is contagious
• Transmitted by direct or indirect transfer of eye and nose discharges
of infected people especially children
• These discharges are spread by houseflies known as ‘musca sorbens’
• Causes a chronic conjunctivitis
• Common in those who live in poor, unhygienic conditions and is
common in dry and dusty weather
Trachoma
• Causative organism is an intracellular obligate bacterium- Chlamydia
trachomatis
• C. trachomatis serovars A,B,C cause trachoma
• Serovars D-K cause genital infection
• Chlamydia has both bacterial and viral characteristics
• Bacterial because it divides by binary fusion and has some level of
cellular organization
• Viral because it is intracellular
Life cycle of Chlamydia trachomatis
Life cycle of Trachoma
Predisposing factors
• Age • Crowded living conditions
• Sex • Poverty
• Personal hygiene • Low education levels
• Lack of clean water supply
• Poor waste disposal
• Poor environmental cleanliness
Clinical presentation
-Acute phase -Cicatricial phase
• Follicular conjunctivitis • Is the late phase
• Mucopurulent discharge • Occurs after repeated infections
• May be associated with • Scarring may present withy dry
nasopharyngeal infection eye symptoms and sometimes
may be asymptomatic
• Trichiasis may lead to
blepharospasms or corneal
opacities
Acute phase
Symptoms • Signs
• Pain • Eyelid oedema
• Redness • Conjunctiva- Mucopurulent
• Excessive tearing discharge
• Photophobia -Follicles- usually numerous in
the fornices, can be on the limbus
• Discharge and leave Herbet’s pits when they
resolve
-Papillae
Trachoma- Staging
-Classified into 4 stages -Stage 2- Pannus
-Stage 1 • Corneal infiltration by leucocytes
(a) Papillary hypertrophy • Vascularization of the upper
• Patient may complain of cornea
redness , itching of the eyes • Usually a late feature, and is as a
• There is usually hyperemia of the result of recurrent corneal
conjunctiva erosions and chronic
inflammation
(b) Follicular hypertrophy
• Patient may complain of more
severe redness and itching
Trachoma staging
-Stage III -Stage IV
• Stage of scarring • Stage of complications
• The patient may complain of • May occur many years after
blurriness of vision, excessive initial infection
tearing, redness, eye discomfort • Includes
-Trichiasis
-Entropion
-Ptosis
-Corneal ulcers
WHO grading of Trachoma
(i) Trachomatous inflammation
(follicular)- TF
(ii) Trachomatous inflammation
(intense)- TI
(iii) Trachomatous scarring – TS
(iv) Trachomatous trichiasis- TT
(v) Corneal Opacity- CO
TF- Trachomatous inflammation
(Follicular)
• 5 or more follicles in the upper
tarsal conjunctiva
• Should be at least 0.5 mm
diameter each
• Indicates active disease
• Peak age 3-5 years
• Limbal follicles may lead to
Herbet’s pits
Herbet’s pits
TI- Trachomatous inflammation
(intense)
• Pronounced inflammatory
thickening of the tarsal
conjunctiva that obscures more
than half of the normal deep
tarsal vessels
• There are usually numerous
follicles which may be partially
or totally obscured by thickened
conjunctiva
TS- Trachomatous scarring
• Presence of scarring on the
tarsal conjunctiva
• Glistening and fibrous in
appearance
• Scarring may obscure the tarsal
blood vessels
• Indicates previous severe
inflammation
• Can lead to trichiasis, secondary
bacterial infection, DES
TT- Trachomatous Trichiasis
• At least one lash rubbing on the
eyeball
• Evidence of recent removal of in-
turned lashes
• Due to subconjunctival fibrosis
• If corrected, visual loss can be
corrected
CO- Corneal opacity
• Visible corneal opacity
• Covering the pupillary margin
• Caused by repeated infections
which subsequently lead to
inflammation
• Also due to cicatricial entropion
with trichiasis
Trachoma
-Differential diagnosis -Investigations
• Conjunctivitis • Good physical examination
- Bacterial • Conjunctival swab for M/C/S
- Viral • Giemsa staining- trachoma
- Toxic • PCR
- Allergic
Management of trachoma
-Supportive measures
• Improve the general nutrition of the patient with extra vitamin
supplementation-A,B,C
Management of trachoma
• Early stages without entropion or trichiasis
• Topical antibiotics
• 1% TEO instill BD for 6 weeks. Can be used upto 3 months.
After cleaning the eyes
• Erythromycin ointment
Management
• Systemic antibiotics
• Oral azithromycin- safe for adults and children
-Adults- 1g stat
-In children Oral azithromycin 20mg/kg as a single dose
• Oral doxycycline 100 mg BD- N.B Not used in children
Management
-Late stages
-Surgical management
• Aim is to redirect the eye lashes and lid margin away from the cornea.
• Epilation of misdirected lashes
• Tarsal plate rotation
• Corneal graft for corneal opacities
WHO ‘SAFE’ Strategy
• S- Surgery for trichiasis
• A- Antibiotics
• F- Facial cleanliness
• E- Environmental changes
A- Antibiotics
• Expensive however have been available through donors
• Mass treatment of a whole endemic area if acute trachoma ≥ 10%
• For acute trachoma 5-10% , mass treatment done on targeted areas
• For acute trachoma <5% ,mass treatment not necessary though
targeted treatment can still be done
F- Facial cleanliness
• Face washing
• Health education on the importance of facial cleanliness
E- Environmental change
• Clean water supply
• Good household sanitation
• Sanitary toilets
• Clean environment
S-Surgery
• Bilamellar tarsal plate rotation
• For Trachoma trichiasis
• Mass surgery if TT>1%
• Surgery can be repeated if there
is recurrence
Prevention and control
1. Health education • Community should:
• Personal hygiene- hand washing, • Seek ways of collecting
face washing rainwater
• Communal hygiene- keep flies • Avoid contaminating the
away by keeping the surroundings available water sources
clean. Keep latrines clean
• Preserve the water resources i.e
2. Availability of clean water for all preserving trees and forests
• Both government and community
play a role
• THE END!!