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TRACHOMA
By C. Sakthi Annamalai
]Introduction
]etiology
]prevalence & clinical profile
]symptoms & signs
]grading
]sequel
]diagnosis
]management
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Introduction
_ Egyptian Opthalmia
_ chronic follicular keratoconjunctivitis
_ leading cause of preventable blindness in the world


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Etiology
_ Causal organism:
Chlamydia trachomatis A,B,Ba,C
_ Predisposing factors:
1. Age - infancy & early childhood
2. Sex - females
3. Race - Jews --> more common
Negroes --> less common
4. Climate - dry & dusty
5. Socioeconomic status - unhygienic
conditions
6. Environmental factors - dust, smoke,
irritants, sunlight
_ Source of infection:
conjunctival discharge of affected persons
superimposed bacterial infections
_ Mode of infection:
1. Direct spread - air or water borne
2. Vector - eye-seeking flies(e.g.. Musca
spp, Hippelatus spp)
3. Maternal transmission - fingers of
doctors & nurses, contaminated
tonometers,towels,handkerchief,beddi
ng, surma rods, Kajal
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Prevalence & clinical profile
Prevalence:
North Africa, Middle East, South East
Asia
500 million affected
15-20% of blindness in the world


Natural History:
acute - first decade
inactive in 2nd decade
sequale - after 20 years
peak - 4th & 5th decades
Clinical profile:
incubation period - 5-21 days,
insidious
clinical course -
if no 2 infection --> symptomless
if 2 infection --> symptoms of
acute conjunctivitis
Trachoma dubium (doubtful
trachoma) In early stage -
difficult to distinguish from
bacterial conjunctivitis
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Symptoms & Signs
Symptoms:
Foreign body
sensation,
lacrimation, slight
stickiness of lids,
scanty mucous
discharge
2 infection -->
symptoms of
acute
mucopurulent
conjunctivitis
Trachomatous
ptosis
Conjunctival signs:
1. Congestion
2. Conjunctival follicles - looks like boiled sagograins
structure of follicles
central part -> mononuclear histiocytes,

cortical part -> zone of lymphocytes with active
proliferation, blood vessels most peripherally
3. Papillary hyperplasia -> reddish flat topped raised
areas, red velvety tarsal conjunctiva, central core of
numerous dilated blood vessels surrounded by
lymphocytes & hypertrophic epithelium
4. Conjunctival scarring - Arlts line
5. Concretions - dead epithelial cells & inspissated mucus
in glands of Henle
Corneal signs:
superficial keratitis O Herbert pits
Herbert follicles - in limbus O Corneal opacity
Pannus - progressive, regressive(pannus siccus)
Corneal ulcer

lymphocytes, Leber cells
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Gradings



~ Mc Callans Classification

~ Jones Classification

~ WHO Classification
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Mc Callans Classification(1908)
* Stage I - Incipient trachoma (or) stage of infiltration
* - hyperemia of palpebral conjunctiva & immature follicles
* Stage II - Established trachoma (or) Stage of florid infiltration
* - mature follicles, papillae & progressive corneal pannus
* IIa - mature follicles
* IIb - marked papillary hyperplasia
* Stage III - Cicatrizing trachoma (or) stage of scarring
* - scarring of palpebral conjunctiva
* Stage IV - Healed trachoma (or) stage of sequel

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Jones Classification
E Class 1 : Blinding trachoma
gserotypes A,B,Ba,C
g2 bacterial infection
geye to eye transfer
E Class 2 : Non blinding trachoma
gserotypes A,B,Ba,C
gno 2 bacterial infection
gmesoendemic or hypoendemic areas with better socioeconomic
status
gmild form with limited transmission
E Class 3 : Paratrachoma
gserotypes D to K
goculogenital --> genitals to eye
gadult inclusion conjunctivitis, Chlamydial opthalmia neonatorum
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WHO Classification (1981)
Follicles
Intense
Scarring
Trichiasis
Opacities
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Sequel:
1. In lids - trichiasis, entropion,tylosis, ptosis, madarosis,
ankyloblepharon
2. Conjunctival - concretions, pseudocyst, Xerosis, symblepharon
3. Corneal - opacity, ectasis, Xerosis, Pannus
4. Others - chronic dacryocystitis, 2 glaucoma

Complications:
Corneal ulcer
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Diagnosis
A. clinical Diagnosis:
presence of at least two sets:
1.Conjunctival follicles & papillae
2. Pannus - Progressive or regressive
3. Epithelial keratitis near superior limbus
4. Signs of circatrisation or its sequel

B. Lab diagnosis:
1. Conjunctival cytology - Giemsa stain --> Plasma cells, Leber cells
2. Inclusion bodies - Giemsa, Iodine or immunofluorescent stain
3. Isolation - Yolk sac inoculation, tissue culture(irradiated Mc Coy cells)
4. Serotyping of TRIC agents - micro immunofluorescence

Differential Diagnosis:
1. Epidemic Keratoconjunctivitis
2. Palpebral form of spring catarrh
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Management
A. active trachoma:
1. Topical treatment regimes -- tetracycline, erythromycin
2. Systemic therapy regimes -- Tetracycline, Doxycycline, Azithromycin
3. Combined topical & systemic
Trachoma sequel:
1. Concretions -- hypodermic needle
2. Trichiasis -- epilation, electrolysis, cryolysis
3. Entropion -- Surgery
4. Xerosis -- artificial tears
Prophylaxis:
1. Hygienic measures
2. early treatment of conjunctivitis
3. WHO recommended blanket antibiotic therapy(intermittent treatment)
1% tetracycline eye ointment twice daily for 5 days in a month
for 6 months
4. Antitrachoma vaccine --> not effective
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W.H.O guidelines
SAFE Strategy to control blindness from trachoma


Surgery for trichiasis
Antibiotic treatment for active infection
Face cleanliness promotion
Environmental improvement