Trachoma

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1. TRACHOMA

2. DEFINITION Trachoma is a chronic keratoconjunctivitis, primarily affecting the superficial epithelium of conjunctiva and cornea simultaneously. It is characterized by a mixed follicular and papillary response of conjunctival tissue.

3. Causative organism. Chlamydia trachomatis 11 serotypes of chlamydia, (A, B, Ba, C, D, E, F, G, H, J and K). ETIOLOGY

4. PREDISPOSING FACTORS 1. Age. infancy and early childhood. Otherwise, there is no age bar. 2. Sex. in the females . 3. Race. very common in Jews and comparatively less common among Negroes. 4. Climate. dry and dusty weather.

5. SOCIOECONOMIC STATUS Unhygienic living conditions Overcrowding Unsanitary conditions Abundant fly population Paucity of water Lack of materials like separate towels, handkerchiefs, and lack of education Understanding about spread of contagious diseases.

6. Exposure to dust, Smoke, Irritants, Sunlight etc. Therefore, outdoor workers are more affected in comparison to office. ENVIRONMENTAL FACTORS

7. MODES OF INFECTION. 1. Direct spread contact by air-borne or water-borne modes. 2.Vector transmission through flies. 3. Material transfer through contaminated fingers of doctors, nurses and contaminated tonometers . 4.Other material transfer common towel, handkerchief, bedding and surma -rods

8. PREVALENCE North Africa Middle East And South East Asia

9. CLINICAL FEATURE Symptoms In the absence of secondary infection Mild foreign body sensation in the eyes Occasional lacrimation slight stickiness of the lids scanty mucoid discharge.

10. In the presence of secondary infection Typical symptoms of acute mucopurulent conjunctivitis develop. Discomfort, foreign body, grittiness Mild photobia Mucopurulent discharge Coloured halos(due to prismatic effect of mucus Symptoms

11. Phase of active trachoma Conjunctival signs 1. Congestion of upper tarsal and forniceal conjunctiva. 2. Conjunctival follicles . Follicles look like boiled sagograins . In later stages signs of necrosis are also seen 3. Papillary hyperplasia . Papillae are reddish, flat topped raised areas which give red and velvety appearance to the tarsal conjunctiva Signs

12. CORNEAL SIGNS S uperficial keratitis Hebert follicle Refer to typical follicles present in the limbal area Progressive pannus Infiltration of cornea is ahead of vascularization Corneal ulcer Signs

13. Phase of cicatricial trachoma Corneal signs Regressive pannus vessels extend a short distance beyond area of infiltration Herbert pits Corneal opacity Corneal blinding pannus Signs

14. Lid signs Entropion Tylosis Ptosis Madarosis Lacrimal apparatus signs Chronic dacryocystitis Chronic dacryoadenitis Signs

15. GRADING OF TRACHOMA Stage I (Incipient trachoma or stage of infiltration). It is characterized by hyperaemia of palpebral conjunctiva and immature follicles. Stage II (Established trachoma or stage of florid infiltration). It is characterized by appearance of mature follicles, papillae and progressive corneal pannus.

16. Stage III ( Cicatrising trachoma or stage of scarring). It includes obvious scarring of palpebral conjunctiva. Stage IV (Healed trachoma or stage of sequelae). The disease is quite and cured but sequelae due to cicatrisation give rise to symptoms.

17. WHO CLASSIFICATION

18. TT: Trachomatous trichiasis. TT is labelled when at least one eyelash rubs the eyeball. Evidence of recent removal of inturned eyelashes should also be graded as trachomatous trichiasis 04 CO: Corneal opacity. Corneal opacity is present over the pupil. This sign refers to corneal scarring that is so dense that at least part of pupil margin is blurred when seen through the opacity. 05

19. SEQUELAE 1. Eyelids   may be trichiasis entropion, tylosis (thickening of lid margin), ptosis, madarosis and ankyloblepharon . 2. Conjunctiva  concretions, pseudocyst, xerosis and symblepharon . 3. Cornea   may be corneal opacity, ectasia, corneal xerosis and total corneal pannus (blinding sequelae). 4. Other sequelae  may be chronic dacryocystitis , and chronic dacryoadenitis

20. COMPLICATIONS Corneal ulcer Which may occur due to rubbing by concretions, or trichiasis with superimposed bacterial infection. Corneal opacification Recurrence post-op

21. DIAGNOSIS at least two sets of signs should be present out of the following: Conjunctival follicles and papillae Pannus progressive or regressive 3. Epithelial keratitis near superior limbus 4. Signs of cicatrisation or its sequelae.   Laboratory tests 1. Conjunctival cytology. Giemsa stained smears showing a predominantly polymorphonuclear reaction with presence of plasma cells and Leber cells is suggestive of trachoma. 2. Detection of inclusion bodies in conjunctival smear may be possible by Giemsa stain, iodine stain or immunofluorescent staining, specially in cases with active trachoma.

22. 3. Enzyme-linked immunosorbent assay (ELISA) for chlamydial antigens. 4. Polymerase chain reaction (PCR) is also useful. 5. Isolation of chlamydia is possible by yolk-sac inoculation method and tissue culture technique. Standard single-passage McCoy cell culture requires at least 3 days. . DIAGNOSIS

23. 6.Serotyping of TRIC agents is done by detecting specific antibodies using microimmunofluorescence (micro-IF) method. Direct monoclonal fluorescent antibody microscopy of conjunctival smear is rapid and inexpensive. DIAGNOSIS

24. DIFFERENTIAL DIAGNOSIS 1. Trachoma with follicular hypertrophy must be differentiated from acute adenoviral follicular conjunctivitis as follows : Distribution of follicles in trachoma is mainly on upper palpebral conjunctiva and fornix, while in adenoviral keratoconjunctivitis lower palpebral conjunctiva and fornix is predominantly involved. Associated signs such as papillae and pannus are characteristic of trachoma. In clinically indistinguishable cases, laboratory diagnosis of trachoma helps in differentiation.

25. 2. Trachoma with predominant papillary hypertrophy needs to be differentiated from palpebral form of spring catarrh as follows: Papillae are large in size and usually there is typical cobble-stone arrangement in spring catarrh. Ph of tears is usually alkaline in spring catarrh, while in trachoma it is acidic, discharge is ropy in spring catarrh. In trachoma, there may be associated follicles and pannus. In clinically indistinguishable cases, conjunctival cytology and other laboratory tests for trachoma usually help in diagnosis. DIFFERENTIAL DIAGNOSIS

26. MANAGEMENT Treatment of active trachoma 1. Topical therapy regimes . Tetracycline[1%] or erythromycin[1%] eye ointment QID for 6 weeks The continuous treatment for active trachoma should be followed by an intermittent treatment especially in endemic or hyperendemic area. 2. Systemic therapy regimes . Tetracycline or erythromycin 250 mg orally QID for 3-4 weeks or OD of 1 gm azithromycin has also been reported to be equally effective in treating trachoma. 3. Combined topical and systemic therapy regime. Preferred when the ocular infection is severe (TI) or when there is associated genital infection.

27. ( i ) 1 per cent tetracycline or erythromycin eye ointment 4 times a day for 6 weeks; and (ii) tetracycline or erythromycin 250 mg orally 4 times a day for 2 weeks. Treatment of trachoma sequelae 1. Concretions should be removed with a hypodermic needle. 2. Trichiasis may be treated by epilation, electrolysis or cryolysis 3. Entropion should be corrected surgically 4. Xerosis should be treated by artificial tears. MANAGEMENT

28. . PROPHYLAXIS 1.Hygienic measures . Help a great deal in decreasing the transmission of disease, as trachoma is closely associated with personal hygiene and environmental sanitation. Therefore, health education on trachoma should be given to public. The use of common towel, handkerchief, surma rods etc A good environmental sanitation will reduce the flies. A good water supply would improve washing habits. 2. Early treatment of conjunctivitis Every case of conjunctivitis should be treated as early as possible to reduce transmission of disease

29. 3. Blanket antibiotic therapy . WHO has recommended this regime to be carried out in endemic areas to minimise the intensity and severity of disease. The regime is to apply 1 percent tetracycline eye ointment twice daily for 5 days in a month for 6 months. PROPHYLAXIS

30. PREVENTION OF TRACHOMA BLINDNESS Effective interventions have been demonstrated in developing nations using the SAFE strategy: Surgery ( bilamilar tarsal rotation) to correct lid deformity and prevent blindness Antibiotics for acute infections and community control, Facial hygiene Environmental change including improved access to water and sanitation and health education.