Trachoma History :- Trachoma was previously known as Egyptian ophthalmia and endemic in the Middle East since prehistoric times. Name comes from Greek word for ROUGH. Other name :- Granular conjunctivitis, blinding trachoma, Egyptian ophthalmia Trachoma is the most common infectious cause of blindness in the world Due to recurrent ocular infection with Chlamydia trachomatis. Trachoma is the leading cause of preventable irreversible blindness in the world. Repeat infection with this organism leads to conjunctival inflammation and scarring, trichiasis, and ultimately blinding corneal opacification Epidemiology:-The World Health Organization (WHO) reports trachoma is endemic to more than 50 countries, with most blinding trachoma in Africa. Worldwide, an estimated 2.2 million people are visually impaired as a result of trachoma, of whom 1.2 million are blind. India has become free from Trachoma-with an overall prevalence found to be only 0.7% in the National Trachoma Survey Report (2014-17).

1. Trachoma
DR RAHUL MAHALA
DNB OPHTHALMOLOGY
BOKARO GENERAL HOSPITAL, BOKARO
JHARKHAND ( INDIA )

2. Trachoma History
Trachoma was previously known as Egyptian ophthalmia and endemic in the Middle
East since prehistoric times.
Name comes from Greek word for ROUGH.
Other name :- Granular conjunctivitis, blinding trachoma, Egyptian ophthalmia.

3. Trachoma
Trachoma is the most common infectious cause of blindness in the world Due to recurrent ocular
infection with Chlamydia trachomatis.
Trachoma is the leading cause of preventable irreversible blindness in the world.
Repeat infection with this organism leads to conjunctival inflammation and scarring, trichiasis, and
ultimately blinding corneal opacification.

4. Epidemiology
The World Health Organization (WHO) reports trachoma is endemic to more than 50 countries,
with most blinding trachoma in Africa.
Worldwide, an estimated 2.2 million people are visually impaired as a result of trachoma, of
whom 1.2 million are blind.
India has become free from Trachoma-with an overall prevalence found to be only 0.7% in the
National Trachoma Survey Report (2014-17).

5. Etiology
Trachoma is caused by Chlamydia trachomatis serotypes A, B, C.
The organism is classified as a special type of bacterium which is a prokaryotic, obligatory
intracellular parasite.
Tow species of the genus are C. trachomatis and C. psittaci.
In endemic areas, children are often infected in the first few years of life.
Female > male
Climate : more common in dry and dusty weather.

6. Risk Factors
Risk factors for trachoma include things that favor transmission of the organism.
1) Poverty:- Trachoma is primarily a disease of extremely poor populations in developing countries.
2) Crowded living conditions:- People living in close contact are at greater risk of spreading infection.
3) Poor sanitation:- Poor sanitary conditions and lack of hygiene.
4) Flies:- People living in areas with problems controlling the fly population may be more susceptible
to infection.
5) Lack of latrines:- Populations without access to working latrines — a type of communal toilet —
have a higher incidence of the disease.

7. Pathophysiology:
Blindness from trachoma is due to recurrent episodes of active infection.
The initial infection is confined to the conjunctival epithelium and triggers an immune response.
Isolated episode of trachomatous conjunctivitis may be relatively innocuous.
Recurrent infection elicits a chronic immune response consisting of a cell-mediated
delayed hypersensitivity (Type IV) reaction to the intermittent presence of chlamydial
antigen and can lead to loss of sight.

8. Prior contact with the organism confers short-term partial immunity but also leads to a
heightened inflammatory reaction upon reinfection.
Repeat infections with subsequent inflammatory responses results in tissue destruction,
scarring, cicatricial entropion with trichiasis, and corneal opacification from lashes rubbing
against the cornea.

9. Mode of infection
fly is an important vector.
Modes:-
1)Vector transmission:-trachoma is common through flies.
2) Direct spread :- infections occurs through contact by airborne or waterborne infections.
3) Material transfer :- can occur through contaminated finger of doctors, nurses and
contaminated tonometer. Other source of infection are use of common towel, handkerchief,
bedding and surma rods.

11. Grading
The WHO has identified five grades in the development of trachoma:
1) Inflammation — follicular
2) Inflammation — intense
3) Eyelid scarring
4) Ingrown eyelashes (trichiasis)
5) Corneal clouding

12. 1) Inflammation — follicular :- The infection is just beginning in this stage. Five or more follicles —
small bumps that contain lymphocytes, a type of white blood cell — are visible with magnification on
the inner surface of your upper eyelid (conjunctiva).
2)Inflammation — intense :- In this stage, your eye is now highly infectious and becomes irritated,
with a thickening or swelling of the upper eyelid.
3) Eyelid scarring:- Repeated infections lead to scarring of the inner eyelid. The scars often appear as
white lines when examined with magnification. Your eyelid may become distorted and may turn in
(entropion).

13. 4) Ingrown eyelashes (trichiasis):-The scarred inner lining of your eyelid continues to deform, causing
your lashes to turn in so that they rub on and scratch the transparent outer surface of your eye
(cornea).
5) Corneal clouding:-The cornea becomes affected by an inflammation that is most commonly seen
under your upper lid. Continual inflammation compounded by scratching from the in-turned lashes
leads to clouding of the cornea.

14. Follicular inflammation Intense inflammation

15. Conjunctival scarring Trichiasis

16. Stages
MacCallan decides trachoma in 4 stages:-
Trachoma stage I :-incipient trachoma/ stage of infiltration
hyperaemia of palpebral conjunctiva and immature follicles
Trachoma stage II :- In IIA) stage of fibroid infiltration, mature follicle. In (IIB) stage marked
papillary hyperplasia, progressive pannus
Trachoma stage III :- cicatrizing trachoma/ stage of scarring
Trachoma stage IV :- healed trachoma/ stage of sequale.

17. Clinical feature
Features of trachoma are divided into:-
1) Active trachoma
2) cicatricial trachoma

18. Active Trachoma
1)Mixed follicular/papillary conjunctivitis associated with a mucopurulent discharge.
In children under the age of 2 years the papillary component may predominate.
2)Superior epithelial keratitis and pannus formation:-infiltration of the cornea
associated with vascularization in the upper part.
Superior epithelial keratitisMixed follicular / papillary conjunctivitis

19. Cicatricial Trachoma
Cicatricial trachoma is prevalent in middle age.
Linear or stellate conjunctival scars in mild cases.
Broad confluent scars (Arlt line) in severe disease.
Arlt line
Stellate
conjunctival scar

20. • Superior limbal follicles may resolve to leave a row of shallow
depressions (Herbert pits)
• Trichiasis, distichiasis, corneal vascularization and cicatricial entropion

21. Symptoms
1:- Mild itching and irritation of the eyes and eyelids
2:-Discharge from the eyes containing mucus or pus
3:-Eyelid swelling
4:-Light sensitivity (photophobia)
5:-Eye pain

22. Diagnosis
1) Micro-immunofluorescence (micro-IF) test using pooled antigens, which is recommended for
routine diagnostic use.
2) Culture of C. trachomatis in irradiated McCoy cells is an expensive test.
3) Monoclonal antibody direct tests. IgA-IPA light microscopy tests form the best combination of
diagnostic tools for chlamydial ocular disease.

23. 1)The presence of follicles more in the upper than lower palpebral conjunctiva
2)Epithelial keratitis in the early stages most marked in the upper part of the cornea
3)A pannus in the upper part of the cornea
4)Limbal follicles or their sequelae as Herbert pits and
5)In the later stages, typical stellate trachomatous scarring in the conjunctiva with linear
conjunctival scarring of the upper tarsus.
From the clinical point of view, the diagnostic features of trachoma depend
on the following characteristics:-

24. Sequelae
Apart from the results of pannus and corneal ulceration, the most disabling effects of trachoma
are caused by distortion of the lids.
Conjunctival sequelae :-
loss of fornices, parenchymatous xerosis, concretion , pseudo pterygium,, symblepharon
Eye lid sequelae :-
ptosis, entropion and trichiasis, tylosis, madarosis, ankyloblepheron.
Corneal sequelae :-
corneal opacity, corneal xerosis, ectasia.

25. Management
The World Health Organization recommends the 'SAFE' strategy for the management of
trachoma.
This strategy was developed in 1997 by The Alliance for the Global Elimination of Blinding
Trachoma by the year 2020 (GET 2020)
4 step approach:-
S: Surgery for Trichiasis
A: Antibiotics for C. trachomatis infection
F: Facial cleanliness
E: Environmental change to improve sanitation and increase access to clean water

26. Antibiotics:-
 Antibiotics for active disease.
 Antibiotics should be administered to those affected and to all family members.
 A single antibiotic course is not always effective in eliminating infection in an individual, and
communities may need to receive annual treatment to suppress infection.
 A single dose of azithromycin (20 mg/kg up to 1 g) is the treatment of choice.
 Erythromycin 500 mg twice daily for 14 days or doxycycline 100 mg twice daily for 10 days
(tetracyclines are relatively contraindicated in pregnancy/breastfeeding and in children <12yr)

27.  Facial cleanliness is a critical preventative measure.
 Environmental improvement, such as access to adequate water and sanitation, as well as
control of flies, is important.
 Surgery is aimed at relieving entropion and trichiasis and maintaining complete lid closure,
principally with bilamellar tarsal rotation.

28. Course and prognosis
Its course is determined largely by the presence or absence of a complicating secondary
bacterial infection and repeated re-infection transmitted by flies and infected relatives.
In the absence of such complications, a ‘pure’ trachoma may be a relatively mild, symptomless
disease, so as to excite little or no attention until perhaps cicatrization manifests itself later in
life.
In many countries where the disease is endemic, secondary infections result in an acute and
incapacitating condition, liable to relapses as a result of re-infection, and leading to gross
cicatricial sequelae which often lead to blindness.