Trachoma

TrachomaTrachoma
J.B.ChandJ.B.Chand
Himalaya Eye HospitalHimalaya Eye Hospital
Pokhara, NepalPokhara, Nepal

3.7.2006 Trachoma JBC 2
DefinitionDefinition
 Most commonMost common infective cause of blindnessinfective cause of blindness
worldwideworldwide
 Chronic granulomatous kerato-conjunctivitisChronic granulomatous kerato-conjunctivitis
 Caused by “Caused by “Chlamydia TrachomatisChlamydia Trachomatis””
 Transmitted under the poor hygieneTransmitted under the poor hygiene
 Inflammation leads to eye lid scarring,Inflammation leads to eye lid scarring,
resulting in triachiasis and entropionresulting in triachiasis and entropion
 Common housefly is the major vector in theCommon housefly is the major vector in the
infection-reinfection cycleinfection-reinfection cycle

Chlamydia TrachomatisChlamydia Trachomatis
 Serotypes A, B, Ba and C ofSerotypes A, B, Ba and C of ChlamydiaChlamydia
trachomatis,trachomatis, highly infectioushighly infectious with eyeswith eyes
 Closer to bacteria then virusCloser to bacteria then virus
 Have cell wallHave cell wall
 Have DNA and RNAHave DNA and RNA
 Multiply by binary fissionMultiply by binary fission
 Sensitive to some antibioticsSensitive to some antibiotics
 Can pass from one child’s eyes to the eyesCan pass from one child’s eyes to the eyes
of other children within a few minutesof other children within a few minutes

Global epidemiologyGlobal epidemiology
 150 million people have active trachoma150 million people have active trachoma
andand most of these are under 15 years ofmost of these are under 15 years of
ageage
 Up to 5.6 million are thought to be blind dueUp to 5.6 million are thought to be blind due
to the trachomato the trachoma
 Occur in middle-eastern crescent, otherOccur in middle-eastern crescent, other
Asia and Islands, Sub-saharan Africa,Asia and Islands, Sub-saharan Africa,
China, India and Latin America andChina, India and Latin America and
CaribbeanCaribbean

Global Blindness by CauseGlobal Blindness by Cause
CausesCauses Blindness %Blindness %
CataractCataract 43%43%
TrachomaTrachoma 11%11%
GlaucomaGlaucoma 15%15%
XerophthalmiaXerophthalmia 6%6%
OnchocerciasisOnchocerciasis 1%1%
OthersOthers 24%24%
TotalTotal 100.0%100.0%
WHO:1998

NBS 1981:Causes of BlindnessNBS 1981:Causes of Blindness
SNSN CausesCauses %%
11 CataractCataract 7272
22 Retinal diseaseRetinal disease 3.33.3
33 GlaucomaGlaucoma 3.23.2
44 Other infectionOther infection 3.23.2
55 TrachomaTrachoma 2.42.4
66 SmallpoxSmallpox 2.22.2
77 TraumaTrauma 2.22.2
88 AmblyopiaAmblyopia 1.31.3
99 Nutritional etiologyNutritional etiology 0.90.9
1010 MiscellaneousMiscellaneous 7.57.5
1111 UndeterminedUndetermined 1.81.8
TotalTotal 100100

Trachoma ( NBS 1981)Trachoma ( NBS 1981)
 1 million1 million of the population had Trachomaof the population had Trachoma
 Cause 2.4%Cause 2.4% of the blindness in Nepalof the blindness in Nepal
 Prevalent inPrevalent in WesternWestern andand FarFar WesternWestern TeraiTerai
 FemalesFemales are affected moreare affected more
 Ethnic groups:Ethnic groups: Tharu,Tharu, Chhetry and MagarChhetry and Magar
account for nearly 60% of trachomaaccount for nearly 60% of trachoma
 Tharus are most affectedTharus are most affected
 BheriBheri andand SetiSeti Zone altogether containZone altogether contain 3/4th3/4th
of the trachoma in Nepalof the trachoma in Nepal

Age and TrachomaAge and Trachoma
All age groups may be
affected by trachoma but
there is a progression of
the disease which may
continue over many years
beginning in the very
young, with the later
scarring complications
evident in older children
and in all ages of adult
life

Clinical FeaturesClinical Features
 Incubation periodIncubation period: 5-21 days: 5-21 days
 OnsetOnset: Insidious, rarely acute: Insidious, rarely acute
 Symptoms:Symptoms:
– Mild F.B. sensation, slight watering,Mild F.B. sensation, slight watering,
stickiness, scanty discharge andstickiness, scanty discharge and
photophobiaphotophobia

WHO ClassificationWHO Classification
1. Trachomatous inflammation-Follicular (T1. Trachomatous inflammation-Follicular (TFF))
2. Trachomatous inflammation-Intense (T2. Trachomatous inflammation-Intense (TII))
3. Trachomatous Scarring (3. Trachomatous Scarring (TTSS))
4. Trachomatous Trichiasis (4. Trachomatous Trichiasis (TTTT))
5. Corneal Opacity (5. Corneal Opacity (CCOO))
FISTOFISTO

Normal Tarsal ConjunctivaNormal Tarsal Conjunctiva

Trachomatous InflammationTrachomatous Inflammation
Follicular (TF)Follicular (TF)
 Active trachomaActive trachoma
with follicularwith follicular
inflammationinflammation
 5 or more follicles5 or more follicles
(0.5mm or more)(0.5mm or more)
upper tarsalupper tarsal
conjunctivaconjunctiva
 Deep conjunctivalDeep conjunctival
vessels should bevessels should be
visiblevisible

Trachomatous inflammation-Trachomatous inflammation-
intense (intense (TITI))
 PronouncedPronounced
inflammatoryinflammatory
thickening ofthickening of
upper tarsalupper tarsal
 Obscures moreObscures more
than half of thethan half of the
normal deepnormal deep
tarsal vesselstarsal vessels

Trachomatous scarring (Trachomatous scarring (TSTS))
 Scarring presentScarring present
in tarsalin tarsal
 White lines,White lines,
bands or sheetsbands or sheets
of fibrosis in theof fibrosis in the
tarsaltarsal

Trachomatous Trichiasis (Trachomatous Trichiasis (TTTT))
 At least 1 eye lashAt least 1 eye lash
rubs the eyeballrubs the eyeball
 If evidence ofIf evidence of
recently removedrecently removed
lasheslashes
graded as TTgraded as TT

Corneal Opacity (Corneal Opacity (COCO))
 Corneal opacityCorneal opacity
obscuring atobscuring at
least part of theleast part of the
pupil marginpupil margin
 Causing a visualCausing a visual
acuity of lessacuity of less
than 6/18than 6/18

Corneal SignsCorneal Signs
 Superficial punctate keratitisSuperficial punctate keratitis
 PannusPannus:Infiltration of cornea associated:Infiltration of cornea associated
with vascularization in the upper corneawith vascularization in the upper cornea
– Progressive pannusProgressive pannus: infiltration ahead of: infiltration ahead of
blood vesselsblood vessels
– Regressive pannusRegressive pannus: blood vessels extend: blood vessels extend
beyond the corneal hazebeyond the corneal haze
 Herbert’s pitsHerbert’s pits: oval or circular pitted: oval or circular pitted
scars left after Herbert’s follicles heal inscars left after Herbert’s follicles heal in
the limbal areathe limbal area

Corneal Signs & ComplicationsCorneal Signs & Complications
Herbert’s pitsHerbert’s pits PannusPannus
EntropionEntropion
Progressive PannusProgressive Pannus

DiagnosisDiagnosis
 At leastAt least twotwo of following fourof following four signs shouldsigns should
be presentbe present to diagnose Trachomato diagnose Trachoma
1.1. Follicles:Follicles: IIn the upper tarsal conjunctivan the upper tarsal conjunctiva
2.2. PannusPannus:Progressive/regressive:Progressive/regressive
3. Epithelial keratitis: in superior cornea3. Epithelial keratitis: in superior cornea
4. Conjunctival cicatrization/sequelae4. Conjunctival cicatrization/sequelae

Differential DiagnosisDifferential Diagnosis
 Other eyeOther eye
condition may becondition may be
difficult todifficult to
differentiate fromdifferentiate from
trachoma and alsotrachoma and also
may be present atmay be present at
the same time asthe same time as
trachomatrachoma
Trachoma TI Vernal Catarrh

Risk Factor of TrachomaRisk Factor of Trachoma
 6 Ds6 Ds::
– DryDry
– DustyDusty
– DirtyDirty
– DungDung
– DischargeDischarge
– Density (Overcrowding in the home)Density (Overcrowding in the home)

Transmission of TrachomaTransmission of Trachoma
 5 Fs5 Fs
– FliesFlies
– FaecesFaeces
– FacesFaces
– FingersFingers
– FomitesFomites
(contaminated(contaminated
material or objectsmaterial or objects
such as clothing orsuch as clothing or
towels)towels)

Minimum FliesMinimum Flies
 Providing goodProviding good
sanitation, ventilated pitsanitation, ventilated pit
or other types ofor other types of
latrines accepted bylatrines accepted by
communitiescommunities
 Burying or burningBurying or burning
rubbishrubbish
 Keeping animals at aKeeping animals at a
distance fromdistance from
communitiescommunities

Water and TrachomaWater and Trachoma
 Distance to waterDistance to water
 Quantity of waterQuantity of water
 Use of waterUse of water
 Behavioral factorsBehavioral factors
concerning water useconcerning water use
may be more importantmay be more important
then the amount ofthen the amount of
waterwater

Factors Influencing the Effects ofFactors Influencing the Effects of
Trachoma in the CommunityTrachoma in the Community
1. Repeated infections1. Repeated infections
2. Crowding/Unhygienic conditions2. Crowding/Unhygienic conditions
3. Carriers3. Carriers
4. Concurrent infections4. Concurrent infections
5. Heat and dust5. Heat and dust
6. Flies6. Flies
7. Standard of living7. Standard of living
8. Trichiasis, entropion8. Trichiasis, entropion

Repeated InfectionsRepeated Infections
 Trachoma producesTrachoma produces poorpoor andand shortshort
lived immunitylived immunity
 In hyperendemic areas, repeatedIn hyperendemic areas, repeated
reinfections occurreinfections occur
 Repeated reinfections produceRepeated reinfections produce
hypersensitive reactions in surroundinghypersensitive reactions in surrounding
tissuestissues
 This produces much more severe formThis produces much more severe form
of diseaseof disease

Crowding and UnhygienicCrowding and Unhygienic
ConditionsConditions
 Trachoma is very infectious and canTrachoma is very infectious and can
spread only in poor and overcrowdedspread only in poor and overcrowded
communities with poor hygienecommunities with poor hygiene
 People treating trachoma everyday doPeople treating trachoma everyday do
not contract it themselves as they follownot contract it themselves as they follow
the basic rules of hygiene and personalthe basic rules of hygiene and personal
cleanlinesscleanliness

CarriersCarriers
 Main carriers are children below 10 yrsMain carriers are children below 10 yrs
especially pre-school childrenespecially pre-school children
 In hyperendemic areasIn hyperendemic areas
– AlmostAlmost all young childrenall young children havehave activeactive
trachomatrachoma
– AdultsAdults havehave inactive trachoma scarsinactive trachoma scars
– Some showSome show active disease,active disease, usuallyusually
reinfectionreinfection
– Adult womenAdult women affected moreaffected more

Concurrent InfectionsConcurrent Infections
 Factors favoring spread of trachomaFactors favoring spread of trachoma
also spread other infective conjunctivitisalso spread other infective conjunctivitis
 Secondary infections will produce moreSecondary infections will produce more
severe clinical picturesevere clinical picture

Heat and DustHeat and Dust
Trachoma is severe in areas where heatTrachoma is severe in areas where heat
and dust are a problemand dust are a problem
 Flies multiply rapidly in hot, dusty placesFlies multiply rapidly in hot, dusty places
 Dust is direct irritant to eyes increasesDust is direct irritant to eyes increases
the inflammatory responsethe inflammatory response
 Dust increases the ocular discharges whichDust increases the ocular discharges which
increase the spread of trachomaincrease the spread of trachoma

FliesFlies
 In trachoma endemicIn trachoma endemic
areas, flies are oftenareas, flies are often
seen on the faces ofseen on the faces of
young childrenyoung children
 They feed on eye andThey feed on eye and
nasal discharges , andnasal discharges , and
therefore spread thetherefore spread the
infection from eye toinfection from eye to
eyeeye

Standard of LivingStandard of Living
 In Europe, Trachoma was a significantIn Europe, Trachoma was a significant
problem in the last century. Itproblem in the last century. It
decreased significantly before discoverydecreased significantly before discovery
of any antibiotic due to improvement inof any antibiotic due to improvement in
living standardliving standard
 With better sanitation, severity andWith better sanitation, severity and
incidence of trachoma fallsincidence of trachoma falls
– Decrease person to person spreadDecrease person to person spread
– Decrease the fly populationDecrease the fly population

Trichiasis and EntropionTrichiasis and Entropion
 These are two complications causingThese are two complications causing
blindnessblindness
 Ingrowing lashes constantly irritate theIngrowing lashes constantly irritate the
corneacornea
 Provoke further corneal ulceration, infectionProvoke further corneal ulceration, infection
vascularization and increased scarringvascularization and increased scarring

Treatment of TrachomaTreatment of Trachoma
 Chlamydia trachomatis is sensitive to:Chlamydia trachomatis is sensitive to:
– TetracyclineTetracycline
– DoxycyclineDoxycycline
– SulfonamideSulfonamide
– ErythromycinErythromycin
 Organism livesOrganism lives insideinside the bodythe body cellscells
 ProtectedProtected from full effects of antibioticsfrom full effects of antibiotics
 ResponseResponse to treatment is therefore, muchto treatment is therefore, much slowerslower..

Trachoma &Trachoma & SAFESAFE StrategyStrategy
 SSurgical correctionurgical correction of trichiasis is required forof trichiasis is required for
patients who are at risk of becoming blindpatients who are at risk of becoming blind
 AAntibiotic treatmentntibiotic treatment of active trachoma where TFof active trachoma where TF
and TI is diagnosedand TI is diagnosed
 FFacial cleanlinessacial cleanliness is a simple and effectiveis a simple and effective
method of preventing infection and reducingmethod of preventing infection and reducing
spreading trachomaspreading trachoma
 EEnvironmental improvementsnvironmental improvements raise the standardraise the standard
of living of communities and help eliminatingof living of communities and help eliminating
entirely this potentially blinding eye diseaseentirely this potentially blinding eye disease

Management of TrachomaManagement of Trachoma
Trachoma
Treatment Prevention
Treatment of
Active Trachoma
Treatment of
Complications

Treatment of Active TrachomaTreatment of Active Trachoma
 Local antibioticsLocal antibiotics
 Systemic antibioticsSystemic antibiotics
 Combined local and systemic antibioticsCombined local and systemic antibiotics

 Tetracycline 1% eye oc BDTetracycline 1% eye oc BD XX dailydaily XX 6 week or6 week or
 Cap. Tetracycline 250mg 4Cap. Tetracycline 250mg 4 XX day for 3 weeks orday for 3 weeks or
 Cap. Doxycycline 100mg daily for 3 weeks orCap. Doxycycline 100mg daily for 3 weeks or
 Cap. Erythromycin 250mgCap. Erythromycin 250mg XX 4/day for 3 weeks4/day for 3 weeks
 Tab. Azithromycin (20mg/kg byTab. Azithromycin (20mg/kg by
mouth) single dose annuallymouth) single dose annually
(Most effective nowadays)(Most effective nowadays)

Local Antibiotic TherapyLocal Antibiotic Therapy
 Better than systemic treatmentBetter than systemic treatment
 CheaperCheaper
– Most trachoma patients are poorMost trachoma patients are poor
 No systemic side effectsNo systemic side effects
 Also effective against concurrent bacterialAlso effective against concurrent bacterial
conjunctivitisconjunctivitis

Topical Antibiotic TreatmentTopical Antibiotic Treatment
 Continuous treatmentContinuous treatment: for individual: for individual
casescases
a) Oc. Tetracycline(1%) or Oc. Erythromycina) Oc. Tetracycline(1%) or Oc. Erythromycin
(1%) x QID x 6 weeks(1%) x QID x 6 weeks
b) Gtt. Sulphacetamide(20%) x TDS +b) Gtt. Sulphacetamide(20%) x TDS +
Oc. Tetracycline x HS x 6 weeksOc. Tetracycline x HS x 6 weeks
 Intermittent treatmentIntermittent treatment: For community: For community
in endemic areasin endemic areas
a) Oc. Tetracycline(1%) or Oc. Erythromycina) Oc. Tetracycline(1%) or Oc. Erythromycin
(1%) x BD x 1wk every month x 6 months(1%) x BD x 1wk every month x 6 months

Systemic Antibiotic TherapySystemic Antibiotic Therapy
 TetracyclineTetracycline oror ErythromycinErythromycin 250 mg x QID250 mg x QID
x 3-4 weeksx 3-4 weeks
oror
 DoxycyclineDoxycycline 100mg x BD x 3-4 weeks100mg x BD x 3-4 weeks
oror
 AzithromycinAzithromycin 20mg/kg body wt. As a single20mg/kg body wt. As a single
dosedose

Combined TherapyCombined Therapy
 Used whenUsed when
– Ocular infection is severeOcular infection is severe
– When there is associated genitalWhen there is associated genital
infectioninfection
 RegimeRegime
a) 1% Tetracycline/Erythromycin ointmenta) 1% Tetracycline/Erythromycin ointment
x QID x 6 Weeksx QID x 6 Weeks
b) Erythromycin/Tetracycline 250mg x QIDb) Erythromycin/Tetracycline 250mg x QID
x 2 weeksx 2 weeks

ImportantImportant
 Do not give systemic antibiotics to womenDo not give systemic antibiotics to women
during pregnancyduring pregnancy
 Doxycycline and tetracycline should not beDoxycycline and tetracycline should not be
given to children under the age of 7 yearsgiven to children under the age of 7 years
 Azithromycin dose is 20mg/kg to aAzithromycin dose is 20mg/kg to a
maximum of 1g and should not be given inmaximum of 1g and should not be given in
pregnancy but can be given to children overpregnancy but can be given to children over
6 months of age6 months of age

Treatment for ComplicationsTreatment for Complications
 TrichiasisTrichiasis: epilation, electro-epilation or: epilation, electro-epilation or
cryotherapycryotherapy
 EntropionEntropion: surgical correction. Control: surgical correction. Control
disease firstdisease first
 Corneal scarringCorneal scarring:: cause for blindness.cause for blindness.
Penetrating keratoplasty when eye is quitePenetrating keratoplasty when eye is quite
 Dry eyeDry eye: Artificial tears, mucous membrane: Artificial tears, mucous membrane
graft.graft.

Prevention of TrachomaPrevention of Trachoma
1. Improve personal and public hygiene1. Improve personal and public hygiene
– Supply safe and pipe waterSupply safe and pipe water
– Clean surroundings: decrease fly populationClean surroundings: decrease fly population
– Teach personal hygiene to school children andTeach personal hygiene to school children and
mothersmothers
2. Antibiotics: WHO2. Antibiotics: WHO Intermittent regimeIntermittent regime inin
endemic areasendemic areas
3. Early treatment of all trachoma cases3. Early treatment of all trachoma cases
4. Vaccination tried-4. Vaccination tried- So far not effectiveSo far not effective

GET 2020 StrategyGET 2020 Strategy
 The objective in these strategy is toThe objective in these strategy is to
eliminate trachoma as a blinding diseaseeliminate trachoma as a blinding disease
 This initiative is called the WHOThis initiative is called the WHO GlobalGlobal
Alliance for the Elimination of TrachomaAlliance for the Elimination of Trachoma
by the year 2020 (GET 2020)by the year 2020 (GET 2020)
 For eye care workers that motto has a veryFor eye care workers that motto has a very
special meaning as 20/20 is perfect visionspecial meaning as 20/20 is perfect vision
 Trachoma is one of the VISION 2020Trachoma is one of the VISION 2020
Priority diseasePriority disease

Thank YouThank You

Trachoma

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (20)

Similar a Trachoma

Similar a Trachoma (20)

Más de JB Chand

Más de JB Chand (7)

Último

Último (20)

Trachoma