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TRACHOMATRACHOMABy C. Sakthi AnnamalaiBy C. Sakthi Annamalai

IntroductionIntroductionetiologyetiology

prevalence & clinical profileprevalence & clinical profilesymptoms & signssymptoms & signs

gradinggradingsequelsequel

diagnosis diagnosis managementmanagement

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IntroductionIntroduction

““Egyptian Opthalmia”Egyptian Opthalmia” chronic follicular keratoconjunctivitischronic follicular keratoconjunctivitis leading cause of preventable blindness in the leading cause of preventable blindness in the

worldworld

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EtiologyEtiology

Causal organism:Causal organism: Chlamydia trachomatis A,B,Ba,CChlamydia trachomatis A,B,Ba,C Predisposing factors:Predisposing factors:1. Age - infancy & early childhood1. Age - infancy & early childhood2. Sex - females2. Sex - females3. Race - Jews --> more common3. Race - Jews --> more common Negroes --> less commonNegroes --> less common4. Climate - dry & dusty4. Climate - dry & dusty5. Socioeconomic status - 5. Socioeconomic status -

unhygienic conditionsunhygienic conditions6. Environmental factors - dust, 6. Environmental factors - dust,

smoke, irritants, sunlightsmoke, irritants, sunlight

Source of infection:Source of infection:conjunctival discharge of affected conjunctival discharge of affected

personspersonssuperimposed bacterial infectionssuperimposed bacterial infections Mode of infection:Mode of infection:1. Direct spread - air or water borne1. Direct spread - air or water borne2. Vector - eye-seeking flies(e.g.. 2. Vector - eye-seeking flies(e.g..

Musca spp, Hippelatus spp)Musca spp, Hippelatus spp)3. Maternal transmission - fingers of 3. Maternal transmission - fingers of

doctors & nurses, contaminated doctors & nurses, contaminated tonometers,towels,handkerchief,tonometers,towels,handkerchief,bedding, bedding, surmasurma rods, Kajal rods, Kajal

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Prevalence & clinical profilePrevalence & clinical profile Prevalence:Prevalence: North Africa, Middle East, South North Africa, Middle East, South

East AsiaEast Asia 500 million affected500 million affected 15-20% of blindness in the world15-20% of blindness in the world

Natural History:Natural History: acute - first decadeacute - first decade inactive in 2nd decadeinactive in 2nd decade sequale - after 20 yearssequale - after 20 years peak - 4th & 5th decadespeak - 4th & 5th decades

Clinical profile:Clinical profile: incubation period - 5-21 days, incubation period - 5-21 days,

insidiousinsidious clinical course -clinical course - if no 2° infection --> if no 2° infection -->

symptomlesssymptomless if 2° infection --> symptoms of if 2° infection --> symptoms of

acute conjunctivitisacute conjunctivitis Trachoma dubiumTrachoma dubium (doubtful (doubtful

trachoma) trachoma) In early stage - In early stage - difficult to distinguish from difficult to distinguish from bacterial conjunctivitisbacterial conjunctivitis

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Symptoms & SignsSymptoms & Signs Symptoms:Symptoms: Foreign body Foreign body

sensation, sensation, lacrimation, lacrimation, slight stickiness slight stickiness of lids, scanty of lids, scanty mucous mucous dischargedischarge

2° infection --> 2° infection --> symptoms of symptoms of acute acute mucopurulent mucopurulent conjunctivitisconjunctivitis

Trachomatous Trachomatous ptosisptosis

Conjunctival signs:Conjunctival signs: 1. Congestion1. Congestion 2. Conjunctival follicles - looks like boiled 2. Conjunctival follicles - looks like boiled sagograinssagograins structure of follicles structure of follicles central part -> mononuclear histiocytes,central part -> mononuclear histiocytes,

cortical part -> zone of lymphocytes with active cortical part -> zone of lymphocytes with active proliferation, blood vessels most peripherallyproliferation, blood vessels most peripherally

3. Papillary hyperplasia -> reddish flat topped raised 3. Papillary hyperplasia -> reddish flat topped raised areas, red velvety tarsal conjunctiva, central core of areas, red velvety tarsal conjunctiva, central core of numerous dilated blood vessels surrounded by numerous dilated blood vessels surrounded by lymphocytes & hypertrophic epitheliumlymphocytes & hypertrophic epithelium

4. Conjunctival scarring - 4. Conjunctival scarring - Arlt’s lineArlt’s line 5. Concretions - dead epithelial cells & inspissated mucus 5. Concretions - dead epithelial cells & inspissated mucus

in in glands of Henleglands of Henle Corneal signs:Corneal signs: superficial keratitis superficial keratitis Herbert pitsHerbert pits Herbert folliclesHerbert follicles - in limbus - in limbus Corneal opacity Corneal opacity Pannus - progressive, regressive(Pannus - progressive, regressive(pannus siccuspannus siccus)) Corneal ulcerCorneal ulcer

lymphocytes, Leber cells

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GradingsGradings

Mc Callan’s ClassificationMc Callan’s Classification

Jones’ ClassificationJones’ Classification

WHO ClassificationWHO Classification

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Mc Callan’s Classification(1908)Mc Callan’s Classification(1908)

Stage I - Incipient trachoma (or) stage of infiltrationStage I - Incipient trachoma (or) stage of infiltration - hyperemia of palpebral conjunctiva & immature - hyperemia of palpebral conjunctiva & immature

folliclesfollicles Stage II - Established trachoma (or) Stage of florid Stage II - Established trachoma (or) Stage of florid

infiltrationinfiltration - mature follicles, papillae & progressive corneal - mature follicles, papillae & progressive corneal

pannuspannus IIa - mature folliclesIIa - mature follicles IIb - marked papillary hyperplasiaIIb - marked papillary hyperplasia Stage III - Cicatrizing trachoma (or) stage of scarringStage III - Cicatrizing trachoma (or) stage of scarring - scarring of palpebral conjunctiva- scarring of palpebral conjunctiva Stage IV - Healed trachoma (or) stage of sequelStage IV - Healed trachoma (or) stage of sequel

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Jones’ ClassificationJones’ Classification

Class 1Class 1 :: Blinding trachoma Blinding trachoma serotypes A,B,Ba,Cserotypes A,B,Ba,C 2° bacterial infection2° bacterial infection eye to eye transfereye to eye transfer

Class 2 : Class 2 : Non blinding trachomaNon blinding trachoma serotypes A,B,Ba,Cserotypes A,B,Ba,C no 2° bacterial infectionno 2° bacterial infection mesoendemic or hypoendemic areas with better socioeconomic mesoendemic or hypoendemic areas with better socioeconomic

statusstatus mild form with limited transmissionmild form with limited transmission

Class 3 : Class 3 : ParatrachomaParatrachoma serotypes D to Kserotypes D to K oculogenital --> genitals to eyeoculogenital --> genitals to eye adult inclusion conjunctivitis, Chlamydial opthalmia neonatorumadult inclusion conjunctivitis, Chlamydial opthalmia neonatorum

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WHO Classification (1981)WHO Classification (1981)

FFolliclesollicles IIntensentense SScarringcarring TTrichiasisrichiasis OOpacitiespacities

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Sequel:Sequel: 1. In lids - trichiasis, entropion,tylosis, ptosis, madarosis, 1. In lids - trichiasis, entropion,tylosis, ptosis, madarosis,

ankyloblepharonankyloblepharon 2. Conjunctival - concretions, pseudocyst, Xerosis, 2. Conjunctival - concretions, pseudocyst, Xerosis,

symblepharonsymblepharon 3. Corneal - opacity, ectasis, Xerosis, Pannus 3. Corneal - opacity, ectasis, Xerosis, Pannus 4. Others - chronic dacryocystitis, 2° glaucoma4. Others - chronic dacryocystitis, 2° glaucoma

Complications:Complications: Corneal ulcerCorneal ulcer

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DiagnosisDiagnosis A. clinical Diagnosis:A. clinical Diagnosis:

presence of at least two sets:presence of at least two sets: 1.Conjunctival follicles & papillae1.Conjunctival follicles & papillae 2. Pannus - Progressive or regressive2. Pannus - Progressive or regressive 3. Epithelial keratitis near superior limbus3. Epithelial keratitis near superior limbus 4. Signs of circatrisation or its sequel4. Signs of circatrisation or its sequel

B. Lab diagnosis:B. Lab diagnosis: 1. Conjunctival cytology - 1. Conjunctival cytology - GiemsaGiemsa stain --> Plasma cells, stain --> Plasma cells, Leber cellsLeber cells 2. Inclusion bodies - Giemsa, Iodine or immunofluorescent stain2. Inclusion bodies - Giemsa, Iodine or immunofluorescent stain 3. Isolation - Yolk sac inoculation, tissue culture(irradiated 3. Isolation - Yolk sac inoculation, tissue culture(irradiated Mc Coy Mc Coy

cellscells)) 4. Serotyping of TRIC agents - micro immunofluorescence4. Serotyping of TRIC agents - micro immunofluorescence

Differential Diagnosis:Differential Diagnosis: 1. Epidemic Keratoconjunctivitis1. Epidemic Keratoconjunctivitis 2. Palpebral form of spring catarrh2. Palpebral form of spring catarrh

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ManagementManagement A. active trachoma:A. active trachoma:

1. Topical treatment regimes -- tetracycline, erythromycin1. Topical treatment regimes -- tetracycline, erythromycin 2. Systemic therapy regimes -- Tetracycline, Doxycycline, Azithromycin2. Systemic therapy regimes -- Tetracycline, Doxycycline, Azithromycin 3. Combined topical & systemic3. Combined topical & systemic

Trachoma sequel:Trachoma sequel: 1. Concretions -- hypodermic needle1. Concretions -- hypodermic needle 2. Trichiasis -- epilation, electrolysis, cryolysis2. Trichiasis -- epilation, electrolysis, cryolysis 3. Entropion -- Surgery3. Entropion -- Surgery 4. Xerosis -- artificial tears4. Xerosis -- artificial tears

Prophylaxis:Prophylaxis: 1. Hygienic measures1. Hygienic measures 2. early treatment of conjunctivitis2. early treatment of conjunctivitis 3. WHO recommended blanket antibiotic therapy(intermittent treatment)3. WHO recommended blanket antibiotic therapy(intermittent treatment) 1% tetracycline eye ointment twice daily for 5 days in a month1% tetracycline eye ointment twice daily for 5 days in a month

for 6 monthsfor 6 months 4. Antitrachoma vaccine --> not effective4. Antitrachoma vaccine --> not effective

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W.H.O guidelinesW.H.O guidelines ““SAFESAFE” Strategy to control blindness from trachoma” Strategy to control blindness from trachoma

SSurgery for trichiasisurgery for trichiasis AAntibiotic treatment for active infectionntibiotic treatment for active infection

FFace cleanliness promotionace cleanliness promotion EEnvironmental improvementnvironmental improvement