Trachoma clinical fetures and management

Trachoma clinical fetures and management

Trachoma clinical fetures and management

Trachoma is a chronic infection of the conjunctiva of theglobe and eyelids caused by Chl. trachomatis serotypes A,B, Ba and C. It is widespread throughout the tropics andsubtropics, and is primarily a disease related to poor personaland public hygiene. It is one of the commonest causesof blindness in the world, with 500 million affected, 2 millionblind and 100 million with severe visual impairment.

Transmission and epidemiology The organisms present in ocular secretions infect otherpeople by direct contagion on contaminated fingers orclothes. Lack of water for washing means that infectedsecretions are wiped on to hands and clothes. Flies mayalso carry the organisms from one person to another. Infectionoccurs early in life, and subsequently there areepisodes of reinfection and secondary bacterial infection.

Pathology and pathogenesis Acute inflammation is present in the conjunctiva. This progressesto a chronic state, with lymphoid aggregates aroundinfected conjunctival cells. It is likely that damage due totrachoma is exacerbated by repeated bacterial infections.The tarsal plates fold inwards due to fibrosis (entropion)and the cornea is continually damaged by the inverted eyelashes,resulting in corneal opacity from scarring. There isevidence that cell-mediated immune responses to thisintracellular pathogen are important in pathogenesis, withevidence of genetic factors determining the expression ofreactivity.

Clinical features The earlier features are hypertrophic follicles on the uppertarsal conjunctiva and at the corneoscleral junction superiorly with time and repeated reinfection this inflammatoryresponse leads to fibrosis. The scarring disorganizesthe arrangement of Meibomian glands, and their orificesare pulled away from the lid margin. The eyelid is invertedand sites of eyelash trauma on the cornea are seen. Newvessels grow into the cornea (pannus formation) andcorneal scarring follows.

Diagnosis Diagnosis is made on the appearances described above.Giemsa staining of scrapings from the affected conjunctivashows intracytoplasmic inclusion bodies. Antigen can bedetected by enzyme-linked immunoassay.

Management and prevention Topical 1 % tetracycline eye ointment, applied two to fourtimes daily for 3 weeks and repeated at 1-month intervalsup to six times, is effective but it has been shown that asingle dose of oral azithromycin, 20mg/kg, was as effectiveas 6 weeks of topical 1 % tetracycline eye ointment, thoughneither gave permanent cure and relapse is frequent.Continued trauma to the cornea must be prevented.Removal of the offending eyelashes helps. Surgical reconstructionof the eyelid may be needed.

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