Symptoms and Treatment of Trachoma | Ophthalmology

Trachoma

What is trachoma?

Trachoma is a bacterial infection that affects your eyes. It is caused by a bacteria called chlamydia trachomatis. It is an infection spread through contact with the eyes, eyelids, and nose or throat of infected people. It can also be spread by handling infected items, such as napkins.

First, trachoma can cause mild itching and irritation of the eyes and eyelids. Then you may notice swelling of the eyelids and pus that dries up in the eyes. Untreated bacterial infection can lead to blindness.

This bacterial infection begins as an infection of the membrane, which covers the outside of the eyeball and scratches the inside surface of the eyelids (conjunctiva). Repeated infections eventually lead to scarring, causing the eyelid margin to turn inward.

The hair is reversed and rubbed over the transparent cornea, causing painful scratches and damage. This can eventually lead to dull, blotchy cornea and eye pain.

In a desperate attempt to ease the pain caused by this trichiasis, or inverted hair, many people resort to pulling their hair out with raw temporary tweezers.

Usually both eyes are affected and the scars can lead to irreversible blindness, usually when a person is between 30 and 40 years old. But in some parts of Oromia, Ethiopia, children and teens also have significant trichiasis, putting them at risk of losing their vision.

This bacterial infection is the leading cause of blindness worldwide. Most cases of trachoma occur in poor areas of Africa, where 85% of people have active disease. In areas where trachoma is prevalent, infection rates in children under 5 years of age are 60% or more.

Early treatment can help prevent complications from trachoma.

Alternate name

  • Granular conjunctivitis
  • Blinding trachoma

Who suffers from trachoma?

Trachoma used to be known as ‘sandy blight’, and has for centuries been associated with dry dusty conditions. It remains a disease of poverty and disadvantage, occurring in pockets where living conditions are crowded, water is scarce, and sanitation is inadequate.

This spreads from person to person through unwashed hands, shared face-wiping cloths, and by flies that have been in contact with the discharge from the eyes or nose of an infected person. Ongoing infection and re-infection fuels the progression of the disease to the stage where vision is lost.

Women suffer much more frequently and severely from granular conjunctivitis than men. This is because women are usually the carers of young children, and end up being exposed to re-infections from infected children. This is tragic because if left untreated, the infection persists and the scarring worsens over years until it’s too late, and blindness is irreversible.

Types of trachoma

The World Health Organization has developed a classification system to classify the five stages of trachoma based on the clinical signs that appear as the disease progresses.

Trachomatous – Follicular Inflammation (TF): The first sign is the presence of follicles, which are small lumps formed by swollen lymphatic tissue at the back of the upper eyelid and sometimes extend to the upper part of the eye. The presence of five or more follicles larger than 0.5 mm in the conjunctival lining at the back of the upper eyelid is considered grade TF.

Trachomatous inflammation – Intensive (TI): The next stage is inflammation of the conjunctiva, which obscures the normal deep blood vessels of the conjunctiva.

Trachomatous scar (TS): Bands of scar tissue form within the lining of the conjunctiva on the inside of the upper eyelid.

Trachomatous Trichiasis (TT): Bands of scar tissue tighten, causing the eyelid margins to rub inward (entropy) and hair toward the eye (trichiasis). Over time, this massage causes friction of the cornea, forming a transparent central sheath in front of the eye.

Corneal opacity: Corneal abrasion infection leads to ulcers and eventually opaque scars that prevent it from entering the eye and causing blindness.

Symptoms of trachoma

The signs and symptoms of trachoma usually affect both eyes and may include:

  • Mild itching and irritation of the eyes and eyelids
  • Eye discharge with mucus or pus
  • Inflammation of the eyelids
  • Sensitivity to light (photophobia)
  • Eye pain
  • The eye is red
  • Sight loss
  • Young children are especially susceptible to infection. But the disease progressesslowly, and the most painful symptoms may not appear until puberty.

Causes of trachoma

Trachoma chlamydia is caused by certain subtypes of trachomatis, which can also cause sexually transmitted chlamydia.

This is spread by discharge from the eyes or nose of an infected person. Hands, clothing, towels, and insects are all means of transmission. In developing countries, visible flies are also a means of transmission.

Living conditions such as poor sanitation, unsanitary water supply, and lack of regular face washing can cause bacteria to infect and re-infect the eyes of people living in trachoma-endemic areas.

The active form is passed on to young children, to those close to them, such as siblings, playmates, and caregivers. In adults, active disease is more common in women who care for children.

Risk factors for trachoma

Factors that increase the risk of trachoma infection:

Crowded living conditions. People who live in close contact are at risk of spreading the infection.

Bad sanitation. Inadequate sanitary conditions, unavailability of water, and poor hygiene, such as a dirty face or hands, can help spread the disease.

Years. In areas where the disease is active, it is most common in children ages 4 to 6.

Sex. In some areas, women are two to six times more likely to be infected than men. This may be due to the fact that women have more contact with children, which is the main reservoir of infection.

Treatment for trachoma

The World Health Organization reports that the number of people at risk for granular conjunctivitis fell from 1.5 billion in 2002 to just 142 million in 2019.

The WHO Alliance for the Global Elimination of Trachoma by 2020 (GET2020) aims to completely eradicate the disease by implementing a safe multi-faceted strategy to prevent and treat trachoma:

S = Surgery to correct altered eyelids and trichiasis

A = Antibiotics (azithromycin) to treat active infection

F = Facial hygiene to reduce human transmission

E = Environmental improvement to reduce human transmission (such as access to safe water and sanitation measures to reduce the fly population)

Single use of azithromycin tablets (zithromax) as an antibiotic treatment for active disease. However, improvement is common if a person does not have access to clean and hygienic water.

When trachoma returns to the inside of the whip, surgery is required to correct the position of the eyelid.

If a significant corneal scar develops, a corneal transplant surgery is required to restore vision.

Several government agencies and international non-governmental development organizations (INGOs), such as the Carter Center’s Trachoma Control Program, are working together to implement the SAFE strategy.

Drugs

In the early stages of trachoma, treatment with antibiotics alone is enough to clear the infection. Your doctor may prescribe a tetracycline or oral azithromycin eye ointment (Zithromax). Azithromycin appears to be more effective than tetracycline, but is more expensive.

The World Health Organization (WHO) has recommended that antibiotics be given to the entire community when more than 10% of children are infected with granular conjunctivitis. The goal of this guide is to treat anyone with this bacterial infection and reduce the spread of trachoma.

Surgery

Further treatment of trachoma, including painful eyelid deformities, may require surgery.

In eyelid rotation surgery (bilaminar twisting), your doctor will make an incision in the eyelid of your scar and rotate your hair away from the cornea. This procedure limits the progression of corneal scarring and helps prevent vision loss.

If your cornea becomes cloudy enough to seriously damage your vision, a corneal transplant is an option that improves vision.

In some cases, you may have a hair removal procedure. This procedure must be done repeatedly. 

Complications

An episode of trachoma caused by chlamydia trachomatis can be easily detected early and treated with antibiotics. Recurrent or secondary infections can lead to complications, including:

  • Inner eyelid scar
  • Eyelid defects, such as the inner crease (entropion) or ingrown hairs (trichiasis), which can scratch the cornea
  • Corneal scar or cloud
  • Partial or complete loss of vision

Prevention

If you have been treated for trachoma with antibiotics or surgery, reinjection is always a concern. For your own protection and the safety of others, make sure family members or others you live with are being tested and, if necessary, being treated for granular conjunctivitis.

This occurs worldwide, but is most common in Africa, Asia, Latin America, the Middle East, and the Pacific Rim. In areas where granular conjunctivitis is common, take extra care to maintain good hygiene, which can help prevent infection.

Good hygiene practices:

  • Face wash and hand wash. Keeping faces and hands clean breaks the rebuilding cycle.
  • Fly control. Reducing the fly population will help eliminate the source of transmission.
  • Adequate waste management. Proper disposal of animal and human waste reduces fly breeding.
  • Better access to water. Having a source of fresh water nearby improves hygienic conditions.

The trachoma vaccine is not available, but prevention is possible. WHO has developed a strategy to eliminate trachoma by 2020. Although the goal was not fully achieved, this bacterial infection cases were significantly reduced. This strategy is called SAFE:

  • Surgery to treat advanced forms of trachoma
  • Antibiotics to treat and prevent infections
  • Facial hygiene
  • Environmental improvements, especially in water, sanitation and fly control
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