Trachoma in Pictures
Clinical grading.
Trachoma is a clinical diagnosis, made by examining the conjunctivae of the eye in good
light using a 2.5x magnification lens.
Fig 1. The upper eye-lid has been turned over to Fig 2. Trachomatous inflammation
examine the conjunctiva over the stiffer part of the TF. There must be 5 or more follicles
upper lid, as dotted in. The normal conjunctiva shown on the upper conjunctiva. Follicles
here is pink, smooth and transparent. Large, deep- must be at least 0.5 mm in diameter
lying blood vessels normally run vertically over the and are round, whitish, paler than the
whole area of the conjunctiva. From the World Health surrounding conjunctiva.
Organisation Prevention of blindness web site.
The initial response to eye infection with trachoma agents is conjunctivitis involving the
palpebral and bulbar conjunctivae. The conjunctiva is inflamed, slightly swollen and
congested, with papillary hypertrophy prominent in the palpebral conjunctiva. This is
followed by lymphoid follicle formation, most commonly on the palpebral conjunctiva (Fig
2). However follicles may also be found on the bulbar conjunctiva. Trachomatous
inflammation grade TF involves the presence of at least five lymphoid follicles on the upper
conjunctiva. Pannus may also be present.
Fig 3. Shallow pits at the limbal margin of Fig 4. Intense trachomatous inflammation, TI.
the bulbar conjunctiva, caused by the rupture The tarsal conjunctiva appears red, rough and
of lymphoid follicles leaving small scarred thickened, obscuring more than half of the
depressions termed Herbert's pits. These are normal, deep, tarsal vessels. There are
considered, together with lymphoid follicles numerous follicles which are partially covered
or vascular pannus, as one of the by the thickened conjunctiva. Figure kindly
characteristic diagnostic signs of trachoma. provided by the World Health Organisation.
Conjunctival follicles, after rupture, may leave shallow pits, termed Herbert's pits (Fig 3).
[Herbert was an English ophthalmic surgeon, 1865 - 1942]. In some areas of the world
secondary bacterial infection with Moraxella or other species is common giving rise to
discharge of pus from the eyes [Wood & Dawson, 1967].
Cicatricial trachoma.
Severe initial infection, but more commonly repeated re-infection in an endemic area, leads
to the development of conjunctival scarring ( Fig 5).
Fig 5. Grade TS. Scarring and fibrosis of the Fig 6. Grade TS. An example of more
tarsal conjunctiva in response to severe or sheet-like fibrosis of the conjunctiva as a
chronic trachoma. This is sometimes called result of trachoma. The conjunctival blood
cicatricial trachoma. The scars, glistening and vessels are almost entirely obscured.
fibrous in appearance, are easily visible as white Severe trachomatous scarring such as this
lines, bands, or even sheets. Scarring and, is usually seen in older adults, and in
particularly, diffuse fibrosis may obscure the women more commonly than men.
deep conjunctival blood vessels. Scarring is
important because it gives rise to the blinding
sequelae of trachoma.
Severe scarring of the tarsal conjunctiva distorts the eyelid, a condition called entropion (
Fig 7). This re-directs the eyelashes inwards so that they lash the orb of the eye, ( trichiasis)
leading to corneal damage and visual loss ( Fig 8).
Fig 7. Grade TT. Trichiasis is defined as Fig 8. Grade TT & CO. The eyelashes have
occurring when at least one eye-lash rubs on abraded the cornea, damaging it, leading to
the eye-ball as a result of entropion of the lid. corneal opacity and undoubted visual loss.
The inturned eye-lashes are irritating, leading The tragedy is that this loss could have been
to attempts to remove them. Evidence of prevented at the right time by surgical
recent attempts to remove inturned eye lashes correction of the eye lid deformity, a
in a trachoma endemic community should also procedure which can be performed in rural
be graded TT. villages, takes about 15 minutes and costs
roughly US$ 20.
