Trachoma
Definition
- It is chronic infective disease affecting the conjunctiva and cornea
caused by Chlamydia trachomatis and characterized by formation of
follicles, papillae and pannus and healed by cicatrization with
potential visual disability and lid deformity.
Etiology
Predisposing factors [5 BAD]
1. BAD health : poor immunity, seborrheic dermatitis, and acne
rosacea.
2. BAD Eye : Uncorrected errors of reflection & Dry eye syndrome
3. BAD hygiene
4. BAD habits : smoking
5. BAD weather
Causative organisms
chlamydiates (Chlamydia trachomatis) which have 15 immuno types
based on their surface protein.
A, B, Ba and C endemic trachoma,
D, E, F inclusion conjunctivitis (neonatal and adult)
L1, L2, L3 lymphogranuloma venerium
Mode of transmission
- Direct and indirect contact with infected material (discharge of
patients) by hands, by clothes, towels, etc.
- Flies play a main role in transmission of the organism.
Pathology of trachoma
Clinical presentation [Macallen’s classification ]
T1 Trachoma at onset ( Follicular conjunctivitis ) ( Stage of non
expressible follicles )
Presentation
Incubation period:
6-12 days.
Symptoms:
Sandy or gritty sensation.
Heaviness of the lids,
conj. Mucus discharge sticking the lashes together
photophobia.
Signs:
On eversion of the upper eyelid, small follicles on the upper tarsal
conjunctiva.
Follicles characters (IMMATURE )
- Non raised - Non expressible (not ruptured
- grayish with pressure).
- Small
The cornea:
shows in its upper part "Trachomatous Pannus"
Fate of follicles
- They may absorb spontaneously or remain for 2-4 months then
change into large follicles.
T2 (Established or florid trachoma) ( Follicular conjunctivitis ) ( Stage
of expressible follicles & papillae )
Presentation
presence of well-developed mature soft follicles with papillary
hypertrophy.
Associated corneal findings may include pannus and limbal follicles
of Herbert's rosettes.
Categories
T2a Mature follicles
T2b Trachomatous papillae, either
T2b':
o marked papillary hypertrophy (papillae are small & not
uniform in size)
T2b'':
o Trachomatous papillae + spring catarrh papillae (flat-
topped papillae)
T2c Trachoma + gonococcal infection
T2v plasma cell infiltration + hyaline degeneration of conjunctiva
(stellwag's browny edema)
T3: (Starting cicatrization) ( Conjunctival scarring ) ( Consequences
of trachoma )
Presentation
Signs of active trachoma 2 (follicles, papillae)
Signs of scarring: Appear as star shaped scars (Stellate conjunctival
scars) (MCQ) or radiating lines white in color, on the upper tarsal
conjunctiva.
Clinicopathologic manifestations
Arlt's line: (MCQ)
a white line of scar tissue involving the sulcus subtarsalis.
PTDs (Post-trachomatous degenerations):
Presentation
o yellowish white degenerated epithelial cells and inspissated
mucus imprisoned in conjunctival crypts between adjacent
papillae (variable sized spots),
Site
o appear on the tarsal conjunctiva.
PTCs (post-trachomatous concretions):
Presentation
o chalky white raised, hard small lesions,.
o Pathologically, they are formed of calcified debris, dried
secretion and shed epithelial cells (calcification of PTDs).
Site
o appear on tarsal conjunctiva
Notes for MCQ
- Anterior symblephraron isn’t a concequance of trachoma
- Patient is infectious when there is immature follciles in palpebral
conjunctival
- Patient NOT infectious in Artl’s line , herbert’s pits , PTCs
T4(Cicatrized or healed trachoma)
Only scar tissue is present
No active inflammation (i.e. no follicles or papillae),
and the disease is no longer infectious
WHO classification
TF: Trachomatous Follicles
✓ F1: Trivial (insignificant/absent)
✓ F2: mild
✓ F3: Moderate
✓ F4: Severe.
TI Trachomatous Intense:
diffuse inflammation of conjunctiva obscuring 50% of large
deep tarsal Vessels.
TS Trachomatous Scarring of conjunctiva.
Grade 1, 2, 3.
TT Trachomatous Trichiasis [MCQ]
at least one in-turning lash or history of removal.
CO Corneal Opacities:
at least obscuring part of the pupil margin or causing vision
6/18 or less
It is recent based on evaluating the severity of trachoma and widely
used nowadays.
Corneal manifestations of trachoma
- Corneal active infection by trachoma occurs at the same time of
conjunctival infection and is not secondary.
- It specifically affects the upper part of the cornea
o because it is covered by the upper eyelid and thus warmer
temperature than the rest of the cornea.
I.Pannus (Curtain like)
Definition
- It is defined as cellular infiltration together with superficial
vascularization of the upper part of the cornea.
- In early stages cellular infiltration, is between the epithelium and
Bowman's membrane.
- Later, this membrane is destroyed resulting in permanent opacity.
Herbert's rosettes
are corneal follicles formed of
cellular aggregations and appear as
grayish small elevated nodules at
the edge of the active pannus.
These heal later, leaving depressed
pits at the lower edge of the pannus
called Herbert's pits ( MCQ)
Rarely present in diseases rather
than trachoma ( MCQ)
Clinical types
1. Thin pannus (pannus tenius): mild, commonest.
2. Vascular pannus (pannus vasculosus): vessels much, cells scanty.
3. Fleshy pannus (pannus carnosus): cells much, vessels few.
4. Annular pannus (pannus annulosus): all around the cornea.
5. Cicatrized pannus (pannus ciccus):
o healed pannus formed of crescentic whitish scar of opacity in the
upper cornea with serrated edge (due to Herbert's pits).
o This opacity is called nebula ex-pannus.
Course of pannus
Progressive pannus:
cellular infiltration precedes beyond the corneal vascularization .
Regressive pannus:
the vascularization extends a short distance beyond the cellular
infiltration; this is due to later regress of the cellular infiltration
Ghost vessels loss of blood inside vessels but vessels still present
II. Trachomatous corneal ulcer
Usually superficial, situated at the lower border of the pannus, and its
shape is linear with a horizontal long axis.
Corneal ulceration may also occur due to mechanical corneal injury
by maldirected lashes or PTCs.
Complications of trachoma (Scarring )
Eyelid complications:
1. Trichiasis
2. Entropion.
It more commonly affects the upper lid.
3. Ptosis: (MCQ)
is partly due to infiltration of Muller's muscle
partly mechanical due to heaviness of the upper lid by severe
infiltration (large follicles and much papilla)
Conjunctival Complications:
1. Xerosis: (MCQ)
dryness of the conjunctiva and cornea due to scarring of the
conjunctiva with obliteration and atrophy of goblet cells and
accessory lacrimal glands.
2. Symblepharon:
usually posterior symblepharon leading to shallow fornix.
3. Hyaline degeneration
of the tarsus and conjunctiva.
Corneal Complications:
Corneal scars in the form of:
1. Diffuse corneal nebulae resulting in irregular astigmatism.
2. Corneal leucoma.
3. Xerosis of the cornea.
4. Corneal opacification ( MCQ)
Lacrimal complications
1. Chronic dacryocystitis. ( MCQ)
2. Chronic dacryoadenitis.
Treatment
Prophylaxis:
1. strict hygiene
2. good sanitation,
3. combat of flies
4. health education.
Medical treatment
This is given only if there is active trachoma.
Regimen (Local & systemic antibiotics)
1. For children ( Erythromycin ) ( MCQ)
2. For adults ( Doxycycline)
3. New treatment (Azithromycin) ( MCQ)
Surgical treatment:
it is only needed in the following stages:
1. Stage T2a: Large mature follicles: These need to be expressed.
(MCQ)
2. Stage T2b: Scraping of papillae is done using a sharp spoon ( MCQ)
3. Stage T3 and T4: With PTDS and PTCS. Both need picking.
Note for MCQ
Structure persist after TTT
- Pannus siccus
- Herbert’s pits
- Arlet’s line
Structure Disappear after TTT
Trachomatous follicles
Treatment of corneal manifestation
- Medical treatment as before + Atropine if there is pannus or ulcers
