SANTIAGO, Kaypee Z.

Low Vision and Geriatric

OP-21 Dr. Christine Rodriguez

TRACHOMA: Cause of Low Vision and Blindness among Pediatric Patients

Definition

Trachoma is a contagious, chronic inflammation of the mucous membranes of the eyes, caused by Chlamydia trachomatis. It is characterized by
swelling of the eyelids, sensitivity to light, and eventual scarring of the conjunctivae and corneas of the eyes.

Description

Trachoma is a disease associated with poverty and unhygienic conditions. It is most common in hot, dry, dusty climates in the developing world where
water is scarce and sanitation is poor. Trachoma is the most common infectious cause of blindness in the world. It has two stages. The first stage is
active infection of the conjunctiva by the bacterium C. trachomatis . The conjunctiva is the clear mucous membrane that lines the inside of the eyelid and
covers the white part (sclera) of the eye. This stage is highly contagious.

Acquiring trachoma does not provide immunity against re-infection, so repeat infections are the norm in many communities where the disease circulates
continuously among family members.

The second stage involves damage to the cornea, the transparent covering of the front of the eye. After repeated infections, the eyelids swell and the
eyelashes begin to turn inward so that they scratch the cornea every time the individual blinks. This scratching is painful, and it scars the cornea,
eventually resulting in the cornea becoming opaque. Individuals are often blind by middle age. Repeated, extended, untreated periods of infection are
required for blindness to occur. An occasional, treated infection does not result in blindness.

Prevalence and Demographics

Trachoma is widespread and present in a high percentage of the population in many parts of Africa, Iraq, Afghanistan, Burma, Thailand, and Viet Nam.
Pockets of high trachoma infection also exist in southern Mexico, eastern Brazil, Ecuador, North Africa, India, China, Siberia, Indonesia, New Guinea,
Borneo, and in Aboriginal communities in central Australia. Although trachoma is rare in developed countries, it is occasionally found in the United States
in some Native American communities and in parts of Appalachia.

The greatest risk for contracting trachoma is having a family member with the disease. Although the disease shows no gender preference, two to three
times more women eventually become blind than men, probably because they are the primary caretakers of small children who are infected. The active
stage of the disease is most prevalent in children ages three to five. Blindness is most common in middle age. The World Health Organization
(WHO) estimates that as of the early 2000s, between 360 and 500 million people are affected by trachoma worldwide and that six million
people are blind because of the disease. In some heavily infected areas, up to 25 percent of the population becomes blind from this infection.

Trachoma affects approximately 500 million people worldwide, primarily in rural communities of the developing world and in the arid areas of tropical and
subtropical zones. About 6-9 million people worldwide are currently blind and many more have suffered partial loss of vision from trachoma. Australia is
the only developed country where trachoma is still a significant health problem; there it affects an estimated 100,000 people.

The frequency of active infection peaks in children ages three to five. In some communities, as many as 90 percent of children under age five
are actively infected.

Mortality/Morbidity

Blindness from any cause is associated with increased risk of mortality in endemic communities. Approximately 1.3 million people are blind because of
trachoma.

Race

• A disease of poverty and poor hygiene, trachoma has no racial preponderance.

• Trachoma persists in areas with poor personal and community hygiene, for example, communities with inadequate access to water and
sanitation in hot, dry, dusty climates.
• Trachoma typically affects the most marginalized, deprived members of a community.

Sex

• Active disease most commonly occurs in preschool children of both sexes and their (usually female) care providers.
• Trichiasis and blindness may be 2-4 times more common in women than men.

Age

• Active disease most commonly occurs in preschool children, with the highest prevalence in children aged 3-5 years.
 • Cicatricial disease is most common in middle-aged adults. The age group in which cicatricial disease begins to appear depends on the
intensity of transmission in the community. In areas of extremely high endemicity, rare cases of trichiasis occur in children younger than 10
years.
• Because of repeat infection, aging may be accompanied by sequential worsening of disease. Young children have follicular trachoma with
intense conjunctival inflammation; young adults, especially mothers, have trachomatous scarring; and middle-aged patients or grandparents
have trichiasis and corneal opacity. However, these signs are not mutually exclusive. Individuals may have episodes of follicular trachoma with
intense conjunctival inflammation even after cicatricial complications develop; therefore, follicles, scarring, and trichiasis may all be present in
the same patient.

Causes, Mode of Transmission and Acquisition

C. trachomatis is spread through direct contact. Infected young children serve as a reservoir of infection. The bacteria are then transmitted by close
physical contact with family members and other caregivers. The bacteria are also spread through shared blankets, pillows, and towels. The bazaar fly
Musca sorbens lays its eggs in human feces that can be contaminated with trachoma bacteria. These flies pick up bacteria on their bodies and can
transmit them to humans.

Certain conditions promote the spread of trachoma bacteria. These include:

• poor personal hygiene

• poor body waste and trash disposal
• insufficient water supply for washing
• shared sleeping space
• close association with domestic animals

Signs and Symptoms

Symptoms begin 5 to 12 days after being exposed to the bacteria. The condition begins slowly as inflammation of the tissue lining the eyelids
(conjunctivitis, or "pink eye"), which if untreated may lead to scarring.

Most commonly children with active trachoma will not present with any symptoms as the low grade irritation and ocular discharge is just accepted as
normal. However, further symptoms may include:

• Eye discharge
• Cloudy cornea
• Swollen eyelids
• Trichiasis (turned-in eyelashes)
• Swelling of lymph nodes in front of the ears
• Seeing bright lights
• Increased heart rate
• Further ear, nose and throat complications.

The major complication or the most important one is corneal ulcer occurring due to rubbing by concentrations, or trichiasis with
superimposed bacterial infection.

Diagnosis

Diagnosis is based on a combination of the patient's history (especially living or traveling in areas with high rates of trachoma) and examination of the
eyes. The doctor will look for the presence of follicles or scarring. He or she will take a small sample of cells from the patient's conjunctivae and examine
them, following a procedure called Giemsa staining, to confirm the diagnosis.

Grading of trachoma

1. McCallan's classification-McCallan in 1908 divided the clinical course of trachoma into 4 stages

Stage 1 (Incipient trachoma) Stage 2 (Established trachoma) Stage 3 (Cicatrising trachoma) Stage 4 (Healed trachoma)
Hyperaemia of palpebral Appearance of mature follicle &
Scarring of palpebral conjunctiva Disease is cured or is not markable
conjunctiva papillae

Scars are easily visible as white Sequelae to cicatrisation cause

Immature follicle Progressive corneal pannus
bands symptoms

2. WHO classification-The World Health Organization recommends a simplified grading system for trachoma.The Simplified WHO Grading System is

summarized below:

• Trachomatous inflammation, follicular (TF) – Five or more follicles of >0.5 mm on the upper tarsal conjunctiva

• Trachomatous inflammation, intense (TI) – Papillary hypertrophy and inflammatory thickening of the upper tarsal conjunctiva obscuring more than half

the deep tarsal vessels

• Trachomatous scarring (TS) - Presence of scarring in tarsal conjunctiva.

• Trachomatous trichiasis (TT) – At least one ingrown eyelash touching the globe, or evidence of epilation (eyelash removal)

• Corneal opacity (CO) – Corneal opacity blurring part of the pupil margin.

Prognosis

The prognosis for full recovery is excellent if the patient is treated promptly. If the infection has progressed to the stage of follicle development,
prevention of blindness depends on the severity of the follicles, the presence of additional bacterial infections, and the development of scarring.

Treatment and Management

Treatment of early-stage trachoma consists of four to six weeks of antibiotic treatment with tetracycline, erythromycin, or sulfonamides. Antibiotics
should be given without waiting for laboratory test results. Treatment may combine oral medication with antibiotic ointment applied directly to the eyes. A
single-dose treatment with azithromycin is an alternative method. Tetracyclines should not be given to pregnant women or children below the age of
seven years.
Patients with complications from untreated or repeated infections are treated surgically. Surgery can be used for corneal transplantation or to correct
eyelid deformities.

There are vaccines available that offer temporary protection against trachoma, but there is no permanent immunization. Prevention depends upon good
hygiene and public health measures:

• seek treatment immediately if a child shows signs of eye infection, and minimize his or her contact with other children
• teach children to wash hands carefully before touching their eyes
• protect children from flies or gnats that settle around the eyes
• if someone has trachoma (or any eye infection), do not share towels, pillowcases, etc; Wash items well
• if medications are prescribed, follow the doctor's instructions carefully

Medical Care

The key to the treatment of trachoma is the SAFE strategy developed by the WHO. The surgical ("S") component of this strategy is described in Surgical
Care below. Antibiotics ("A"), facial cleanliness ("F"), and environmental improvement ("E") are described in this section.

• Antibiotic therapy
o The WHO recommends 2 antibiotics for trachoma control: oral azithromycin and tetracycline eye ointment.
 Azithromycin is better than tetracycline, but it is more expensive.
 Azithromycin is the drug of choice because it is easy to administer as a single oral dose. Its administration can be directly
observed. Therefore, compliance is higher than with tetracycline and can actually be measured, whereas, with the home
administration of tetracycline, the level of compliance is unknown.
 Azithromycin has high efficacy and a low incidence of adverse effects. When adverse effects occur, they are usually mild;
gastrointestinal upset and rash are the most common adverse events.
  Infection with C trachomatis occurs in the nasopharynx; therefore, patients may reinfect themselves if only topical
antibiotics are used.
 Beneficial secondary effects of azithromycin include its treatment of genital, respiratory, and skin infections.
• Facial cleanliness
o Epidemiologic studies and community-randomized trials have shown that facial cleanliness in children reduces both the risk and the
severity of active trachoma.
o To be successful, health education and promotion activities must be community based and require considerable effort.
• Environmental improvement
o Environmental improvement activities are the promotion of improved water supplies and improved household sanitation, particularly
methods for safe disposal of human feces.
o These activities should be prioritized.
o The flies that transmit trachoma preferentially lay their eggs on human feces lying exposed on the soil. Controlling fly populations by
spraying insecticide is difficult. Studies on the impact of fly control on trachoma have had variable results. Trials undertaken to
evaluate the installation of pit latrines suggested that the prevalence of trachoma was reduced but failed to demonstrate a
statistically significant effect.
o General improvements in personal and community hygiene are almost universally associated with a reduction in the prevalence—
and eventually the disappearance—of trachoma. This is true not only in Europe, the Americas, and Australia but also in Africa and
Asia.

Surgical Care

• Eyelid surgery to correct trichiasis is important in people with trichiasis, who are at high-risk for trachomatous visual impairment and blindness.
Eyelid surgery to correct entropion and/or trichiasis may prevent blindness in individuals at immediate risk.
• Eyelid rotation limits the progression of corneal scarring. In some cases, it can result in a slight improvement in visual acuity, probably due to
restoration of the visual surface and reductions in ocular secretions and blepharospasm.