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Trachoma
Nabina Paneru
Introduction
• Chronic infectious disease of conjunctiva and cornea
• Caused by Chlamydia Trachomatis
• May undergo spontaneous resolution or may progress to conjunctival
scarring
Scarring
and visual
loss
Corneal
ulceration
- Trichiasis
- Entropian
• Public health problem in 41 countries of Africa, Central and South America,
Asia, Australia and the Middle east
• Responsible for the irreversible blindness or visual impairment of about 1.9
million people
• Causes about 1.4% of all blindness worldwide
• Economic cost from blindness and visual impairment is US$ 2.9 – 5.3
billion annually, increasing to US$ 8 billion when trichiasis is included.
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian
• Trachomatous Inflammation - Follicular (TF)- which mostly requires topical
treatment.
• Trachomatous Inflammation – Intense (TI)- during which topical and systemic
treatments are considered.
• Trachomatous Scarring (TS) – when scars are visible as in the tarsal conjunctiva
and which may obscure tarsal blood vessels.
• Trachomatous Trichiasis (TT) – when an individual is referred for eyelid surgery;
and
• Corneal Opacity – a stage during which a person is irreversibly blind.
Agent Factors
• Classical endemic trachoma – Chlamydia trachomatis of immune types A, B or C
• Sexually transmitted – Chlamydia trachomatis serotypes D, E, F, G, H, I, J, O, R, K
- May also infect eyes – Inclusion conjunctivitis
- Rarely produce permanent visual loss
- May cause respiratory infections in infants
• Other pathogenic organisms
- Morax-Axenfeld diplobacillus – most innocuous
- Koch – Weeks bacillus – most widespread
- Gonococcus – most dangerous
Contd.
• Chlamydia trachomatis – obligatory intracellular bacteria
• Reservoir
- Children with active disease
- Chronically affected older children and adults
• Source of infection
- Ocular discharges of infected persons and
• Communicability – low infectivity
- Infective as long as active lesions are present in the conjunctiva
Host factors
• Age- children of 2-5 years are most infected
- Endemic areas- children show signs at age of only a few months
• Sex – prevalence equal in younger age groups
- In older age groups – female affected more
• Pre-disposing factors – direct sunlight, dust, smoke, irritants like kajal
Environmental Factors
• Poor hygiene
• Crowded households
• Water shortage and
• Inadequate latrines and sanitation facilities
Mode of transmission
• In endemic communities – eye to eye transmission
- Direct or indirect contact with ocular discharges of infected persons or
fomites – fingers, towels, kajal
- Mechanical transmission by eye – seeking flies
• In areas with sporadic cases – venereal transmission
• Familial disease
• Incubation period – 5 to 12 days
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian
Natural history of C. trachomatis infection
Ocular
infection with
chlamydia
trachomatis
Conjunctival
inflammation
and follicle
formation
Eyelid
scarring
• Trichiasis
(ingrown
eyelashes)
Corneal
opacification
and blindness
Active
Trachoma
Cicatricial
disease
Trachoma, entropian, ectropian
Sign and Symptoms
• Mild itching and irritation of the eyes and eyelids
• Discharge from the eyes containing mucus or pus
• Eyelid swelling
• Light sensitivity (photophobia)
• Eye pain
Diagnosis
• History taking and physical examinations
• Culture
Management
• Assessment
• Medical treatment
• Surgical correction
• Surveillance
• Health education
• Evaluation
Medical Treatment
• Objective: reduce severity, lower incidence and thence prevalence in
long run
• Antibiotic of choice – 1% ophthalmic ointment or oily suspension or
tetracyclines
• Erythromycin and Rifampicin also used
• Treatment can be mass or selective
Mass Treatment
• Prevalence of moderate or severe trachoma is >5% in children under
10 years
• Application of 1% tetracycline ointment to all children
- Twice daily for 5 days each month for 6 consecutive months, or
- Once daily for 10 days each moth for 6 consecutive months
- Erythromycin is alternative antibiotic
Selective treatment
• In communities with low to medium prevalence
• Whole population at risk is screened – case finding
• Treatment is applied only to those with a active problem
• Principles of treatment remaining the same
Surgical treatment
• For painful eyelid deformities
• WHO recommends surgery for people with the advanced stage of trachoma
- Eyelid rotation surgery (bilamellar tarsal rotation): in this, incision is made
in scarred lid and eyelashes are rotated away from cornea. This procedure
limits the progression of corneal scarring and may help prevent further loss
of vision.
- Corneal transplantation in case of clouded cornea
- Epilation : removal of eyelashes
Surveillance
• Once control of blinding trachoma is achieved
• Necessary for several years after active inflammatory trachoma is
controlled
• Whole family should be under surveillance
Health Education
• Mothers of young children should be target
• Measures of personal and community hygiene
• Permanent change in behavior patterns and in environmental factors
• Final solution – improvement of living conditions and quality of life
Evaluation
• Evaluated at frequent intervals
• Effect of intervention judged by –
- Age specific rates of active trachoma
- Prevention of trichiasis and entropian
Trachoma Control
• WHO’s goal – eliminate trachoma as a public health problem by the year
2020
• Elimination of trachoma as a public health problem is defined as:
- Reduction in prevalence of trichiasis (TT) “unknown to the health
system” to less than 1 cases per 1000 total population
- Reduction in the prevalence of the active trachoma sign “TF” in
children aged 1-9 years to less than 5%
Trachoma, entropian, ectropian
Get 2020
• In 1997, WHO launched the WHO Alliance for the Global Elimination of
Trachoma by the year 2020 – GET 2020
• Partnership which supports country implementation of the SAFE strategy
and the strengthening of national capacity through epidemiological
assessment, monitoring, surveillance, project evaluation and resource
mobilization
• ICTC – International Coalition of Trachoma Control
Entropian
Definition
• It is the condition in which eyelid margin turns inward which causes
corneal irritation.
• It is the condition characterized by turning in of the lid margin with its
lashes usually the lower eyelid.
Etiology
• Elderly person with relaxed palpebral skin and mucosa.
• Inflammation of the eyelids and eye.
• After a long wearing of bandage
• Trachoma
• Burns of the conjunctiva
• Injuries of the eyelids.
Types
1. Congenital entropian
2. Cicatricial entropian: caused by cicatricial contraction of the palpebral
conjunctiva
3. Spastic entropian: due to spasm of orbicularis muscle
4. Senile (involutional) entropian: occurs in elderly people and only
affects the lower eyelid
5. Mechanical entropian: due to lack of support provided by globe.
Clinical Features
• Foreign body sensation
• Lacrimation
• Painful
• Redness
• Photophobia
• Corneal ulcer
Treatment
• Surgical correction: Skin muscle operation
- Wheeler oblicularis operation
- Tarsectomy
Ectropian
Definition
• It is a condition in which the lid margins rolls outward from the
eyeball, which causes the lower lid to droop and expose the cornea and
conjunctiva causing conjunctivitis and corneal ulcer.
Etiology
• Spasmodic contraction of the margin of the orbicularis muscle
• General loss of muscular tone esp. in old age
• Contracture due to the scars of burns of the face
• Damage to facial nerve
• Tumor/granuloma of the lower eyelid
• Inflammation of the eyelid and eye e.g. blepharitis
Types
1. Senile ectropian: lower eyelid affected in old age due to loss of tone of
orbicularis muscle.
2. Cicatricial ectropian: results from destruction of the skin of lower eyelid by
burns, ulcers, trauma, chronic conjunctivitis, blepharitis or diseases of eyelid.
3. Paralytic ectropian: occurs as a result of weakness of orbicularis muscle due to
paralysis of facial nerve.
4. Mechanical ectropian: weight of the tumor or granuloma of the lower eyelid.
5. Spastic ectropian: results from blepherospasm.
Clinical Features
• Constant epiphora
• Chronic conjunctivitis due to exposure of conjunctiva-irritation,
discomfort and mild photophobia
• Corneal ulcer
Treatment
• Surgical correction: Tarsorrhaphy
Kuhnt-szymanowski operation
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian
Trachoma, entropian, ectropian

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Trachoma, entropian, ectropian

  • 2. Introduction • Chronic infectious disease of conjunctiva and cornea • Caused by Chlamydia Trachomatis • May undergo spontaneous resolution or may progress to conjunctival scarring Scarring and visual loss Corneal ulceration - Trichiasis - Entropian
  • 3. • Public health problem in 41 countries of Africa, Central and South America, Asia, Australia and the Middle east • Responsible for the irreversible blindness or visual impairment of about 1.9 million people • Causes about 1.4% of all blindness worldwide • Economic cost from blindness and visual impairment is US$ 2.9 – 5.3 billion annually, increasing to US$ 8 billion when trichiasis is included.
  • 8. • Trachomatous Inflammation - Follicular (TF)- which mostly requires topical treatment. • Trachomatous Inflammation – Intense (TI)- during which topical and systemic treatments are considered. • Trachomatous Scarring (TS) – when scars are visible as in the tarsal conjunctiva and which may obscure tarsal blood vessels. • Trachomatous Trichiasis (TT) – when an individual is referred for eyelid surgery; and • Corneal Opacity – a stage during which a person is irreversibly blind.
  • 9. Agent Factors • Classical endemic trachoma – Chlamydia trachomatis of immune types A, B or C • Sexually transmitted – Chlamydia trachomatis serotypes D, E, F, G, H, I, J, O, R, K - May also infect eyes – Inclusion conjunctivitis - Rarely produce permanent visual loss - May cause respiratory infections in infants • Other pathogenic organisms - Morax-Axenfeld diplobacillus – most innocuous - Koch – Weeks bacillus – most widespread - Gonococcus – most dangerous
  • 10. Contd. • Chlamydia trachomatis – obligatory intracellular bacteria • Reservoir - Children with active disease - Chronically affected older children and adults • Source of infection - Ocular discharges of infected persons and • Communicability – low infectivity - Infective as long as active lesions are present in the conjunctiva
  • 11. Host factors • Age- children of 2-5 years are most infected - Endemic areas- children show signs at age of only a few months • Sex – prevalence equal in younger age groups - In older age groups – female affected more • Pre-disposing factors – direct sunlight, dust, smoke, irritants like kajal
  • 12. Environmental Factors • Poor hygiene • Crowded households • Water shortage and • Inadequate latrines and sanitation facilities
  • 13. Mode of transmission • In endemic communities – eye to eye transmission - Direct or indirect contact with ocular discharges of infected persons or fomites – fingers, towels, kajal - Mechanical transmission by eye – seeking flies • In areas with sporadic cases – venereal transmission • Familial disease • Incubation period – 5 to 12 days
  • 17. Natural history of C. trachomatis infection Ocular infection with chlamydia trachomatis Conjunctival inflammation and follicle formation Eyelid scarring • Trichiasis (ingrown eyelashes) Corneal opacification and blindness Active Trachoma Cicatricial disease
  • 19. Sign and Symptoms • Mild itching and irritation of the eyes and eyelids • Discharge from the eyes containing mucus or pus • Eyelid swelling • Light sensitivity (photophobia) • Eye pain
  • 20. Diagnosis • History taking and physical examinations • Culture
  • 21. Management • Assessment • Medical treatment • Surgical correction • Surveillance • Health education • Evaluation
  • 22. Medical Treatment • Objective: reduce severity, lower incidence and thence prevalence in long run • Antibiotic of choice – 1% ophthalmic ointment or oily suspension or tetracyclines • Erythromycin and Rifampicin also used • Treatment can be mass or selective
  • 23. Mass Treatment • Prevalence of moderate or severe trachoma is >5% in children under 10 years • Application of 1% tetracycline ointment to all children - Twice daily for 5 days each month for 6 consecutive months, or - Once daily for 10 days each moth for 6 consecutive months - Erythromycin is alternative antibiotic
  • 24. Selective treatment • In communities with low to medium prevalence • Whole population at risk is screened – case finding • Treatment is applied only to those with a active problem • Principles of treatment remaining the same
  • 25. Surgical treatment • For painful eyelid deformities • WHO recommends surgery for people with the advanced stage of trachoma - Eyelid rotation surgery (bilamellar tarsal rotation): in this, incision is made in scarred lid and eyelashes are rotated away from cornea. This procedure limits the progression of corneal scarring and may help prevent further loss of vision. - Corneal transplantation in case of clouded cornea - Epilation : removal of eyelashes
  • 26. Surveillance • Once control of blinding trachoma is achieved • Necessary for several years after active inflammatory trachoma is controlled • Whole family should be under surveillance
  • 27. Health Education • Mothers of young children should be target • Measures of personal and community hygiene • Permanent change in behavior patterns and in environmental factors • Final solution – improvement of living conditions and quality of life
  • 28. Evaluation • Evaluated at frequent intervals • Effect of intervention judged by – - Age specific rates of active trachoma - Prevention of trichiasis and entropian
  • 29. Trachoma Control • WHO’s goal – eliminate trachoma as a public health problem by the year 2020 • Elimination of trachoma as a public health problem is defined as: - Reduction in prevalence of trichiasis (TT) “unknown to the health system” to less than 1 cases per 1000 total population - Reduction in the prevalence of the active trachoma sign “TF” in children aged 1-9 years to less than 5%
  • 31. Get 2020 • In 1997, WHO launched the WHO Alliance for the Global Elimination of Trachoma by the year 2020 – GET 2020 • Partnership which supports country implementation of the SAFE strategy and the strengthening of national capacity through epidemiological assessment, monitoring, surveillance, project evaluation and resource mobilization • ICTC – International Coalition of Trachoma Control
  • 33. Definition • It is the condition in which eyelid margin turns inward which causes corneal irritation. • It is the condition characterized by turning in of the lid margin with its lashes usually the lower eyelid.
  • 34. Etiology • Elderly person with relaxed palpebral skin and mucosa. • Inflammation of the eyelids and eye. • After a long wearing of bandage • Trachoma • Burns of the conjunctiva • Injuries of the eyelids.
  • 35. Types 1. Congenital entropian 2. Cicatricial entropian: caused by cicatricial contraction of the palpebral conjunctiva 3. Spastic entropian: due to spasm of orbicularis muscle 4. Senile (involutional) entropian: occurs in elderly people and only affects the lower eyelid 5. Mechanical entropian: due to lack of support provided by globe.
  • 36. Clinical Features • Foreign body sensation • Lacrimation • Painful • Redness • Photophobia • Corneal ulcer
  • 37. Treatment • Surgical correction: Skin muscle operation - Wheeler oblicularis operation - Tarsectomy
  • 39. Definition • It is a condition in which the lid margins rolls outward from the eyeball, which causes the lower lid to droop and expose the cornea and conjunctiva causing conjunctivitis and corneal ulcer.
  • 40. Etiology • Spasmodic contraction of the margin of the orbicularis muscle • General loss of muscular tone esp. in old age • Contracture due to the scars of burns of the face • Damage to facial nerve • Tumor/granuloma of the lower eyelid • Inflammation of the eyelid and eye e.g. blepharitis
  • 41. Types 1. Senile ectropian: lower eyelid affected in old age due to loss of tone of orbicularis muscle. 2. Cicatricial ectropian: results from destruction of the skin of lower eyelid by burns, ulcers, trauma, chronic conjunctivitis, blepharitis or diseases of eyelid. 3. Paralytic ectropian: occurs as a result of weakness of orbicularis muscle due to paralysis of facial nerve. 4. Mechanical ectropian: weight of the tumor or granuloma of the lower eyelid. 5. Spastic ectropian: results from blepherospasm.
  • 42. Clinical Features • Constant epiphora • Chronic conjunctivitis due to exposure of conjunctiva-irritation, discomfort and mild photophobia • Corneal ulcer
  • 43. Treatment • Surgical correction: Tarsorrhaphy Kuhnt-szymanowski operation