Active trachoma is an ancient disease that was once prevalent throughout the world, primarily in Africa and Middle East. Approximately 41 million people in the world still suffer from the condition. Read on to know more about the causes, symptoms, diagnosis, and treatment of this infectious disorder.
This is a highly contagious bacterial infection of the eye and a predominant cause of infectious blindness in the world. It forms an important constituent of Neglected Tropical Diseases that is generally endemic in low-income populations. It normally develops in infants and young children and may ultimately lead to permanent loss of vision. Due to this reason it is also denoted as “Blinding Trachoma”.
The condition may affect both eyes and gradually turns chronic in the absence of any treatment.
Trachoma other names
The condition is known by other names like:
- Granular conjunctivitis
- Egyptian ophthalmia
The condition is localized in parts of least developed countries like Africa, Asia, Middle East, and Latin America. Active form of this infection is prevalent in 1 of 5 families in these regions. In 2002, nearly 1.3 million people were visually impaired with this condition.
It is most common in preschool children aged between 3-5 years. Females are more prone to this form of ocular infection.
In the initial stages, the condition is marked by certain primary symptoms that include:
Picture 1 – Trachoma
- Pus discharge
- Irritation of the eyes and eyelids
- Itchy eyes
- Pain and discomfort in the eyes
- Blurred vision
- Swollen eyelids
- Discomfort in the ear, nose and throat
- Halos around lights
- Extreme dryness of the eyes
The development of the condition has been described in 5 stages by a grading system.
Trachomatous inflammation, follicular (TF)
In the initial stages, the infection is characterized by conjunctivitis or “red eye” that begins 5 to 12 days after the bacterial attack. Affected patients experience acute inflammation of the eye, which is a consequence of regular episodes of bacterial infection. A cluster of white bumps can be seen on the inner surface of the upper eyelid called conjunctiva. These are basically conjunctival follicles or lymphoid germinal centres that appear elevated. The phase is also known as “Active Trachoma” and is most common in pre-school children. In this stage, affected individuals may suffer from eye irritability and discharge.
Trachomatous inflammation, intense (TI)
This particular phase is manifested by acute infection and swelling or thickening of the upper eyelid.
Trachomatous scarring (TS)
In this form, white fibrous tissues or scars may develop on the inner surfaces of the eyelids called tarsal conjunctiva. This results in Entropion – a condition in which the lower eyelid folds or turns inward, causing distortion of the eye.
Trachomatous trichiasis (TT)
Continuous scarring of the inner lining of the eyelid may cause the eyelashes to rub against the eye surface. It generally occurs due to buckling of the eyelid that may lead to further scarring and pain.
Corneal clouding or corneal opacity (CO)
In this form, affected patients develop corneal opacity that is marked by a cloudy spot in the cornea as well as acute inflammation. Clouding of the cornea is a repercussion of continuous scratching and rubbing of the eyelashes. There are chances of a secondary infection in the eye that may often give rise to ulcers on the cornea, leading to partial or complete visual loss. Numerous blood vessels and scars may develop on the upper cornea, also known as Pannus.
It is caused by Chlamydia trachomatis bacterium that usually spreads through direct contact with eyes, nose, and throat discharge. Hands, clothing, and towels laden with these secretions are the other modes of transmission of this infection. However, flies are considered as the major route of rapid transmission. It is frequently passed from child to child, especially in school and also from child to mother. Hence, exchange of infected eye discharge is transmitted at a faster pace within the family.
Poor sanitation, as seen in low-developed countries, is a major attribute of this infection. A host of other factors can also be related to the condition, such as:
- Inadequate water supply
- Crowed living conditions
- Absence of latrines or toilets
- Poverty-affected environment
- Presence of numerous flies
- Nearness to livestock
In young children, detection of the condition is generally difficult, owing to the absence of any major symptoms. Mild irritation as well as pus discharge from the eye is assumed normal by physicians. Severe symptoms are noticeable only in adulthood.
The diagnosis of this condition, in the initial stages, involves a thorough physical examination and evaluation of the affected eye. This is specifically carried out to check for any abnormality in the undersurface of the upper eyelid. Presence of scars and growth of a cluster of new blood vessels in the cornea may reveal ocular infection.
Drainage culture is a common laboratory test conducted to confirm the presence of Chlamydia trachomatis. The ocular discharge of affected patients is generally sent for culture and identification of the bacteria.
A wide variety of treatment options, which entirely depend on the stage of the infection, are available for curing this disorder. Many non-profit organizations have collaborated with national governments to implement techniques recommended by World Health Organization (WHO) for complete eradication of the infectious disorder. It includes:
The early stages of the ophthalmic infection can be treated with the antibiotic Azithromycin that is generally administered in children orally from the age of six months. It can also be used during pregnancy. Tetracycline ointment can also be applied over the eyelids twice a day for six weeks. Although Azithromycin is believed to be more effective, many underdeveloped countries are unable to use it owing to its high cost.
Long-term scarring could be detrimental to the eye, causing permanent visual loss due to which surgical intervention may become necessary. Bilamellar tarsal rotation is a well-known eyelid rotation procedure. Here, an incision is made in the scarred lid and the eyelashes are completely rotated away from the cornea. Further development of corneal scarring could be prevented with this method and can be performed on an outpatient basis.
If the cornea is found to be very cloudy, corneal transplantation may be required.
Young children with ocular and nasal discharge as well as flies on the faces are more likely to develop active form of the infection. Many community-based health education programs are currently focusing on face-washing in order to inhibit the infection from aggravating further.
Improvement of the environment
Proper usage of water and latrine, pest control as well as healthcare education may help in preventing the spread of bacteria. However, implementing such procedures may prove challenging in the underdeveloped areas.
The condition still persists in major regions of the poor-developed countries, despite its major eradication by WHO. Women being the caretakers in the family are more vulnerable to this form of ophthalmic condition. Poverty-stricken conditions make Trachoma more difficult to control due to which it continues to pass from generation to generation.
Improved sanitation and living conditions are the most important steps that need to be followed to control the infection.
The chance of recovery is good if the condition is diagnosed and treated with oral and topical antibiotics before a patient reaches the stage of corneal scarring.
The condition was first recognized in Egypt in 15 B.C. It was later reported in ancient China and Mesopotamia. It gradually turned out to be a major health issue in Europe during the 19th Century. It broke out in the army barracks of Europe after the Egyptian Campaign (1798–1802) and the Napoleonic Wars (1798–1815). In the early 20th century, rigid measures were adopted to control the spread of the infection. At present, none of the countries except Africa, Middle East, and Asia have reported any serious cases of the condition.
Picture 2 – Trachoma Image
The Centers for Disease Control in USA have eradicated the bacterial infection completely. Previous cases were observed in North America and Appalachia, especially in the boxing, wrestling, and sawmill industries. An act was signed by President Woodrow Wilson in the year 1913 for provision of funds for elimination of the condition. A thorough check-up of the immigrants, who were entering U.S through Ellis Island, New York, was always done. In the late 1930’s, a few ophthalmologists came up with sulfonamide antibiotics as a treatment procedure.
Trachoma Support Groups
International Trachoma Initiative (ITI) is a non-profit organization that is extensively involved in the elimination of blinding trachoma. Pfizer and the Edna McConnell Clark Foundation are the founding partners of ITI. It later collaborated with WHO to implement the various treatment strategies. It is now a significant associate of international partners called the International Coalition for Trachoma Control (ICTC). The 2020 INSight is a global strategic plan of ICTC to eradicate the infectious blindness completely from the world.
Trachoma is completely preventable and curable provided it is diagnosed early. Prevention of vision loss requires immediate treatment, in addition to proper hygiene maintenance, especially in poor tropical countries.