TRACHOMA

• At one time known as Egyptian

Ophthalmia, endemic in middle east
during prehistoric period, spread far and
wide in Europe by French army during
Napoleonic wars. Trachoma is still a
leading cause of preventable blindness
world wide, third after cataract and
glaucoma.

October 15, 2008 Dr Sanjay Shrivastava 1

 Epidemiology
• Approximately 1/5th population of world is
affected by Trachoma, amounting to 150
million people across the 48 countries . It
is estimated that 6 million people are blind
in both eyes. It still remains a significant
problem in areas of Africa, South East
Asia, the Middle East and Australia.

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 Etiology
• Trachoma is caused by Chlamydia
Trachomatis immunotypes / serotypes A,B
and C. Chlamydia organisms shares
properties of both, bacteria and virus. It is
an obligatory intracellular bacteria.

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 Predisposing Factors
• Unhygienic and crowded surroundings
• Low socio-economic status
• Lack of water
• No race is exempted

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 Transmission

• Direct transmission from eye to eye

through discharge
• Through fomites, flies and eye cosmetics
• Disease is contagious in acute phase
• Incubation period is 5 -12 days

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 Clinical Features

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 Symptoms
• Pure Trachoma is usually asymptomatic
condition or there may be minimum
symptoms
• There may be redness, irritation,
discharge, foreign body sensation,
watering and photophobia
• Systemic symptoms like rhinitis, pre
auricular lymphadenopathy and upper
respiratory tract infection may be present
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 Symptoms … Contd
• Onset is usually sub-acute, but may occur
as acute when infection is massive as
occurs in experimental or accidental or
clinical infection

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 Signs
• Primary infection is epithelial, involving
conjunctiva and cornea characterized by:
conjunctival congestion, upper tarsal
conjunctiva appears red and velvety, later
may become uniformly thick like jelly.
Follicles are found in lower fornix, upper
fornix, upper margin of tarsus, caruncle,
plica, palpabral conjunctiva, bulbar
conjunctiva near limbus
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 Signs … contd.

• Follicles are small (0.5 mm in diameter)

but may measure up to 5 mm in diameter.
• Papillary enlargement.

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 Corneal Signs
• Superficial Keratitis in upper part
• Epithelial erosion, extending deep into
stroma
• Pannus is lymphoid infiltration with
vascularization seen in upper half, tending
to spread towards the centre . Whole
cornea may be covered with pannus .
Vessels are superficial between epithelium
and Bowman’s membrane.
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 Corneal Signs.. Contd
• Stages of Pannus:
Progressive (infiltration is beyond
vascularization)
Regressive (infiltration has receded and
vessels are ahead of infiltration)
• Corneal ulcer , chronic, occurs anywhere
but commonest at the advancing edge of
pannus, are shallow ulcer with little
infiltration.
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 Pathology
• Chlamydia Trachomatis is seen in
conjunctival scarping in the form of
colonies in the epithelial cells as
Halberstaedter Prowazek inclusion bodies
• Inclusion bodies are composed of
innumerable elementary bodies
embedded in carbohydrate matrix

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 Pathology … Contd
Elementary bodies, attacking epithelial cells,
enlarge to become initial bodies in the
cytoplasm of the cells. Numerous initial
bodies, in cells divide to form innumerable
elementary bodies embedded in
carbohydrate matrix. The nucleus of cell is
displaced , degenerates and cell burst to
release elementary bodies, to attack new
cells.
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 Pathology … contd.
• In acute inflammatory stage ,
polymorphonuclear cell infiltration is noticed and
later on lymphocytes are dominant
• Lymphocytic infiltration in Adenoid layer
• Aggregation of lymphocyte without capsule
forms follicles
• Follicles shows necrosis and contains large
multinucleated Laber cells
• An attack confers little immunity

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 Pathology …. Contd.
• Trachomatous infiltration may spread
deep into subepithelial tissues of the
palpabral conjunctiva and even invade the
tarsal plate
• Invasion of lacrimal passages may also be
there.
• Fibrosis around follicles giving rise to
cicatricial bands (Arlt line in superior
tarsus)
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 Diagnosis
• Culture of Chlamydia Trachomatis in
irradiated McCoy cells
• Micro-Immunofluorescence (Micro-IF) test
• Monoclonal Direct Antibody test
• Demonstration of inclusion bodies in
conjunctival epithelial scrapping

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 Clinical Diagnosis
• Is based on identification of at least two of the
following signs:
1. Follicles
2. Epithelial Keratitis
3. Pannus
4. Limbal Follicles/ Herbert Pits
5. Typical Trachomatous Scarring (Stellate or
Linear Scarring of upper tarsus)
• Diagnosis is confirmed by demonstration of
inclusion bodies
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 Trachoma Classification
I. MacCallan’s Classification
Stage I : Immature follicles on tarsus ,
SPK and Pannus
Stage II : Florid superior tarsal follicular
reaction with mature follicles or marked
papillary hyperplasia , pannus, limbal
follicles, superior corneal epithelial
infiltrates
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 MacCallan Classification
Stage –III : Signs of stage II with
cicatrization
Stage – IV : Cicatrization and its sequelae

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 II. WHO Classification (FISTO)
Stage – I Trachomatous Infiltration – Follicular
(TF): 5 or more follicles of at least 0.5 mm in
diameter. If treated properly, patient recovers
with no or minimal scarring
Stage -II Trachomatous Infiltration – Intense (TI):
Follicles, papillae, thickening of conjunctiva
obscuring >50% conjunctival blood vessels.
Severe infection with high risk of complication.

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 WHO Classification… Contd
Stage – III : Trachomatous scarring (TS)
Stage – IV : Trachomatous Trichiasis (TT)
Stage - V : Corneal Opacity (CO) corneal
opacity occupying pupillary area

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 Sequelae of Trachoma
• Distortion of lids
• Trachomatous Ptosis
• Entropion
• Trichiasis
• Tylosis

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 Late Complications
• Sever dry eye
• Keratitis
• Corneal scarring
• Fibrovascular pannus
• Corneal Bacterial Superinfection

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 Treatment
• Tetracycline, Erythromycin, Rifampicin
and Sulphonamides are effective orally
• Topical Erythromycin and Tetracycline
ointment

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 Treatment … contd
Treatment of TF Stage – Topical
Erythromycin eye ointment twice a day for
6 weeks
Oral Azithromycin 1 Gm single dose
Tetracycline 250 mgm qid for 2 weeks
Doxycycline 100 mgm twice for 2 weeks

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 Treatment … Contd
Treatment of TI Stage : same as TF stage

Treatment of TS stage : Ocular lubricants

Treatment of TT Stage : Epilation , tarsal

rotation , radiofrequency/ diathermy or
electrolysis epilation or cryotherapy

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 Treatment … Contd
• Treatment of CO Stage : After treatment of
lid deformities LKP or PKP, depending on
depth of corneal opacity

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 WHO’s GET 2020
• WHO in 1997 started Global Elimination of
Trachoma by 2020 programme called
WHO GET 2020 programme, under which
‘SAFE’ strategy has been adopted.
• S : Surgery for entropion/ trichiasis
• A : Antibiotics for infectious trachoma
• F : Facial cleanliness to reduce
transmission
• E : Environmental improvement
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 Trachoma Control Programme
• Tetracycline eye ointment 1% twice daily
on 5 consecutive days every month for 12
months
• Mass treatment should be annual in
endemic zones ( <35% children are
affected) and biannually in hyperendemic
zones (>50% children are affected)

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 Ophthalmia Nodosa
Nodular conjunctivitis, resembling
tuberculosis, due to irritation caused by
caterpillar hairs.

Small semi-translucent pinkish, reddish or

pale gray nodules formed in bulbar,
palpabral conjunctiva, cornea and rarely in
iris tissue.
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 Ophthalmia Nodosa .. Contd
Hairs are surrounded by giant cells and
lymphocytes.

Treatment: Symptomatic, local steroids in

selected cases, under supervision and
excision of conjunctival nodules.

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 Chronic Non-specific Conjunctivitis
Is a clinical condition resulting from
continuation of acute conjunctivitis or due
to variety of etiological factors,
characterized by chronic redness in one or
both eyes with persistence of annoying
symptoms.

October 15, 2008 Dr Sanjay Shrivastava 33

 Etiology
1. Exposure to Chronic irritants like,
smoke, dust, heat, poor quality air, late
hours, alcohol abuse.
2. Hypersensitivity to allergen.
3. Concretions, misdirected eyelash(es),
dacryocystitis , chronic rhinitis, sinusitis,
blepharitis, seborrhoea , dandruff etc
4. Unilateral Conjunctivitis foreign body
retained in conjunctiva or dacryocystitis
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 Symptoms
* Discomfort, burning, grittyness,
especially in the evening when eyes
becomes red and eyelid margins feel hot
and dry.
* Difficulty in keeping eyes open.
* Increased secretions, mucoid or
mucopurulent discharge, lids may stick
together in the morning on waking up.
together
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 Signs
• Hyperaemic lid margins
• Conjunctival congestion particularly in
lower fornix
• Papillary hyperplasia

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 Treatment
• Elimination of cause
• Treatment of infection foci in nose and
upper respiratory passage
• Treatment of conjunctival infection with
appropriate antibiotic
• Treatment of meibomian gland
abnormality by mechanical expression and
warm compression.
October 15, 2008 Dr Sanjay Shrivastava 37
 Allergic Conjunctivitis
• Allergy or Hypersensitivity: is a state which
is commonly regarded as an unfortunate
by-product of the process of immunity
whereby the tissues react by an abnormal
and injurious response to foreign
substances (allergens)

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 Allergy

• Two types of reactions:

a. Immediate and
b. Delayed Hypersensitivity

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 Immediate Hypersensitivity

• Ten days after initial exposure to foreign

protein, anaphylactic reaction follows after
second exposure to same protein.
Characterized by circulating antibodies.

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 Delayed Hypersensitivity
• There are no circulating humoral antibodies of
any kind. The sensitization is the property of the
cells themselves. The hypersensitivity is caused
by prior contact of the tissue with a protein and
seems to be due to the development of sessile
antibodies on or within the cells so that when
they are re-exposed to the same antigen a
reaction causing cellular damage develops
which may even involve necrosis.

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 Delayed Hypersensitivity
• This reaction does not occur immediately
and reach its maximum only after 24 to 72
hours.
• Typical example is tuberculin reaction.

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 Autosensitization
• In this case individual’s own tissue protein
are altered and thus rendered “foreign” by
a pathogenic agent, either bacterial or a
chemical acting as a haptene, repeated
contacts may result in hypersensitivity
reaction eg Sulphonamide allergy and
autosensitization induced by the
haemolytic Streptococcus.

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 Physical Allergy
• Certain individuals react to physical
agents such as heat, cold, light or
mechanical irritation by a typical
hypersensitive response often of urticarial
type. Some individuals are hypersensitive
to light of a certain wave-band.

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 Physical Allergy
• The reaction is due to auto-antigen
liberated in the tissues either due to
alteration of their specificity or due to their
capability of reacting with antibody only
under the physical condition created by
the stimulus.

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 Types of Allergic Conjunctivitis
1. Simple Allergic Conjunctivitis
A. Immediate Anaphylactic (Hay fever) type
mediated by circulating antibody
B. Delayed Type
(i) Contact Dermatoconjunctivitis due to local
chemicals
(ii) Microbial Allergic Conjunctivitis
(iii) Keratoconjunctivitis Medicamentosa due
to ingestion of drugs like arsenic and gold.
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 Types of Allergic Conjunctivitis
2. Interstitial Allergic Conjunctivitis
A. Phlyctenular Keratoconjunctivitis –
Delayed reaction- Endogenous microbial
allergy.
B. Vernal Catarrh – Allergic disease of
immediate type – an exogenous allergy.

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 Acute or Sub-acute Allergic
Catarrhal Conjunctivitis
• Is an allergic condition characterized by
hyperaemia which is not as intense as found in
bacterial conjunctivitis, accompanied by watery
secretion containing eosinophils. Itching is a
prominent symptom.
• Etiology: Exogenous allergen, contact with
animals, pollens, flowers, chemicals, cosmetics,
dye, medications etc. and sometimes bacterial
protein of endogenous nature, the most common
being staphylococcal infection.
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 Clinical Picture
• Symptoms: Itching, watering, redness,
swelling of lids and there may symptoms
of hay fever
• Signs: Conjunctival congestion, edema of
lids may be there, watery discharge,
presence of eosinophils and elevated IgE
level

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 Treatment
1. Removal of allergen from environment
2. Astringent lotion, adrenalin 1:10000,
antihistaminic drops (chlorpheniramine),
mast cell stabilizers (sodium
cromoglycate, olopatadine, ketotifen etc)
3. Short course corticosteroid drops
4. Topical 2% sodium cromoglycate drops.

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