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Clinical Summary

Trachoma is the leading cause of infectious blindness in the world. It is endemic in areas of Africa, Asia, Latin America, the Middle East, and aboriginal communities in Australia. It is a chronic follicular conjunctivitis caused by Chlamydia trachomatis. Trachoma is prevalent in populations with limited access to adequate sanitation and clean water; it is spread through ocular and respiratory secretions as well as flies.

The distinct active phase produces mild itching, irritation, and eye discharge, as well as conjunctival inflammation, particularly of the superior tarsal plate. This may progress to marked photophobia, blurred vision, and eye pain. The scarring, or cicatricial, phase occurs after repeated or severe infection; chronic inflammation causes the upper lid to shorten (entropion), with subsequent eyelash inversion (trichiasis). Trichiasis may cause painful corneal abrasions and subsequent corneal edema, ulceration, scarring, opacities, and, ultimately, blindness. Lacrimal gland involvement leads to dryness and increased irritation. Trachoma usually affects both eyes. Diagnosis is largely clinical but may be confirmed by culture. Community-based efforts on hygiene education and behavior modification can decrease the incidence.

FIGURE 21.80

Trachoma. Extensive inflammatory response with trichiasis. (Photo contributor: Seth W. Wright, MD.)

Management and Disposition

For acute and subacute infections, the most effective treatment is a single dose of azithromycin; tetracycline ophthalmic ointment is an alternative. Eyelid surgery to correct trichiasis and entropion may prevent blindness.

Pearls

  1. Trachoma was once endemic to North America and Europe, but has disappeared with improved sanitation and living conditions.

  2. It is extremely contagious and may be spread through direct contact with eye, nose, or throat secretions.

  3. Young children are particularly susceptible, but the disease progresses slowly and the more painful symptoms may not emerge until adulthood.

  4. Adult women are at much greater risk due to their close contact with small children, who are the main reservoir of infection.

  5. The WHO is attempting to eradicate trachoma by 2020 through their public health program known as SAFE. This multifaceted approach involves surgery for advanced disease, antibiotics, facial cleanliness, and environmental/sanitation improvements.

FIGURE 21.81

Trachoma. Chronic corneal scarring with excessive tearing in an African patient. (Photo contributor: Meg Jack, MD.)

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