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Trachoma Clinical Presentation

  • Author: Hugh Ringland Taylor, AC, MD, MBBS, BMedSc(Melb), DO(Melb), FRANZCO, FRACS, FAAO, FACS, FAICD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Aug 10, 2015
 

History

Two phases of the disease process exist: the active phase and the scarring (cicatricial) phase. As implied above, though, these phases are not stages along a linear pathway of disease pathogenesis; both phases may coexist in the same patient.

The active phase resembles many other diseases in which follicular conjunctivitis is a feature. Without laboratory facilities, the diagnosis is solely based on the clinical appearance of active trachoma in someone living in a community where trachoma is endemic or suspected to be endemic.

Most patients with active trachoma are relatively asymptomatic.

The cicatricial phase has unique clinical features, which lead to definitive diagnosis in most cases.

Determine the amount of time that the patient has spent in a trachoma-endemic community and/or near a pool of infection.

Conjunctival scarring alone tends to be asymptomatic, though the associated disturbance of the architecture of the tear film (due to scarring and destruction of mucous and serous glands) often leads to dry eye.

Trichiasis causes an intensely irritating foreign body sensation, as well as blepharospasm. Ultimately, it leads to corneal scarring.

Many patients self-epilate before their presentation.

Corneal opacities or scars that cover any part of the pupil impair the patient's vision.

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Physical

Active trachoma is characterized by a mucopurulent keratoconjunctivitis. The conjunctival surface of the upper eyelid shows a follicular and inflammatory response. The cornea may have limbal follicles, superior neovascularization (pannus), and punctate keratitis. Infection with C trachomatis concurrently occurs in other extraocular mucous membranes, commonly the nasopharynx, leading to a nasal discharge.

Follicular trachoma

Follicular trachoma (designated TF in the WHO simplified trachoma grading scheme) is seen in the image below.

Trachomatous inflammation, follicular (TF), is the Trachomatous inflammation, follicular (TF), is the presence of 5 or more follicles (each at least 0.5 mm in diameter) on the central part of the upper tarsal conjunctiva. Images from the Slides/Text Teaching Series, No. 7, Trachoma, published by The International Centre for Eye Health, Institute of Ophthalmology, 11-43 Bath St, London EC1V 9EL, United Kingdom. Photograph courtesy of John D. C. Anderson, MD.

Follicular trachoma is defined as the presence of 5 or more follicles at least 0.5 mm in diameter in the central part of the upper tarsal conjunctiva.

Follicular trachoma indicates active disease.

This form is most commonly found in children, with a peak prevalence in those aged 3-5 years. The prevalence rapidly decreases in school-aged children as they leave the pool of re-infection (ie, their family childcare group).

Follicles are germinal centers that primarily consist of lymphocytes and monocytes.

The presence and involution of follicles at the limbus (corneoscleral border) give rise to the pathognomonic lesion of past active trachoma, Herbert pits.

Intense inflammatory trachoma

Intense inflammatory trachoma (designated TI in the WHO simplified trachoma grading scheme) is seen in the image below.

Trachomatous inflammation, intense (TI) is pronoun Trachomatous inflammation, intense (TI) is pronounced inflammatory thickening of the upper tarsal conjunctiva that obscures more than one half the normal deep tarsal vessels. Photograph courtesy of Allen Foster, MD.

Intense inflammatory trachoma is defined as pronounced inflammatory thickening of the upper tarsal conjunctiva that obscures more than one half of the normal deep tarsal vessels.

The cause is an intense inflammatory response. Like follicular trachoma, intense inflammatory trachoma indicates active disease.

The normally thin tarsal conjunctiva develops a velvety thickening.

Papillae are visible under slit lamp examination.

Intense inflammatory trachoma indicates an increased potential for significant conjunctival scarring and, hence, a higher ultimate risk of blinding disease.

Surveying the prevalence of intense inflammatory trachoma in children can help in predicting the risk of future blinding trachoma in that cohort of children.

Trachomatous scarring

Trachomatous scarring (designated TS in the WHO simplified trachoma grading scheme) is seen in the image below.

Trachomatous conjunctival scarring (TS) is the pre Trachomatous conjunctival scarring (TS) is the presence of easily visible scars in the tarsal conjunctiva.

Trachomatous scarring is defined as the presence of easily visible scars in the tarsal conjunctiva.

Trachomatous scarring indicates past inflammatory disease and a risk of future trichiasis. The more severe the scarring, the higher the risk of subsequent trichiasis.

This form may be associated with the development of dry eye syndrome, but chronic, low-grade bacterial conjunctivitis and dacryocystitis may also lead to a weeping eye.

Trichiasis 

Trichiasis (designated TT in the WHO simplified trachoma grading scheme) is seen in the image below.

Trachomatous trichiasis (TT) is defined as the pre Trachomatous trichiasis (TT) is defined as the presence of at least 1 eyelash rubbing on the eyeball or evidence of recent removal of in-turned lashes. Photograph courtesy of John D. C. Anderson, MD.

Trichiasis is defined as at least 1 eyelash rubs on the eyeball or evidence of recent removal of in-turned eyelashes.

This is a potentially blinding lesion that can lead to corneal opacification.

Trichiasis is due to subconjunctival fibrosis over the tarsal plate that leads to lid distortion.

Some vision can be restored with the successful correction of trichiasis.

Corneal opacity

Corneal opacity (designated CO in the WHO simplified trachoma grading scheme) is seen in the image below.

Easily visible corneal opacity over the pupil; it Easily visible corneal opacity over the pupil; it is so dense that at least part of the pupil margin is blurred when viewed through the opacity. Photograph courtesy of John D. C. Anderson, MD.

Corneal opacity is defined as easily visible corneal opacity over the pupil that is so dense that it blurs at least part of the pupillary margin when it is viewed through the opacity.

Corneal opacity or scarring reflects the prevalence of vision loss and blindness resulting from trachoma.

This condition includes pannus, epithelial vascularization, and infiltration only if it involves the central cornea.

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Causes

Trachoma is caused by repeated conjunctival infection with C trachomatis. Important individual-level risk factors for active trachoma include having siblings with active disease, having a dirty face, and crowded sleeping arrangements. At the community level, adequate water access for personal hygiene, sanitation, and fly control determine the risk of endemic trachoma.

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Contributor Information and Disclosures
Author

Hugh Ringland Taylor, AC, MD, MBBS, BMedSc(Melb), DO(Melb), FRANZCO, FRACS, FAAO, FACS, FAICD Harold Mitchell Professor of Indigenous Eye Health, Melbourne School of Population and Global Health, University of Melbourne

Hugh Ringland Taylor, AC, MD, MBBS, BMedSc(Melb), DO(Melb), FRANZCO, FRACS, FAAO, FACS, FAICD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Coauthor(s)

Anthony W Solomon, MBBS, DTM&H, PhD, MRCP Wellcome Trust Intermediate Clinical Fellow, Senior Lecturer, Department of Clinical Research, London School of Hygiene and Tropical Medicine; Honorary Consultant Physician, The Hospital for Tropical Diseases, UK

Anthony W Solomon, MBBS, DTM&H, PhD, MRCP is a member of the following medical societies: American Society of Tropical Medicine and Hygiene, Royal College of Physicians, Royal Society of Tropical Medicine and Hygiene

Disclosure: Received grant/research funds from International Trachoma Initiative for researcher; Received member of trachoma expert committee from International Trachoma Initiative for review panel membership; Received member of scientific advisory board from Queen Elizabeth Diamond Jubilee Trust for review panel membership.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Anastasios J Kanellopoulos, MD Assistant Program Director, Clinical Associate Professor, Department of Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, New York University

Anastasios J Kanellopoulos, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Eye Bank Association of America, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Denise Mabey, FRCOphth, MBBS Consulting Staff, Department of Ophthalmology, St Thomas Hospital of London

Disclosure: Nothing to disclose.

References
  1. Bobo LD, Novak N, Munoz B, Hsieh YH, Quinn TC, West S. Severe disease in children with trachoma is associated with persistent Chlamydia trachomatis infection. J Infect Dis. 1997 Dec. 176(6):1524-30. [Medline].

  2. Thylefors B, Dawson CR, Jones BR, West SK, Taylor HR. A simple system for the assessment of trachoma and its complications. Bull World Health Organ. 1987. 65(4):477-83. [Medline]. [Full Text].

  3. West SK, Munoz BE, Mkocha H, Gaydos C, Quinn T. Risk of Infection with Chlamydia trachomatis from Migrants to Communities Undergoing Mass Drug Administration for Trachoma Control. Ophthalmic Epidemiol. 2015 Jun. 22 (3):170-5. [Medline].

  4. Kalua K, Chirwa T, Kalilani L, Abbenyi S, Mukaka M, Bailey R. Prevalence and risk factors for trachoma in central and southern Malawi. PLoS One. 2010 Feb 5. 5(2):e9067. [Medline]. [Full Text].

  5. Baker MC, Mathieu E, Fleming FM, et al. Mapping, monitoring, and surveillance of neglected tropical diseases: towards a policy framework. Lancet. 2010 Jan 16. 375(9710):231-8. [Medline].

  6. Solomon AW, Pavluck AL, Courtright P, Aboe A, et al. The Global Trachoma Mapping Project: Methodology of a 34-Country Population-Based Study. Ophthalmic Epidemiol. 2015 Jun. 22 (3):214-25. [Medline].

  7. Katibeh M, Hosseini S, Yaseri M, Aminifar MN, Mahdavi A, Jafarinasab MR, et al. Prevalence and Risk Factors for Trachoma in Rural Areas of Sistan-va-Baluchestan Province, Iran: A Population-Based Study. Ophthalmic Epidemiol. 2015 Jun. 22 (3):208-13. [Medline].

  8. Ramyil A, Wade P, Ogoshi C, Goyol M, Adenuga O, Dami N, et al. Prevalence of Trachoma in Jigawa State, Northwestern Nigeria. Ophthalmic Epidemiol. 2015 Jun. 22 (3):184-9. [Medline].

  9. Evans JR, Solomon AW. Antibiotics for trachoma. Cochrane Database Syst Rev. 2011 Mar 16. CD001860. [Medline].

  10. West S, Munoz B, Lynch M, et al. Impact of face-washing on trachoma in Kongwa, Tanzania. Lancet. 1995 Jan 21. 345(8943):155-8. [Medline].

  11. Reacher M, Foster A, Huber J. Trichiasis surgery for trachoma: the bilamellar tarsal rotation procedure. WHO/PBL 93.29. Geneva: World Health Organization;. 1993.

  12. Dawson CR, Schachter J, Sallam S, Sheta A, Rubinstein RA, Washton H. A comparison of oral azithromycin with topical oxytetracycline/polymyxin for the treatment of trachoma in children. Clin Infect Dis. 1997 Mar. 24(3):363-8. [Medline].

  13. Grayston JT, Wang SP, Yeh LJ, Kuo CC. Importance of reinfection in the pathogenesis of trachoma. Rev Infect Dis. 1985 Nov-Dec. 7(6):717-25. [Medline].

  14. Mabey DC, Solomon AW, Foster A. Trachoma. Lancet. 2003 Jul 19. 362(9379):223-9. [Medline].

  15. Solomon A, Burton M. What's new in azithromyin?. Community Eye Health. 2004 Dec. 17(52):54-6. [Medline]. [Full Text].

  16. Taylor HR, Johnson SL, Schachter J, Caldwell HD, Prendergast RA. Pathogenesis of trachoma: the stimulus for inflammation. J Immunol. 1987 May 1. 138(9):3023-7. [Medline].

 
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Trachomatous inflammation, follicular (TF), is the presence of 5 or more follicles (each at least 0.5 mm in diameter) on the central part of the upper tarsal conjunctiva. Images from the Slides/Text Teaching Series, No. 7, Trachoma, published by The International Centre for Eye Health, Institute of Ophthalmology, 11-43 Bath St, London EC1V 9EL, United Kingdom. Photograph courtesy of John D. C. Anderson, MD.
Trachomatous inflammation, intense (TI) is pronounced inflammatory thickening of the upper tarsal conjunctiva that obscures more than one half the normal deep tarsal vessels. Photograph courtesy of Allen Foster, MD.
Trachomatous conjunctival scarring (TS) is the presence of easily visible scars in the tarsal conjunctiva.
Trachomatous trichiasis (TT) is defined as the presence of at least 1 eyelash rubbing on the eyeball or evidence of recent removal of in-turned lashes. Photograph courtesy of John D. C. Anderson, MD.
Easily visible corneal opacity over the pupil; it is so dense that at least part of the pupil margin is blurred when viewed through the opacity. Photograph courtesy of John D. C. Anderson, MD.
The image on the left shows intense inflammatory trachoma, and the image on the right shows allergic conjunctivitis with the typical cobblestone papillae. Courtesy of John D. C. Anderson, MD, and Murray McGavin, MD.
 
 
 
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