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Trachoma Treatment & Management

  • 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
 

Medical Care

The key to the treatment of trachoma is the SAFE strategy developed by the WHO. The surgical ("S") component of this strategy is described in Surgical Care below. Antibiotics ("A"), facial cleanliness ("F"), and environmental improvement ("E") are described in this section.

Antibiotic therapy

The WHO recommends 2 antibiotics for trachoma control: oral azithromycin and tetracycline eye ointment. Azithromycin eye drops have also been shown to be very effective.

Azithromycin is better than tetracycline, but it is more expensive.

National trachoma control programs in a number of countries are fortunate to be beneficiaries of a philanthropic donation of azithromycin.

Azithromycin is the drug of choice because it is easy to administer as a single oral dose.[9] Its administration can be directly observed. Therefore, compliance is higher than with tetracycline and can actually be measured, whereas, with the home administration of tetracycline, the level of compliance is unknown.

Azithromycin has high efficacy and a low incidence of adverse effects. When adverse effects occur, they are usually mild; gastrointestinal upset and rash are the most common adverse events.

Infection with C trachomatis occurs in the nasopharynx; therefore, patients may reinfect themselves if only topical antibiotics are used.

Beneficial secondary effects of azithromycin include its treatment of genital, respiratory, and skin infections.

Current WHO recommendations for antibiotic treatment of trachoma are as follows:

  • Determine the district-level prevalence of follicular trachoma in 1- to 9-year-old children. If the prevalence is 10% or higher, conduct mass treatment with antibiotic of all people throughout the district. If the prevalence is less than 10%, conduct assessment at the subdistrict or community level in areas of known disease.
  • If assessment at the subdistrict or community level is undertaken in subdistricts or communities where the prevalence of follicular trachoma in 1- to 9-year-old children is 10% or more, conduct mass treatment of all people with antibiotics.
  • If assessment at the subdistrict or community level is undertaken in subdistricts or communities where the prevalence of follicular trachoma in 1- to 9-year-old children is 5% or more but less than 10%, targeted treatment should be considered. Targeted treatment could involve the identification and treatment of all members of any family in whom one or more members have follicular trachoma.
  • If assessment at the subdistrict or community level is undertaken in subdistricts or communities where the prevalence of follicular trachoma in 1- to 9-year-old children is less than 5%, antibiotic distribution may not be necessary, though targeted treatment can be considered.
  • Where the baseline prevalence of follicular trachoma in children aged 1-9 years is 10% or more, annual treatment should be undertaken for at least 3 years before review. Where the baseline prevalence of follicular trachoma in children aged 1-9 years is 30% or more, annual treatment should be undertaken for at least 5 years before review.
  • Development of significant resistance to either azithromycin or tetracycline has not yet been demonstrated in C trachomatis.
  • Macrolide resistance may be induced in Streptococcus pneumoniae by the mass distribution of azithromycin for trachoma, but multiple rounds of treatment and/or the presence of macrolide resistant isolates at baseline may be necessary for epidemiologically significant resistance to emerge.

Facial cleanliness

Epidemiologic studies and community-randomized trials have shown that facial cleanliness in children reduces both the risk and the severity of active trachoma.[10]

To be successful, health education and promotion activities must be community based and require considerable effort.

Environmental improvement

General improvements in personal and community hygiene are almost universally associated with a reduction in the prevalence—and eventually the disappearance—of trachoma. This is true not only in Europe, the Americas, and Australia but also in Africa and Asia.

Environmental improvement activities are the promotion of improved water supplies and improved household sanitation, particularly methods for safe disposal of human feces.

These activities should be prioritized.

The flies that transmit trachoma preferentially lay their eggs on human feces lying exposed on the soil. Controlling fly populations by spraying insecticide is difficult. Studies on the impact of fly control on trachoma have had variable results. Trials undertaken to evaluate the installation of pit latrines suggested that the prevalence of trachoma was reduced but failed to demonstrate a statistically significant effect.

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Surgical Care

The key to the treatment of trachoma is the SAFE strategy. “S” stands for trichiasis surgery. The antibiotics (“A”), facial cleanliness (“F”), and environmental improvement (“E”) components of this strategy are described in Medical Care.

Eyelid surgery to correct trichiasis is important in people with trichiasis, who are at high-risk for trachomatous visual impairment and blindness. Eyelid surgery to correct entropion and/or trichiasis may prevent blindness in individuals at immediate risk.

Eyelid rotation limits the progression of corneal scarring. In some cases, it can result in a slight improvement in visual acuity, probably due to restoration of the visual surface and reductions in ocular secretions and blepharospasm.

The WHO has produced a training manual on the bilamellar tarsal rotation procedure.[11]  Details are as follows:

  • This procedure involves a full-thickness incision of the scarred lid and external rotation of the distal margin by using 3 sutures.
  • In regions where access to ophthalmologists is limited, well-trained and well-supported health workers can perform bilamellar tarsal rotation.
  • Results of randomized clinical trials have confirmed the superiority of this method over other techniques.
  • Even after successful surgery, patients remain at risk for recurrence. Therefore, long-term follow-up care and intermittent screening are important after surgery.
  • Recurrence rates vary greatly between surgeons. Ongoing audit is an essential element of trichiasis surgery programs.

Evidence supports the adjuvant use of single-dose azithromycin to patients at the time of surgery.

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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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