Trachoma Treatment & Management

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 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.^[5] 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 community level in areas of known disease.
    • If assessment at the community level is undertaken in 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 community level is undertaken in 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 should involve the identification and treatment of all members of any family in whom one or more members have follicular trachoma.
    • If assessment at the community level is undertaken in 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.
  • 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.^[6]
  • To be successful, health education and promotion activities must be community based and require considerable effort.
• Environmental improvement

  • 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.
  • 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.

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.^[7]

  • 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.