Trachoma
- 1. MANAGEMENT OF TRACHOMA By : 4th year medical students Under supervision of Prof. Dr. Ahmed Youssef
- 2. Introduction Trachoma is a Greek word means rough eye Globally, 41 million people suffer from active infection It is caused by Chlamydia trachomatis. This disease was the main reason that led to vision loss in our country
- 3. Diagnosis Diagnosis of this disease requires : 1. History 2. Clinical picture 3. Laboratory tests 4. Differential diagnosis
- 4. History The patient may report contact with an infected individual Complain of ocular irritation and discharge. Advanced cases: pain and foreign body sensation may be reported. Some report Diminution of vision.
- 6. Symptoms Initial: Mild irritation of the eyes Watery discharge from the eyes. Symptoms caused by repeated infection: blurred vision eye pain severe photophobia (sensitivity to light) As the trachoma progresses to its final stage: Loss of some, and then all, vision occurs.
- 7. Signs
- 8. Conjunctiva Mac-Callans Classification : Stage T-I: Immature follicles (Non-Expressible)
- 9. Stage T-II: T-II, A Typical Follicles T-II, B: Papillary Trachoma
- 10. Stage T-III: Healing trachoma Stage T-IV: Healed trachoma
- 11. WHO Classification Stage N Normal Tarsal conjunctiva
- 12. Stage TF Trachomatous inflamation - Follicular
- 13. Stage TI Trachomatous inflamation - intense
- 17. Cornea 1. Stage of avascular superficial punktate keratitis:
- 20. 4. Trachomatous corneal ulcers: Typical trachomatous ulcers Central corneal ulcers
- 21. Pathognomic signs the diagnosis of trachoma is likely to be correct if at least two of the following criteria are present: Follicles on the upper palpebral conjunctiva in the mid- tarsal region Linear scars of the tarsal conjunctiva (Arlts syndrome) Active keratitis Follicles in the limbus or their sequelae (Herberts pits) Pannus in the upper third of the cornea.
- 23. Cell Culture Direct Fluorescent Antibody
- 25. Differential Diagnosis Condition Differentiating signs/symptoms Differentiating tests Chlamuydia Inclusion Conjunctivitis Generally occurs in adults not living in areas where trachoma is endemic. Swab culture detects genital strains of Chlamydia trachomatis. Viral conjunctivitis A common cause of conjunctival follicle.It can be distinguished from trachoma by an acute history and mucopurulent discharge. Herbert pits or pannus are absent. Both conditions may lead to tarsal conjunctival scarring. A swab for HSV and adenovirus could be considered. Bacterial Conjunctivitis Bacterial infection, such as Moraxella can be a rare cause of follicle formation. Absence of Herbert pits Microscopy, culture and sensitivity testing on a conjunctival swab may reveal a bacterial cause.
- 26. Condition Differentiating symptom / Sign Differentiating test Idiopathic trichiasis May be difficult to differentiate clinically from trichiasis due to trachoma, although it is unlikely to have tarsal scarring. Absence of Herbert pits. Trachoma is more likely in an area where it is endemic Differentiated clinically. Trichiasis due to other chronic inflammatory conditions Trichiasis can be idiopathic or secondary to a large range of chronic inflammatory diseases such as blepharitis and chronic conjunctivitis. Absence of Herbert pits. Trachoma is more likely in an area where it is endemic No differentiating tests performed. Corneal opacity due to other causes There are many other causes of corneal opacity. However, when seen in conjunction with trichiasis and other signs of trachoma in a patient who has spent a significant amount of their life in a trachoma-endemic area, a diagnosis of trachomatous corneal opacity is likely. No differentiating tests performed.
- 27. Complications 1. Lid complications (more in the upper lid): Trichiasis (usually multiple). Cicatricial entropion. Mechanical ptosis due to Heaviness of eye lid Chronic Meibomianitis.
- 28. 2. conjunctival complications: Posterior symblepharon (shallow fornix) It may obliterate ducts of the main lacrimal gland leading to loss of reflex lacrimation. Xerosis due to atrophy of goblet cells.
- 29. 3. Corneal complications: Corneal ulcers. Corneal opacities. Complications of xerosis. Keratectasia (very rare).
- 30. 4. Lacrimal complications: Epiphora due to fibrosis of lacrimal puncti or canaliculi. Dacryocystitis (chronic) due to fibrosis of nasolacrimal duct. Dacryoadenitis.
- 31. Treatment Prophylactic treatment This disease persists in communities without adequate access to water and sanitation. The WHO recommended the S A F E strategy as the trachoma control program, which includes
- 32. SAFE S urgery to correct advanced stages of the disease A ntibiotics to treat active infection F acial cleanliness to reduce disease transmission E nvironmental change to increase access to clean water and improved sanitation.
- 33. Curative Treatment Medical treatment General treatment Oral sulphonamides To kill chlamydia trachomatis & to avoid 2ry infection Dose: Sluphadiazine 1 gm tablet 3 times daily for 10 15 days Side effects: Allergy Crystalline urea Bone marrow depression Oral systemic antibiotic If the patient is sensitive to sulphonamides Examples: Azithromycin, Erythromycin & Tetracycline, doxycycline (for adults only)
- 34. Local treatment Local broad spectrum antibiotic Terramycin ointment (1 %) 3 times daily for 2 months Sulphacetamide drops (10-30 %) 6 times daily for 2 months Atropin ointment If the cornea is involved
- 35. Surgical Treatment Expression of follicles In typical follicular trachoma (T-ll, A) By ripe by Gradys forceps. Scraping of papillae In papillary trachoma (T-ll, B) By sharp spoon Picking of PTDs & PTCs In projecting PTDs & PTCs (T-lll & T-lV) By Beers knife with a pointed blade
- 36. Treatment of complications Complication of Eye lid: Pure trichiasis For upper lid we do van Millngen operation For lower lid we do Webster operation. Cicatricle entropion For upper lid we do snellen's operation. For lower lid we do Webster's operation.
- 37. Mechanical ptosis Due to increase the weight by papillae and Just remove the papillae. Multiple chalizia Due to fibrosis of Miebomian gland duct We give Antibiotic to prevent 2ry bacterial infection Plus steroids to decrease inflammation and fibrosis.
- 38. Complication of Lacrimal system: Spread of infection Chronic dacryoadenitis Chronic dacryocystitis Epiphora Overcome the obstruction of the pathway surgically Usually the puncti are the site of fibrosis (do 2 or 3 snip operation)
- 39. Complication of conjunctiva: Posterior symblypharon Synechotomy surgery to cut the adhesion Mucous membrane graft to cover opposite surfaces Keratoplasty if the cornea is affected Xerosis Medical by: Tear substitutes Lacriset Tear preservative
- 40. Complication of the cornea Pannus Thin pannus: Medical Treatment Thick Pannus: Medical treatment & scraping by sharp spoon Vascular Pannus: Medical treatment, periotomy & actual cautery of blood vessles Ulceration Opacities Keratectesia
- 41. Follow Up Long-term, intermittent follow-up care is required for patients with active or cicatricial disease. Annual follow-up care Surgical patients require because of the potential for recurrence
- 42. References Wikipedia.org E-medicine.medscape.com "Trachoma control: a guide for program managers." World Health Organization The Global Network for Neglected Tropical Diseases International Trachoma Initiative Reacher M, Foster A, Huber J. Wright HR, Turner A, Taylor HR C. Savona Ventura, University of Malta, 2003 Gupta, UC and Preobragenski, W
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