हहे त:त -

•उष्णभभितप्तस्य जल प्रववेशशाद दरद वे क्षणशात त स्वप्नववपरयर्य्यवशाच्च।

प्रसक्तससंररोदन करोपशरोकक्लवेशशाभभिघशातदततममैथन
थ शाच्च।।

शथक्तशारनशालशाम्लकथलत्थमशाषतनषवेवणशादववेगववतनग्रहशाच्च।

स्ववेदशादथरो धदमतनषवेवणशाच्च छदर ववर्य्यघतशादवमनशाततयरोगशात त।

वशाष्पग्रहशात त सदक्ष्मतनररीक्षणशाच्च नवेतवे ववकशारशान्जनयनन्त दरोषशाषाः।। (सथ.उ.त.१/२६-२७)

Immediately enter in to cold water after exposure of hotness, excessive seeing of

things which are too far.Practice to sleep in that position which is not
suitable.Continuous crying, Anger, Mental illness, Trauma , Excessive sexual
intercorse, Continuous use of Aranala(kanji), Sour things ,Kulattha, Masha etc.
Suppress the in supressable urges. Excessive sweating, Excessive smoking, Supress
the urge of vomitting or vamana atiyoga, Supress the urge of crying, Excessive
seeing of too small things.

पपररु
र्व प

• ततशाववलसं सससंरम्भिमशथकण्डदपदवे हवत त। गथरुषशातरोदरशागशाधमैजथष्र्य्य टञ्चशाव्यक्तलक्षणमैषाः।।

सशदलसं वत्मर्य्यकरोषवेषथ शदकपण

द शार्य्यभिमवेव च। ववहन्यमशानसं रुपवे वशा कक्रियशास्वकक्ष यथशा परथ शा।।

दृष्ट्वमैव धधीमशान त बथध्यवेत त दरोषवेणशाधधनष्ष्ठितसं तथ तत त।। (सथ.उ.त.१/२१-२३)

Turbidity in eye, redness and pain, tearing from eyes, itching sensation in eyes,
signs of eye stool, heaviness in eye, burning sensation in eyes, pricking like pain in
eyes pain in eyelids and feeling like throns filled in it, here is a difficulty in
visualization and interference in eye function.

रुप:-
• स्तशाववण्यषाः कण्डथरशा गथव्यर रक्तसषर्य्यपसनन्नभिशाषाः। वपडकशाश्च रुजशावत्यषाः परोथक्य इतत
ससंकज्ञितशाषाः।।

(सथ.उ.त.३/११)

सशाववण्य इत्यशादद| सशाववण्यरो बहथसशावशाषाः| कण्डथरशा इतत कण्डथयथक्तशाषाः| रुजशावत्य इतत

कफजशा अवप

ववेदनशायथक्तशा इत्यथर्य्यषाः| इमशाषाः सशाध्यशाषाः||११|| तनबन्धसङ्ग्रह व्यशाख्यशा (डल्हण ककत)

According to Acharya sushruta; Pidakas (follicles) originate in eyelid and in which

there is strava (oozing), kandu (itching), ruja (pain) and resembling red mustard
seeds are called as Pothaki.

• परोथक्यषाः वपदटकशा: श्ववेतशा: सषर्य्यपशाभिशा घनशा: कफशात त।

शरोफरोपदवे हरुक्कण्डदवपनच्छलशाशथसमनन्वतशा:।।

(अ.ह.उ. ८/९)

According to Acharya vagbhatta, Pothaki are white coloured pitika (eruptions)

resembling Sarsapa(mustard), hard, associated with shopha (swelling), upadeha
(coating),ruka (pain),kandu (itching) and picchila (slimy) ashru (tears).It is caused
by vitiation of Kapha dosha.

• स्तशाववण्य कण्डथरशा गव्थ यर रक्तसषर्य्यपसनन्नभिशाषाः। रुजशावत्यश्च वपडकशा परोथक्य इतत

ककीततर्य्यतशा:।।

(भिशा.प्र.म.खसं.४/७)

परोथतत पयशार्य्यप्नरोतत वत्मर्य्यप्रदवे शसं कफजन्यरक्तसषर्य्यपतथल्यवपडकशारुपवेजवेतत परोथककी ।।

In Bhavprakasha it is described as, Pidakas (follicles) originate in eyelid and in
which there is strava (oozing), kandu (itching), ruja (pain) and resembling red
mustard seeds are called as Pothaki.

• परोथककीनशासं लक्षणमशाह– सशाववण्य इत्यशादद| सशाववण्यरो बहथसशावशाषाः| गथव्यर्य्य इतत गगौरवयथतशाषाः|

रुजशावत्य इतत

रक्तसम्बन्धशात त, कफजशा अवप ववेदनशानन्वतशाषाः||७८||. (मशा.तन.मधथकरोष)

• श्ववेतशा आककत्यशा च सषर्य्यपसदकशशा घनशा: ससंहतशा: शरोफशाददसमनन्वतशाश्च वपटकशा:

कफशादवेतरोभिर्य्यवनन्त।

तशा नशाम्नशा परोथक्य इत्यथच्यन्तवे।।

ससंपप्रापपत:-

• भसरशाङनथसशाररभभिदरषमैववगथणमैरुध्वर्य्यमशागतमैषाः। जशायन्तवे नवेतभिशागवेषथ ररोगशाषाः परमदशारुणशाषाः।।

(सथ.उ.त.१/२०)

Aggrevated or vitiated doshas goes upward and produces many eye diseases.

• सवर्य्यररोगतनदशानरोक्तमैरदहतमैषाः कथवपतशा मलशाषाः। अचक्षथष्यमैववशवेषवेणवे प्रशायषाः वपत्तशानथसशाररणषाः।।

भसरशाभभिरुध्वर्य्य प्रसत
क शा नवेतशावयवमशाधशतशाषाः। वत्मर्य्य सनन्धसं भसतसं ककष्णसं दृनष्टसं वशा सवर्य्यमकक्ष वशा
ररोगशान त कथयर्य्यषाः।।

(अ.ह.उ. ८/१-२)

Due to exposure of that ahara-vihara which are harmful to the eye , pitta followed
by other doshas gets vitated & goes upward and making sthanasamshraya in
vartma, sandhi,sweta,krushna and drashti and produces diseases of that part or
whole eye.
पथ
क ग्दरोषशाषाः समस्तशा वशा यदशा वत्मर्य्यव्यपशाशयशाषाः | भसरशा व्यशाप्यशावततष्ष्ठिन्तवे
वत्मर्य्यस्वधधकमदनच्छर्य्य तशाषाः ||३||

वववध्यर्य्य मशासंससं रक्तसं च तदशा वत्मर्य्यव्यपशाशयशान त | ववकशारशाञ्जनयन्त्यशाशथ नशामतस्तशानन्नबरोधत

||४||

तनबन्धसङ्ग्रह व्यशाख्यशा (डल्हण ककत)

सम्प्रशानप्तमशाह- पथ
क धगत्यशादद| यदशा पथ
क कत समस्तशा वशा अधधकमनद च्छर्य्य तशा अततशयप्रकथवपतशा
दरोषशा वत्मर्य्यव्यपशाशयशाषाः अपशब्दस्यरोपसगर्य्यस्य मध्यवचनत्वशादवत्मर्य्यमध्यगतशाषाः भसरशा व्यशाप्य
वत्मर्य्यस्ववततष्ष्ठिन्तवे, तदशा वत्मर्य्यव्यपशाशयशान त ववकशारशान त शधीघसं जनयन्तधीतत सम्बन्धषाः| अमथसं पशाष्ठिसं
पनञ्जकशाकशाररो न पष्ठितत, जवेज्जटपदष्ठितत्वशादस्मशाभभिरवप पदष्ठितषाः

Treatment

• उत्सशाङ्धगनधी बहलकदर्य्य मवत्मर्य्यनधी च श्यशावसं च यच्च पदष्ठितसं नत्वह बदवत्मर्य्य |

नक्लष्टसं च परोथककयथतसं खलथ यच्च वत्मर्य्य कथम्भिधीककनधी च सह शकर्य्यरयशा च लवेख्यशाषाः ||

(स.थ उ.८/७)

According to Acharya shushruta Utsangini, Bahalvartma, kardamvartma,

baddhvartma, klishtvartma, pothaki, kumbhikpidika and vartmasharkara are
Lekhana sadhya vyadhis.

• सवेक आश्च्यरोतनसं वपण्डरो बबडशालस्तपर्य्यणसं तथशा। पट

थ पशाकरोङ्ञ्जनसं चमैभभि: कल्पमैनरतमप
थ शाचरवे त त।।

(भिशा.प्र.म.खसं.४/२८)
In Bhavprakasha common treatment for eye disease is found in which he
suggested seka, ashchyotana, pindi, bidalaka, putapaka and anjana.

• परोथककीववर्य्यभलख्य शथण्ष्ठिठीसमैन्धवमशागधधकशाचदणर: प्रततसशायर्य्य प्रक्षशाल्यचरोष्णम्भिसशा

खददरसशारशाढककीभशग्रथपतकषशायवेण सवेचयवेत त। ततश्चशाम्रजम्बप्र

द वशालक्वशाथवेनशा

आश्च्यरोतनम त। बतफलशाखददरसशाररोदकवेन वशा मधथससंयथक्तवेन। ववडङ्गलशाक्षशादशावर-

त्वग्गमैररकशालमनरोह्वशाचदण:र्य्य क्षगौदशानन्वतरो असंजनम त।। (अ.ससं.१२/७)

In Ashtanga Sangraha, treatment for pothaki is described as, in pothaki Lekhana

karma should be done firstly, then after pratisarana should be done by sunthi
saindhava and magdhika churna, then eyes should be washed by warm water,
then parisheka by Kashaya of khadira, adhaki and shigrupatra, then ashchyotana
by amra, jambu, praval kwatha or madhu samyukta kwatha of triphala and
khadirsara should be done, then anjana karma by twak, gairika, manohwa churna
mixed with madhu or haridra, daruharidra, triphala and yashtimadhu mixed with
madhu and makshika.

• एवमप्यनथपशमवे जलरोकसरो यरोजयवेत त। पन

थ षाः पथनवशार्य्य लवेखयवेत त। पररषवेकञ्चबतफलशा-

मधक
थ दववहररदशाकषशायवेण मधथयक्
थ तवेन कथयशार्य्यत त। मस्
थ तशकर्य्यरशाकवपत्थपतशाम्बन
थ शा वशा।।
(अ.ससं.१२/८)

For shamana of pothaki Jalauka should be used. Then repeated Lekhana should be
completed.Then parisheka by kwath of haridra, daruharidra, triphala and
yashtimadhu or musta, sharkara, kapittha patra should be done.

• परोथककीभलर्य्यखखतशाषाः शण्
थ ष्ठिठीसमैन्धवप्रततसशाररतशाषाः। उष्णशाम्बक्ष
थ शाभलतशाषाः भसञ्ञवेत त
खददरशाढककभशग्रभथ भिषाः।।21

अनप्सदमैवदर्य्यतनशशाशवेष्ष्ठिशामधक
थ मै वशार्य्य समशाकक्षकमैषाः। (अ.ह.उ.९/२१)
In Ashtanga Hridaya, treatment for pothaki is described as , in pothaki Lekhana
karma should be done firstly, then after pratisarana should be done by sunthi and
saindhava , then eyes should be washed by warm water, then parisheka by Kwatha
of khadira, adhaki and shigru or kwath of haridra, daruharidra, triphala and
yashtimadhu should be done.

TRACHOMA
Trachoma (previously known as Egyptian ophthalmia) is a chronic
keratoconjunctivitis, primarily affecting the superficial epithelium of conjunctiva
and cornea simultaneously. It is characterized by a mixed follicular and papillary
response of conjunctival tissue, pannus formation and in late stages cicatrization
giving rough appearance. The word 'Trachoma' comes from the Greek word for
'rough' which describes the surface appearance of the conjunctiva in chronic
trachoma. It is still one of the leading causes of preventable blindness in the
world.

ETIOLOGY

A. CAUSATIVE ORGANISM :-

Trachoma is caused by the bacterium Chlamydia trachomatis, biovar

TRIC. The organism is epitheliotropic and produces intracytoplasmic
inclusion bodies called HP bodies (Halberstaedter Prowazek bodies).
Presently, 12 serovars of Chlamydia trachomatis biover TRIC (A, B, Ba,
C, D, E, F, G, H, J and K) have been identified using
microimmunofluorescence techniques.
• Serovars A, B, Ba and C are associated with hyperendemic ( blindness)
trachoma.

• Serovars D to K are associated with inclusion conjunctivitis

(oculogenital chlamydial disease).

B. PREDISPOSING FACTORS include :

• Age: The infection is usually contracted during infancy and early childhood.
Otherwise, there is no age bar.

• Sex: As far as sex is concerned, there is general agreement that preponderance

exists in the females both in numbers and in severity of the disease.

• Race: No race is immune to trachoma, but the disease is very common in Jews
and comparatively less common among Negroes.

• Climate: Trachoma is more common in areas with dry and dusty weather.

• Socioeconomic status: The disease is more common in poor classes owing to

unhygienic living conditions, overcrowding, unsanitary conditions, abundant fly
population, paucity of water, lack of materials like separate towels and
handkerchiefs, and lack of education and understanding about spread of
contagious diseases.

• Environmental factors like exposure to dust, smoke, irritants, sunlight, etc.

increase the risk of contracting disease. Therefore, outdoor workers are more
affected in comparison to office workers.

C. SOURCE OF INFECTION:
In trachoma endemic zones, the main source of infection is the conjunctival
discharge of the affected person. Therefore, superimposed other bacterial
infections help in transmission of the disease by increasing the conjunctival
secretions.

D. MODES OF INFECTION :
Infection may spread from eye to eye by any of the following modes:

1. Direct spread of infection may occur through contact by airborne or

waterborne modes.

2. Vector transmission or trachoma is common through flies.

3. Material transfer plays an important role in the spread of trachoma.

Material transfer can occur through contaminated fingers of doctors,
nurses and contaminated tonometers. Other sources of material transfer of
infection are use of common towels, handkerchiefs, bedding and surma-
rods.

PREVALENCE AND EPIDEMICS:

In areas where trachoma is endemic, active (inflammatory) trachoma is common
among preschool-aged children, with prevalence rates which can be as high as
60–90%. Infection becomes less frequent and shorter in duration with increasing
age. Infection is usually acquired when living in close proximity to others with
active disease, and the family is the main setting for transmission. An individual’s
immune system can clear a single episode of infection, but in endemic
communities, re-acquisition of the organism occurs frequently.

After years of repeated infection, the inside of the eyelid can become so severely
scarred (trachomatous conjunctival scarring) that it turns inwards and causes the
eyelashes to rub against the eyeball (trachomatous trichiasis), resulting in
constant pain and light intolerance; this and other alterations of the eye can lead
to scarring of the cornea. Left untreated, this.condition leads to the formation of
irreversible opacities, with resulting visual impairment or blindness. The age at
which this occurs depends on several factors including local transmission intensity.
In very highly endemic communities, it can occur in childhood, though onset of
visual impairment between the ages of 30 and 40 years is more typical.

impairment or blindness results in a worsening of the life experience of affected

individuals and their families, who are normally already amongst the poorest of
the poor. Women are blinded up to 4 times as often as men, probably due to their
close contact with infected children and their resulting greater frequency of
infection episodes.

Trachoma is a worldwide disease, but it is highly prevalent in North Africa, Middle

East and certain regions of South-East Asia. It is believed to affect some 500
million people in the world. There are about 150 million cases with active
trachoma and about 30 million having trachiasis, needing lid surgery. Trachoma is
responsible for 15-20% of the world's blindness, being second only to cataract.

CLINICAL AND PATHOLOGICAL FEATURES:

Clinical features of trachoma can be described into two phases:

I. PHASE OF ACTIVE TRACHOMA:

Phase of active trachoma usually occurs during childhood due to active Chlamydial
infection.

• Incubation period of active trachoma varies from 7 to 14 days.

• Onset of the disease is usually insidious (subacute), however, rarely it

may present in acute form.

SYMPTOMS: Symptoms of active trachoma are determined by the absence or

presence of secondary other bacterial infection (a very common situation).

In the absence of secondary infection, a pure trachoma is characterized by

following symptoms:

• Mild foreign body sensation

• Occasional lacrimation

• Slight stickiness of the lids, and

• Scanty mucoid discharge.

Note: the above symptoms are so mild that the disease is usually neglected,so,
the term trachoma dumium was suggested.

In the presence of secondary other bacterial infection, typical symptoms of acute

mucopurulent conjunctivitis develop.

SIGNS:
A. CONJUNCTIVAL SIGNS:

1. Congestion of upper tarsal and forniceal conjunctiva.

2. Conjunctivital follicles. Follicles look like boiled sago- grains and are commonly
seen on upper tarsal conjunctiva and fornix, but may also be present in the lower
fornix, plica semilunaris and caruncle. Sometimes, follicles may be seen on the
bulbar conjunctiva (pathognomonic of trachoma).

Pathological structure of follicles: Follicles are formed due to scattered

aggregation of lymphocytes and other cells in the adenoid layer. Central part of
each follicle is made up of mononuclear histiocyte, few lymphocytes and large
multinucleated cells called Leber cells. The cortical part is made up of a zone of
lymphocytes showing active proliferation. Blood vessels are present in the most
peripheral part. In later stage signs of necrosis are also seen. Presence of Leber
cells and signs of necrosis differentiate trachoma follicles of other forms of
follicular conjunctivitis.

3. Papillary hyperplasia: Papillae are reddish, flat topped raised areas which give
red and valvety appearance to the tarsal conjunctiva.

Pathologically each papilla consists

of central core of numerous dilated
blood vessels surrounded by
lymphocytes and covered by
hypertrophic epithelium.

B. CORNEAL SIGNS:

1. Superficial keratitis may be

present in the upper part.

2. Herbert follicles refers to typical follicles present in the limbal area.

Histologically these are similar to conjunctival follicles.

3. Progressive pannus, i.e. infiltration of the cornea associated with the

vascularization is seen in upper part. The vessels are superficial and lies between
epithelium and Bowman's membrane. Later on, Bowman's membrane is also
destroyed. Pannus in active trachoma is progressive in which infiltration of cornea
is ahead of vascularization.
4. Corneal ulcer may sometime develop at the advancing edge of pannus. Such
ulcers are usually shallow which may become chronic and indolent.

II. STAGE OF CICATRICIAL TRACHOMA

Cicatricial phase of trachoma manifests in middle age. It results due to continued
mild grade chronic inflammation. In fact recurrent infection elicits chronic immune
response consisting of cell mediated delayed hypersensitivity (Type IV) reaction to
the intermittent
presence of chlamydial antigen,
which is responsible for
cicatricial phase of trachoma.
The end stage of cicatricial
trachoma is also referred to as
sequelae of trachoma. This phase
is characterized by
following clinical features:

A. CONJUNCTIVAL SIGNS

I. Conjunctival scarring, which may be irregular, star- shaped or linear. Linear scar
present in the sulcus subtarsalis is called Arlt's line.
II. Concentrations are hard looking whitish deposits varying from pin point to 2
mm in size. There are not calcareous deposits, but are formed due to
accumulation of dead epithelial cells and inspissated mucus in the depressions
called glands of Henle. Hence, the name is misnomer.

III. Other conjunctival sequelae include concretions, pseudocyst, xerosis and

symblepharon.

B. CORNEAL SIGN

I. Regressive pannus (pannus siccus) in which vessels extend a short distance

beyond the area of infiltration.

II. Herbert pits are oval or circular pitted scars, left after healing of Herbert follicles
in the limbal area.

III. Corneal opacity may be present in the upper part. It may even extend down
and involve the papillary area. It is the end result of trachomatous corneal lesions.

IV. Other corneal sequelae may be corneal ectasia, corneal xerosis and total
corneal pannus (blinding sequelae).

C. LID SIGNS

Sequelae in the lids may be trachiasis, entropion, tylosis (thickening of lid

margins), ptosis, madarosis and dacryoadenitis

GRADING OF TRACHOMA

MCCALLAN'S CLASSIFICATION:
McCallan in 1908, divided the clinical course of the trachoma into four stages:

• Stage I (Incipient trachoma or stage of infiltration). It is characterized by

hyperaemia of palpebral conjunctiva and immature follicles.

• Stage II (Established trachoma or stage of florid infiltration). It is

characterized by appearance of mature follicles, papillae and progressive corneal
pannus.
• Stage III (Cicatrising trachoma or stage of scarring). It includes obvious scarring
of palpebral conjunctiva

• Stage IV (Healed trachoma or stage of sequelae). The disease is quiet and cured
but sequelae due to cicatrization, give rise to symptoms.

WHO CLASSIFICATION:-
The latest simplified classification suggested by WHO in 1987 as follows (FISTO):

1.TF: Trachomatous inflammation- follicular. It is the stage of active trachoma with

predominantly follicular inflammation. To diagnose this stage at least five or more
follicles (each 0.5 mm or more in diameter) must be present on the upper tarsal
conjunctiva. Further, the deep tarsal vessels should be visible through the follicles
and Papillae.

2. TI: Trachomatous inflammation intense. This stage is diagnosed when

pronounced inflammatory thickening of the upper tarsal Conjunctival obscures
more than half of the normal deep tarsal vessels.

3. TS: Trachomatous scarring. This stage is diagnosed by the presence of scarring

in the tarsal conjunctiva. These scars are easily visible as white, bands or sheets
(fibrosis) in the tarsal conjunctiva.

4. TT: Trachomatous trichiasis. TT is labelled when at least one eyelash rubs the
eyeball. Evidence of recent removal of inturned eyelashes should also be graded
as Trachomatous trichiasis.

5. CO: Corneal opacity. This stage is labelled when easily visible corneal opacity is
present over the pupil. This sign refers to corneal scarring that is so dense that at
least part of pupil margin is blurred when seen through the opacity. The definition
is intended to detect corneal opacities that cause significant visual impairment
(less than 6/18).
COMPLICATION
The only complication of trachoma is corneal ulcer which may occur due to
rubbing by concretions, or trichiasis with superimposed bacterial infections

DIAGNOSIS

A.Clinical diagnosis of trachoma is made from its typical signs. Clinical grading
of each case should be done as per WHO classification into TF, TI, TS, TT or CO.

B. Laboratory diagnosis. Advanced laboratory tests are employed for research

purposes only. Laboratory diagnosis of trachoma includes:

1. Conjunctival cytology. Giemsa- stained smears showing a predominantly

polymorphonuclear reaction with presence of plasma cells and Leber cells of
trachoma.

2. Detection of inclusion bodies in conjunctival smear may be possible by Giemsa

stain, iodine stain or immunofluorescent staining, especially in the cases with
active trachoma.

3. Enzyme linked immunosorbent assay (ELISA) for chlamydial antigens.

4. Polymerase chain reaction (PCR) is also useful.

5. Isolation of chlamydia is possible by yolk-sac inoculation method and tissue

culture technique.

6. Serotyping of TRIC agents is done by detecting specific antibodies using

microimmunofluorescence (micro- IF) method. Direct monoclonal fluorescent
antibody microscopy of conjunctival smear is rapid and inexpensive.

MANAGEMENT
Management of trachoma includes curative as well as prophylactic measures.

A. TREATMENT OF TRACHOMA
I. Treatment of active trachoma:

Stage TF and TI of WHO classification constitute active trachoma in which acute

infection is present, and therefore treatment is directed at eliminating the
chlamydia organism.

Antibiotics, thus constitute the main stay of treatment of active trachoma. This
can be given topically or systemically or in combination.

1. Topical therapy regimes are best for individual cases and consist of:

• Tetracycline (1%) or erythromycin (1%) eye ointment twice daily for six

weeks, or

• Sulfacetamide (20%) eye drops three times a day along with 1%

tetracycline eye ointment at bed time for 6 weeks

2. Systemic Antibiotic therapy regimes include:

• Tetracycline or erythromycin 250 mg orally, four times a day for 3-4

weeks or

• Doxycycline 100 mg orally twice daily for 3-4 weeks, constitute the

traditional standard systemic therapy.

• Azithromicine 20 mg/kg weight upto maximum 1 gram as single oral

dose is as effective as 6 weeks of topical therapy so is presently

considered the first drug of choice. It is not used in pregnancy and child

below 6 years of age.

3. Combined topical and systemic therapy regimes. It is preferred when the ocular
infection is severe (TI) or when there is associated genital infection. It includes;

• Tetracycline (1%) or erythromycin eye ointment 2 times a day for 6

 weeks; and

• Azithromicine single oral dose (first choice) or tetracycline or

erythromycin 250 mg orally 4 times a day for 2 weeks.

II. Treatment of cicatricial (inactive) trachoma

Stages TS, TI and CO of WHO classification constitute the inactive trachoma during
which infection is no longer present, i.e. only trachoma sequelae are present, and
therefore, treatment is directed towards these sequelaes as below:

Stage TS measures include:

• Concretions should be removed with a hypodermic needle.

• Conjunctival xerosis should be treated by artificial tears (lubricating

drops).

Stage TI includes trichiasis and cicatricial entropion

• Trachiasis, a few misdirected cilia, should be treated with permanent

lash removal measures such as electrolysis, cryolysis and radio

frequency epilation.

• Bilamelar tarsal resection is the surgical procedure of choice for

Multiple misdirected lashes.

• Cicatricial entropion should be corrected surgically.

Stage CO constitutes marked visual disability or blindness. After treating other

trachoma sequelae, following measures must be taken:

• Penetrating keratoplasty (PK) is indicated for significant corneal

scarring. However, the outcome is less than optimum, as these

patients have extensive corneal vascularisation.

 • Keratoprosthesis (KP) is indicated in bilateral blind cases with

extensive corneal scarring and ocular surface problems

• Punctual occlusion and lateral tarsorrhaphy, which takes care of the

coexistent ocular surface problems, may be useful adjuncts for

increasing the success of the above surgeries.

B. PROPHYLAXIS FOR TRACHOMA INFECTION AND

BLINDNESS:-
Since immunity is very poor and short lived, reinfections and recurrences are likely
to occur. So, prophylactic measures are essential.

WHO defines blinding trachoma elimination as:

• TF prevalence, 5% in 1-9 years children, and

• TI prevalence, 1 per 1000 in total population.

SAFE STRATEGY:-
The WHO's GET 2020 program (Global Elimination of Trachoma by 2020), has
adopted the so called SAFE strategy for prophylaxis against Trachoma infection
and prevention of blindness.

SAFE strategy includes;

S : Surgery (Tertiary prevention),

A : Antibiotic use (Secondary prevention),

F : Facial hygiene (Primary prevention), and

E : Environmental changes (Primordial prevention).

1. Environmental changes (Primordial prevention):

Flies and other fomites are the common causes of spread of Trachoma. So,
environmental sanitation will constitute the primordial prevention for trachoma.
Recommended environmental sanitation measures include:

• Provision of water latrines and good water supply to reduce flies and

improve washing habits,

• Refuse dumps,

• Sprays to control flies,

• Animal pens away from human household, and

• Health education to improve personal and environmental hygiene.

2.Facial hygiene (Primary prevention):

Facial hygiene is critical measure for primary prevention of trachoma and should
include:

•Frequent face wash with clean water to eliminate the potentially infectious
ocular secretions.

•Avoidance of common use of towel, handkerchief, surma-rods, etc.are important

facial hygienic measures to prevent spread of trachoma infections.

3.Antibiotics for prevention against Trachoma (Secondary prevention):

Use of antibiotics constitutes the secondary prevention against trachoma. Current

WHO recommendation for community based mass antibiotic therapy in endemic
areas are as below:

I. In areas with 10% or more prevalence of active trachoma (TF in children

1-9 years) recommendation are as follow:

• Oral Azithromicine (single dose of 20 mg/kg up to 1 gm), should be administered
to all community members.

• Tetracycline eye ointment twice daily for 6 weeks is recommended for all
pregnant women, children, 6 months and those allergic to macrolides.

Note. The mass antibiotic therapy should be given once in a year for continuous 3
years, after which reassessment of prevalence should be made. The annual
treatment should be continued till the TF prevalence in 1-9 years children of that
area becomes less than 5%.

II. In areas with prevalence between more than 5% and less than 10%, the
targeted antibiotic therapy is recommended only among family members and
close contacts of the patients.

III. In areas with prevalence less than 5%, treatment of the patients only is
recommended.

4. Surgery (Tertiary prevention):

Surgery for trachiasis and entropion constitutes tertiary prevention for

Trachomatous corneal blindness. WHO recommends bilamellar tarsal rotation
surgery at community level for affected persons.
TRACHOMA

Key facts

Trachoma is a disease of the eye caused by infection with the bacterium

Chlamydia trachomatis.

It is a public health problem in 44 countries, and is responsible for the blindness

or visual impairment of about 1.9 million people.

Based on March 2019 data, 142 million people live in trachoma endemic areas
and are at risk of trachoma blindness.

Blindness from trachoma is irreversible.

Infection spreads through personal contact (via hands, clothes or bedding) and by
flies that have been in contact with discharge from the eyes or nose of an infected
person. With repeated episodes of infection over many years, the eyelashes may
be drawn in so that they rub on the surface of the eye, with pain and discomfort
and permanent damage to the cornea.

The World Health Assembly adopted resolution WHA51.11 in 1998, targeting the
global elimination of trachoma as a public health problem.

The elimination strategy is summarized by the acronym "SAFE", which means

Surgery for advanced disease, Antibiotics to clear C. trachomatis infection, Facial
cleanliness and Environmental improvement to reduce transmission.

In 2018, 146 112 people received surgical treatment for advanced stage of the
disease, and 89.1 million people were treated with antibiotics. Global-level
antibiotic coverage in 2018 was 50%.
Trachoma is the leading infectious cause of blindness worldwide. It is caused by an
obligate intracellular bacterium called Chlamydia trachomatis. The infection is
transmitted by direct or indirect transfer of eye and nose discharges of infected
people, particularly young children who harbour the principal reservoir of
infection. These discharges can be spread by particular species of flies.

Environmental risk factors influencing the transmission of the disease include:

inadequate hygiene

crowded households

inadequate access to water

inadequate access to and use of sanitation.

Distribution

Trachoma is hyperendemic in many of the poorest and most rural areas of 37

countries of Africa, Central and South America, Asia, Australia and the Middle
East.

It is responsible for the blindness or visual impairment of about 1.9 million

people. It causes about 1.4% of all blindness worldwide.

Overall, Africa remains the most affected continent, and the one with the most
intensive control efforts.

As of 4 April 2019, 13 countries had reported achieving elimination goals. These

countries are: Cambodia, China, Gambia, Ghana, Islamic Republic of Iran, Iraq, Lao
People’s Democratic Republic, Mexico, Morocco, Myanmar, Nepal, Oman and
Togo. Eight of those countries – Cambodia, Islamic Republic of Iran, Lao People’s
Democratic Republic, Ghana, Mexico, Morocco, Nepal and Oman – had been
validated by WHO as having eliminated trachoma as a public health problem.

Economic impact

The burden of trachoma on affected individuals and communities is enormous.

The economic cost in terms of lost productivity from blindness and visual
impairment is estimated at US$ 2.9–5.3 billion annually, increasing to US$ 8 billion
when trichiasis is included.

Prevention and control

Elimination programmes in endemic countries are being implemented using the

WHO-recommended SAFE strategy. This consists of:

Surgery to treat the blinding stage (trachomatous trichiasis);

Antibiotics to clear infection, particularly mass drug administration of the

antibiotic azithromycin, which is donated by the manufacturer to elimination
programmes, through the International Trachoma Initiative;

Facial cleanliness; and

Environmental improvement, particularly improving access to water and

sanitation.

Most endemic countries have agreed to accelerate the implementation of this

strategy to achieve elimination targets.

Data reported to WHO by Member States for 2018 show that 146 112 people with
trachomatous trichiasis were provided with corrective surgery in that year, and
89.1 million people in endemic communities were treated with antibiotics to
eliminate trachoma.

Elimination efforts need to continue to satisfy the target set by World Health
Assembly resolution WHA 51.11, which is elimination of trachoma as a public
health problem (1). Particularly important will be the full engagement of multiple
actors involved in water, sanitation and socioeconomic development.

WHO response

WHO adopted the SAFE strategy in 1993. WHO’s mandate is to provide leadership
and coordination to international efforts aiming to eliminate trachoma as a public
health problem, and to report on progress towards that target.

In 1996, WHO launched the WHO Alliance for the Global Elimination of Trachoma
by 2020. The Alliance is a partnership which supports implementation of the SAFE
strategy by Member States, and the strengthening of national capacity through
epidemiological surveys, monitoring, surveillance, project evaluation, and
resource mobilization.

(1) Elimination of trachoma as a public health problem is defined as: (i) a

prevalence of trachomatous trichiasis “unknown to the health system” of <0.2% in
adults aged ≥15 years (approximately 1 case per 1000 total population), and (ii) a
prevalence of trachomatous inflammation—follicular in children aged 1–9 years of
<5%, sustained for at least two years in the absence of ongoing antibiotic mass
treatment, in each formerly endemic district; plus (iii) the existence of a system
able to identify and manage incident trachomatous trichiasis cases, using defined
strategies, with evidence of appropriate financial resources to implement those
strategies.