Trachoma

Overview

Trachoma (truh-KOH-muh) is a bacterial infection that affects your eyes. It's caused by the bacterium Chlamydia trachomatis. Trachoma is contagious, spreading through contact with the eyes, eyelids, and nose or throat secretions of infected people. It can also be passed on by handling infected items, such as handkerchiefs.

At first, trachoma may cause mild itching and irritation of your eyes and eyelids. Then you may notice swollen eyelids and pus draining from the eyes. Untreated trachoma can lead to blindness.

Trachoma is the leading preventable cause of blindness worldwide. Most trachoma cases occur in poor areas of Africa, where 85% of people with active disease reside. In areas where trachoma is prevalent, infection rates among children under 5 can be 60% or more.

Early treatment may help prevent trachoma complications.

Symptoms

Signs and symptoms of trachoma usually affect both eyes and may include:

• Mild itching and irritation of the eyes and eyelids
• Eye discharge containing mucus or pus
• Eyelid swelling
• Light sensitivity (photophobia)
• Eye pain
• Eye redness
• Vision loss

Young children are particularly susceptible to infection. But the disease progresses slowly, and the more painful symptoms may not emerge until adulthood.

The World Health Organization (WHO) has identified five stages in the development of trachoma:

• Inflammation — follicular. The early infection has five or more follicles — small bumps that contain lymphocytes, a type of white blood cell — visible with magnification on the inner surface of your upper eyelid (conjunctiva).
• Inflammation — intense. In this stage, your eye is now highly infectious and becomes irritated, with a thickening or swelling of the upper eyelid.
• Eyelid scarring. Repeated infections lead to scarring of the inner eyelid. The scars often appear as white lines when examined with magnification. Your eyelid may become distorted and may turn in (entropion).
• In-turned eyelashes (trichiasis). The scarred inner lining of your eyelid continues to deform, causing your lashes to turn in so that they rub on and scratch the transparent outer surface of your eye (cornea).
• Corneal clouding (opacity). The cornea becomes affected by an inflammation that is most commonly seen under your upper lid. Continuous inflammation compounded by scratching from the in-turned lashes leads to clouding of the cornea.

All the signs of trachoma are more severe in your upper lid than in your lower lid. Without intervention, a disease process that begins in childhood can continue to advance into adulthood.

When to see a doctor

Call your doctor if you or your child has itchy or irritated eyes or discharge from the eyes, especially if you live in or recently traveled to an area where trachoma is common. Trachoma is a contagious condition. Treating it as soon as possible helps prevent serious infection.

Causes

Trachoma is caused by certain subtypes of Chlamydia trachomatis, a bacterium that can also cause the sexually transmitted infection chlamydia.

Trachoma spreads through contact with discharge from the eyes or nose of an infected person. Hands, clothing, towels and insects can all be routes for transmission. In developing countries, eye-seeking flies also are a means of transmission.

Risk factors

Factors that increase your risk of contracting trachoma include:

• Crowded living conditions. People living in close contact are at greater risk of spreading infection.
• Poor sanitation. Poor sanitary conditions, inadequate access to water, and lack of hygiene, such as unclean faces or hands, help spread the disease.
• Age. In areas where the disease is active, it's most common in children ages 4 to 6.
• Sex. In some areas, women's rate of contracting the disease is two to six times higher than that of men. This may be attributed to the fact that women have more contact with children, who are the primary reservoir of infection.
• Flies. People living in areas with problems controlling the fly population may be more susceptible to infection.

Complications

One episode of trachoma caused by Chlamydia trachomatis is easily treated with early detection and use of antibiotics. Repeated or secondary infections can lead to complications, including:

• Scarring of the inner eyelid
• Eyelid deformities, such as an inward-folding eyelid (entropion) or ingrown eyelashes (trichiasis), which can scratch the cornea
• Corneal scarring or cloudiness
• Partial or complete vision loss

Prevention

If you've been treated for trachoma with antibiotics or surgery, reinfection is always a concern. For your protection and for the safety of others, be sure that family members or others you live with are screened and, if necessary, treated for trachoma.

Trachoma can occur worldwide but is more common in Africa, Asia, Latin America, the Middle East and the Pacific Rim. When in regions where trachoma is common, take extra care in practicing good hygiene, which can help prevent infection.

Proper hygiene practices include:

• Face washing and hand-washing. Keeping faces and hands clean may help break the cycle of reinfection.
• Fly control. Reducing fly populations can help eliminate a source of transmission.
• Proper waste management. Properly disposing of animal and human waste can reduce breeding grounds for flies.
• Improved access to water. Having a fresh water source nearby can help improve hygienic conditions.

No trachoma vaccine is available, but prevention is possible. The WHO has developed a strategy to prevent trachoma, with the goal of eliminating it by 2020. While the goal hasn't been entirely achieved, trachoma cases have declined sharply. The strategy, titled SAFE, involves:

• Surgery to treat advanced forms of trachoma
• Antibiotics to treat and prevent the infection
• Facial cleanliness
• Environmental improvements, particularly in water, sanitation and fly control

Diagnosis

Your doctor can diagnose trachoma through a physical examination or by sending a sample of bacteria from your eyes to a laboratory for testing. But lab tests aren't always available in places where trachoma is common.

Treatment

Trachoma treatment options depend on the stage of the disease.

Medications

In the early stages of trachoma, treatment with antibiotics alone may be enough to eliminate the infection. Your doctor may prescribe tetracycline eye ointment or oral azithromycin (Zithromax). Azithromycin appears to be more effective than tetracycline, but it's more expensive.

The World Health Organization (WHO) recommends giving antibiotics to an entire community when more than 10% of children have been affected by trachoma. The goal of this guideline is to treat anyone who has been exposed to trachoma and reduce the spread of trachoma.

Surgery

Treatment of later stages of trachoma — including painful eyelid deformities — may require surgery.

In eyelid rotation surgery (bilamellar tarsal rotation), your doctor makes an incision in your scarred lid and rotates your eyelashes away from your cornea. The procedure limits the progression of corneal scarring and may help prevent further loss of vision.

If your cornea has become clouded enough to seriously impair your vision, corneal transplantation may be an option that could improve vision.

You may have a procedure to remove eyelashes (epilation) in some cases. This procedure may need to be done repeatedly.

Preparing for an appointment

You're likely to start by seeing your primary care doctor if you or your child has symptoms of trachoma. Or you may be referred immediately to an eye specialist (ophthalmologist). When you make the appointment, ask if you need to do anything in the meantime, such as keeping your child home from school or child care.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment make a list of:

• Symptoms of the person seeking treatment, including any details about changes in vision
• Key personal information, such as recent travel, use of new makeup products, and a change of contacts or glasses
• All medications and any vitamins or supplements that the person seeking treatment is taking
• Questions to ask the doctor

For eye irritation, some basic questions to ask your doctor include:

• What's the most likely cause of these symptoms?
• Other than the most likely cause, what are other possible causes for these symptoms?
• What kinds of tests are needed?
• Is the condition likely temporary or chronic?
• What is the best course of action?
• Will this condition cause any long-term complications?
• Should my child or I follow any restrictions, such as staying home from school or work?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Is there a generic alternative to the medicine you're prescribing for me?
• Do you have any brochures or other printed material for me? What websites do you recommend visiting?

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

• Have you ever had a similar problem?
• When did you first begin experiencing symptoms?
• How severe are your symptoms? Do they seem to be getting worse?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Is anyone else in your household having similar symptoms?
• Have you been treating your symptoms with any medications or drops?

What you can do in the meantime

While you are waiting for your appointment, practice good hygiene to reduce the possibility of spreading your condition by taking these steps:

• Don't touch your eyes without first washing your hands.
• Wash your hands thoroughly and frequently.
• Change your towel and washcloth daily, and don't share them with others.
• Change your pillowcase often.
• Discard eye cosmetics, particularly mascara.
• Don't use anyone else's eye cosmetics or personal eye care items.
• Discontinue wearing your contact lenses until your eyes have been evaluated; then follow your eye doctor's instructions on proper contact lens care.
• If your child is infected, have him or her avoid close contact with other children.