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Ophthalmology (Eye Conditions)

Trachoma

A chronic infectious disease of the eye caused by specific serotypes of Chlamydia trachomatis. It is the leading infectious cause of blindness worldwide, spread through direct contact, fomites, and eye-seeking flies.

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Referral and warning signs

When to refer

Refer ALL patients with Trichiasis (TT) for surgical assessment/management. Refer patients with significant Corneal Opacity (CO) for assessment. Refer cases of active trachoma unresponsive to standard treatment.

Red flags

  • Trichiasis (eyelashes rubbing cornea).
  • Corneal opacity impairing vision.
  • Signs of corneal ulceration (pain, photophobia, discharge with TT).

Signs and symptoms

  • Active Trachoma (Common in children):
  • - Follicular Conjunctivitis (TF): Small white/yellow follicles (lymphoid aggregates) on upper tarsal conjunctiva.
  • - Intense Conjunctival Inflammation (TI): Diffuse redness, thickening, and papillary hypertrophy of upper tarsal conjunctiva obscuring >50% deep tarsal vessels.
  • - Mild itching, irritation, discharge.
  • Cicatricial Trachoma (Common in adults, result of repeated infection):
  • - Trachomatous Scarring (TS): Fibrous white scars on upper tarsal conjunctiva.
  • - Trachomatous Trichiasis (TT): >=1 eyelash rubbing on the eyeball, often due to entropion (inward turning of eyelid margin).
  • - Corneal Opacity (CO): Visible corneal scarring leading to visual impairment/blindness.

Risk factors

  • Living in endemic areas with poor sanitation and hygiene.
  • Poverty.
  • Crowded living conditions.
  • Limited access to clean water.
  • Presence of eye-seeking flies.
  • Young children are main reservoir of active infection.

Diagnosis

Clinical assessment

Diagnosis based on clinical signs using the WHO simplified grading system (TF, TI, TS, TT, CO) by examining the upper tarsal conjunctiva (evert upper eyelid) and cornea.

Investigations

  • Clinical examination is standard for diagnosis and grading.
  • Lab tests (NAAT for Chlamydia) used mainly for surveillance/research.

Management

Non-pharmacological management

  • SAFE Strategy (WHO Recommended Public Health Approach):
  • - Surgery: For trichiasis (TT) to correct entropion/epilate lashes.
  • - Antibiotics: For active infection (TF/TI) and community mass drug administration (MDA).
  • - Facial Cleanliness: Promoting regular face washing, especially in children.
  • - Environmental Improvement: Access to clean water, sanitation, fly control.

Pharmacological treatment

  • Treatment of Active Infection (TF/TI): (LOC: HC3)
  • - Topical: Tetracycline eye ointment 1% BID for 6 weeks.
  • - Systemic (Preferred for public health/MDA, also individual): Azithromycin 1g PO single dose (Adults) OR 20mg/kg PO single dose (Children).
  • - Alternative Systemic: Erythromycin 500mg PO QID for 14 days (Child: 12.5mg/kg QID).
  • Treatment of Complications:
  • - Trichiasis (TT): Requires surgical correction (eyelid rotation surgery) to prevent corneal damage. Epilation (plucking lashes) is temporary relief. Refer for surgery. (LOC: HC4/H)
  • - Corneal Opacity (CO): Corneal transplantation may be possible in specialized centres for severe visual loss (rarely feasible).

Monitoring

Follow-up after treatment for active infection. Monitoring for recurrence of trichiasis after surgery.

Complications

  • Trichiasis (in-turned eyelashes scratching cornea).
  • Corneal abrasion and ulceration.
  • Corneal opacity and scarring.
  • Severe visual impairment and blindness.
  • Dry eye syndrome.

Prevention

  • Implementation of the full SAFE strategy.
  • Improved personal hygiene (face washing).
  • Improved environmental sanitation (latrines, waste disposal).
  • Fly control.
  • Access to clean water.

Patient education

  • Explanation of trachoma and how it spreads.
  • Importance of antibiotic treatment for active infection (completing course).
  • Need for surgery if trichiasis present.
  • Importance of facial cleanliness and hygiene.
  • Environmental improvements needed.
  • Seeking care for eye irritation or vision changes.

Uganda-specific notes

Trachoma is endemic in certain districts, particularly Karamoja region. The SAFE strategy is implemented through national programs. Azithromycin MDA is used. Trichiasis surgery capacity is being built.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.1.4

  • National Trachoma Control Programme Guidelines, MOH Uganda

    (Specific program documents)

For learning and professional reference. Use current local guidance and clinical judgement.

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