Continuing Education Activity

Trachoma is an eye disease caused by infection with the Chlamydia trachomatis bacterium and is one of the leading causes of blindness worldwide today. The infection causes roughening and scarring of the eyelid's inner surface and erosion of the corneal surface. Preventative screening measures and early diagnosis are fundamental. Untreated ocular complications can eventually lead to blindness.  Screening and proper hygiene education programs have been initiated across the globe to limit and irradicate trachoma, especially in underdeveloped countries. Preventative and empirical antibiotic treatment, adequate patient assessment, and surgical options for ocular complications are essential when dealing with patients at risk of contracting this infection. Facial cleanliness, environmental improvements to sanitation, clean drinking water, and control of flies are among the strategies used to address the prevention of this severe ocular disease. This activity reviews the characteristics of trachoma, outlines its evaluation and management, highlights the interprofessional team's role in improving patient care, and provides healthcare professionals with the knowledge and tools to optimize outcomes for this prevalent condition. 

Objectives:

• Identify the etiology and epidemiology of trachoma.

• Assess the presentation of a patient and physical exam findings associated with trachoma.

• Apply prevention, treatment, management, and education strategies for trachoma.

• Collaborate with the interprofessional team to educate, treat, and monitor patients with trachoma to improve patient outcomes and limit complications, as well as implement education, environmental, and hygiene programs to prevent trachoma infection in areas at risk.

Introduction

Trachoma is an eye disease caused by infection with the Chlamydia trachomatis bacterium.[1][2] This bacterial illness mostly affects the conjunctiva, and, in the absence of treatment, the natural history of trachoma is marked by recurrent cycles of infection, inflammation, and scarring, which frequently lead to permanent blindness.

The World Health Organization (WHO) has classified 20 illnesses and disease groupings as neglected tropical diseases, including trachoma, which is considered the most frequent infection that causes visual impairment in underprivileged countries.[3] 

Trachoma has diminished in most North American and European countries as living standards have increased.[4] Intentional management measures during the past few decades have been linked to sharp drops in the disease's worldwide burden.[5] However, the prevalence has persisted in certain cultures after lengthy and intense interventions.

There are two possible stages of this disease.

First-phase symptoms include persistent keratoconjunctivitis (see Image. Bacteria conjunctivitis), which consists of an inflammation of the conjunctiva known as active trachoma.[6] This is caused by recurrent infection with conjunctival strains of the bacterium Chlamydia trachomatis.

Periods of intense conjunctival inflammation cause eyelid scarring, which marks the beginning of the second stage of the illness. Trichiasis is a disorder in which the eyelashes rotate inward and come in touch with the eyeball due to scarring.[7] A condition called entropion, in which some or all of the eyelid edge is curled inward can coexist with trichiasis.[8] Inverted eyelashes that scratch the cornea increase the risk of corneal opacity and visual problems, leading to blindness in severe chronic conditions.[9] Any of these Chlamydia trachomatis-induced pathological processes or clinical manifestations indicate that trachoma is present (see Image. Trichiasis).

It is essential to understand how trachoma is transmitted to implement preventative measures. Primary means of transmission for trachoma include direct and indirect contact with secretions from infected people's noses and eyes. Numerous factors contribute to the spread of trachoma, such as crowded living circumstances, inadequate cleanliness, and restricted access to medical treatment. In addition, the disease can spread among populations due to socioeconomic position, climate, and cultural customs. Studies have reported these as means of transmission as the 'three F's':[10]

• Face-to-Face Contact: Close contact with an affected person can quickly transfer the highly infectious trachoma disease. This frequently occurs when people kiss, embrace, or share intimate objects like towels and washcloths.[11] The bacteria can spread from person to person by exchanging infected nasal and ocular secretions during face-to-face contact.
• Flies: Flies are a major factor in the spread of trachoma, especially species such as Musca sorbens.[12] These flies are attracted to the secretions from people's noses and eyes and serve as mechanical vectors as they carry the bacteria on their bodies and transfer the infection from one person to another. This route of transmission is particularly prevalent in unsanitary places where flies are abundant.
• Fomites: The bacteria can also spread through polluted inanimate items or surfaces.[13] Infected people may transfer the bacterium to linens, towels, or everyday cutlery. Others who come into contact with these contaminated fomites and then touch their face or eyes risk contracting the bacteria.

Etiology

The causative agent of trachoma, the Chlamydia trachomatis bacterium, is transmitted from infected to uninfected individuals in numerous ways: direct eye-to-eye spread during close contact, hand-eye contact, indirect spread on fomites, and transmission by eye-seeking flies.[14] 

Several factors, including congested living arrangements, poor hygiene habits, and restricted access to sanitary facilities and clean water, contribute to the spread of trachoma.[15] These circumstances facilitate the growth of Chlamydia trachomatis, enabling the bacteria to live on in communities and continue the infection cycle. Understanding the origins of trachoma is crucial for formulating focused measures meant to stop the disease's spread, address ongoing infections, and lessen its long-term effects.

Human disorders caused by Chlamydia trachomatis include ocular infections like trachoma and infections contracted through sexual activity.[16] Trachoma primarily targets the conjunctiva. The bacteria's life cycle and the host's immune system interact intricately in the genesis of trachoma.

When Chlamydia trachomatis enters the eye, the infection starts. The bacteria enter the conjunctiva's epithelial cells and go through a biphasic developmental cycle there. The infectious form of the bacteria, known as the elementary bodies, first binds to and penetrates the host cells.[17] Once inside, they undergo differentiation to become reticulate bodies, which multiply in the cytoplasm of the host cell.[18]

The typical clinical signs of trachoma, such as conjunctival inflammation, follicular enlargement, and, ultimately scarring of the eyelids, are caused by the localized inflammatory response that the reticulate bodies generate during their replication.[19] The pathophysiology and regulation of trachoma are significantly influenced by the immunological response that the infection triggers. Even while an efficient immune response can aid in the infection's clearance, recurrent or persistent infections can cause chronic inflammation and scarring, which can result in long-term problems such as trichiasis and blindness.[20]

Epidemiology

Trachoma is considered to be the third leading cause of blindness worldwide after cataracts and glaucoma.[21] Almost 8 million people are either blind or have severe visual impairment due to trachoma, according to some estimates.[22] Africa, some regions of the Middle East, the Indian subcontinent, Southeast Asia, and South America show the highest prevalence today.[23] Studies have reported that in June 2021 almost 2 million people across the world were becoming blind because of trachoma, and an estimated 137 million people are at risk of trachoma.[24] Epidemiological studies in 2023 showed that approximately 116 million people worldwide lived in areas that warranted preventative measures for trachoma prevention and elimination and that only 18 of the known 62 trachoma-endemic countries had managed to eradicate the disease as a public health problem.[25][26]

Targeted public health measures have significantly reduced the prevalence of trachoma, a disease that was once widespread in many regions of the world. Nonetheless, it continues to be an issue in some areas, especially in low- and middle-income nations with restricted access to hygienic and medical services. Numerous factors, such as socioeconomic level, geographic location, and cultural habits, have an impact on the epidemiology of trachoma.

Numerous countries that still require active preventative measures for trachoma are from Africa.[27] North America and Europe showed a significant reduction in disease prevalence due to general improvement in living standards rather than specific interventions.[14] Although the goal of eradicating trachoma worldwide by 2020 was not achieved, there is still hope, with the implementation of treatment and preventative programs in endemic regions to reach the goal of elimination of this disease by 2030.[28]

Trachoma disproportionately affects women and children.[29] The reasons behind this gender gap include the fact that women are more likely to be exposed to contaminated water and unsanitary conditions due to their involvement with childcare and household duties.[30] Studies have shown that the odds ratio can be 1.8 to 4 times higher in females.[31]

Another significant factor influencing the occurrence of trachoma is age, with children under the age of ten having the largest burden. Due to their limited capacity to practice basic hygiene and close contact with sick individuals, young children are especially prone to trachoma. In this age period, the prevalence of active trachoma usually peaks before falling into adolescence and maturity.[32] On the other hand, people who have untreated childhood infections run the danger of long-term consequences like blindness and trichiasis.

Although the prevalence of trachoma has dramatically decreased in many parts of the world, it still poses a serious threat to public health in some areas, especially for marginalized groups that have little access to sanitary facilities and medical care. Targeted treatments that enhance facial cleanliness, increase access to clean water, and provide antibiotics to a large population in endemic locations are necessary to eradicate trachoma as a public health issue.

Pathophysiology

The pathophysiology of trachoma is characterized by the development of conjunctival scarring, which results from recurrent cycles of tissue repair and inflammation.[33] Extracellular matrix proteins like collagen and fibronectin are deposited throughout the scarring process, causing fibrosis and contraction of the conjunctival tissue.[33] If treatment for this fibrotic scarring is not received, it may result in eyelid entropion (turning inward of the eyelid) and trichiasis (misalignment of the lashes), which may cause corneal abrasions, ulcerations, and eventually blindness.[34] Bacterial infection, inflammatory reactions, tissue remodeling, and host factors interact intricately in the pathophysiology of trachoma (see Image. Trichiasis).[35] 

Trachoma is associated mainly with infection by serovars A, B, Ba, and C of the Chlamydia trachomatis bacterium. Serovars D-K are conventionally associated with adult inclusion conjunctivitis. Other species of the Chlamydiaceae family, such as Chlamydophilia psittaci and Chlamydophila pneumoniae, have also been implicated. 

Trachoma infection occurs as an initial 'active' inflammatory stage, which is more common in preschool children. This may be mild and only result in trachomatous conjunctivitis (follicular/papillary). The presence of papillary hypertrophy characterizes intense cases.

Recurrent infection, however, elicits a chronic immune response. The presence of intermittent chlamydial antigens provokes this reaction. It is a cell-mediated delayed hypersensitivity (Type 4) response. This repeated insult leads to scarring and other forms of permanent damage. This chronic 'cicatricial' stage most commonly occurs in middle age. Most of the scarring in this stage is prominent on the upper tarsal plate. This scar tissue contracts, leading to in-turning of the lid, causing entropion, and this entropion eventually leads to trichiasis. Entropion is the most common cause of trichiasis in trachoma patients. Trichiasis, however, may also result from aberrant lashes or metaplastic lashes in rare cases. Ultimately, blinding corneal opacification can develop.

The obligate intracellular bacterium Chlamydia trachomatis and the host's immune system interact intricately in the pathophysiology of trachoma, leading to conjunctival scarring, tissue destruction, and increasing inflammation.[36] The conjunctival epithelial cells are the site of attachment and invasion for the elementary bodies of C. trachomatis during the early infection. These elementary bodies become reticulate bodies after they are inside the host cell, where they multiply inside the infected cells' cytoplasm.[18][37] As a result of this intracellular multiplication, immune cells such as neutrophils, macrophages, and lymphocytes infiltrate the conjunctival tissue, causing an inflammatory response.

Proinflammatory cytokines and chemokines are released as a result of the inflammatory cascade that the C. trachomatis infection stimulates, intensifying the immune response and causing tissue damage. On the conjunctival surface, follicles (aggregations of lymphocytes, plasma cells, and epithelial cells) form due to chronic inflammation. The follicles have the potential to develop into papillary hypertrophy, which is typified by the papillae conjunctivae becoming enlarged and hyperplasia.[38]

Understanding these mechanisms is imperative to devising focused interventions that try to stop the disease from worsening and lessen the amount of blindness caused by trachoma.

Histopathology

In children who have been infected with Chlamydia trachomatis, active trachoma is common. The classic findings include a hyperplastic conjunctival epithelium and widespread inflammatory infiltrates such as B and T lymphocytes, neutrophils, macrophages, and plasma cells.[39] A generalized increase in collagen types 1, 3, and 4 is seen on staining for collagen subtypes. Studies have also revealed the deposition of new type 5 fibers.[40] In adults with scarring, however, the conjunctival epithelium is atrophic, and goblet cells are lost.[41] A thick scar of type 5 collagen replaces the loose subepithelial stroma. These newer fibers get attached to the tarsal plate tightly. This eventually leads to distortion. Conjunctival inflammation is often observed.

The normal conjunctiva undergoes histological and immunological changes in the presence of active trachoma and trachomatous scarring.[38] Goblet cells that release mucin are scattered throughout the non-keratinized, stratified epithelium of three to five cell layers that comprise a normal conjunctiva. The epithelium is covered with the tear film. Connective tissue components such as lymphoid cells and blood arteries can be found in the deeper lamina propria. A mixed inflammatory cell infiltration and telangiectasia of capillaries and tiny venules are signs of inflammation caused by a Chlamydia trachomatis infection. In the lamina propria, B cells comprise most of the mass and the core of lymphoid follicles, which are composed of T cells, macrophages, and B cells.[42] When large enough, lymphoid follicles can be observed in the everted tarsal conjunctivae, where they deform the shape of the overlaying epithelium. Goblet cells are diminished in the scarred conjunctiva. The volume of the tear film is decreased, and its composition is altered. The lamina propria exhibits a scar that is becoming more and more disordered. The tarsal plate and extracellular matrix can also include scars.

Chronic inflammation brought on by trachoma progression results in papillary hypertrophy, typified by larger and hyperplastic conjunctival papillae.[43] These papillae have more inflammatory cells, including lymphocytes and plasma cells, and are coated in a layer of squamous epithelium. In extreme situations, there may be significant collagen deposition, fibrosis, scarring, and loss of normal tissue architecture in the conjunctiva.[44]

Follicular conjunctivitis, or the development of follicles inside the conjunctival tissue, is one of the distinctive hallmarks of trachoma histology.[45] Typically, a mantle of lymphocytes and epithelial cells surrounds the core germinal center of these follicles. When trachomatous follicles are examined histologically, the development of germinal centers, lymphocytic infiltration, and hypertrophy of the surrounding epithelium are frequently observed. Histopathological examination of tissues affected by trachoma may show structural anomalies such as conjunctival scarring, fibrosis, metaplastic alterations, and inflammatory changes. The characteristic of conjunctival scarring is the replacement of normal tissue architecture by fibrous tissue, which leads to the rupture of the epithelial barrier and loss of goblet cells. Entropion, trichiasis, and other abnormalities of the eyelids can result from fibrotic alterations.[46]

Overall, histopathological examination of tissues affected by trachoma provides valuable insights into the underlying mechanisms of disease progression and the structural changes associated with chronic inflammation and scarring. This microscopic analysis helps guide clinical management and therapeutic interventions to prevent further tissue damage and preserve vision in affected individuals.

History and Physical

History

Patients with trachoma will usually present with redness of the eyes, itching and irritation of the eyes and eyelids, discharge from the eyes, swelling of the eyelids, eye pain, and photophobia. It is important to determine the duration of the symptoms. When gathering the patient's medical history, healthcare professionals should ask about symptoms that could indicate trachoma and potential risk factors for the illness. A history of travel to endemic areas (e.g., North Africa, Middle East, India) should be obtained. Concomitant vaginitis, cervicitis, or urethritis should be ruled out if the patient is sexually active.

Physical Examination

Healthcare professionals should concentrate on looking for indications of trachoma in the eyes and surrounding structures(see Image. Trichiasis).[19] Essential elements of the assessment consist of:[47]

• Evaluation of conjunctival follicles: Tiny, elevated nodules that resemble follicles are present on the conjunctival surface and indicate trachoma. These follicles might be dispersed widely or clustered in the eye's inferior fornix.
• Examining the conjunctiva and eyelids: Symptoms of conjunctival inflammation include redness, swelling, and discharge. Check the eyelids for signs of entropion, the inward bending of the eyelid, or trichiasis, which can cause corneal abrasions and vision problems.  
• Visual acuity assessment: Use standard testing tools such as the Snellen chart or visual acuity cards to identify any impairment.
• Assessment of conjunctival scarring: Prolonged inflammation in trachoma patients may cause conjunctival scarring, which can include fibrotic bands, alterations in tissue texture, and loss of normal architecture.
• Analyzing the integrity of the cornea: Examine the cornea for any signs of opacities, abrasions, or ulcerations. These conditions can be brought on by persistent irritation from trichiasis or corneal exposure from abnormalities in the eyelids.
• Evaluation of local lymph nodes and preauricular lymph nodes: A palpator to feel for any enlargements that might point to chlamydial infection-related lymphadenopathy.

A thorough medical history and physical examination are essential for trachoma diagnostic evaluation. Identifying distinctive indications and risk variables for the ailment can direct suitable diagnostic examinations and therapeutic measures to avert problems and maintain visual integrity in impacted individuals. 

Active Trachoma[48][49]

• Mixed follicular/papillary conjunctivitis. There may be some associated mucopurulent discharge.
• Superior epithelial keratitis is commonly seen.
• Corneal vascularization may lead to the development of pannus.

Cicatricial Trachoma[10][50]

• Stellate or linear conjunctival scars, or broad confluent scars (sometimes referred to as Arlt's line) in advanced stages. Although the entire conjunctiva is involved, the effects are more prominent on the upper tarsal plate.
• When the follicles in this region resolve, a row of shallow depressions called Herbert's pits[51] might be formed in the superior limbus.
• Trichiasis, distichiasis, corneal vascularization, and entropion may be seen.
• Severe corneal opacification can occur.
• Destruction of goblet cells and the ductules of the lacrimal glands eventually leads to a dry eye.

Evaluation

The diagnosis of trachoma relies chiefly on history and the clinical signs, as seen on slit-lamp examination. While many diagnostic tests have been developed to detect the organism, no 'gold standard' investigation exists.[52][53] Some of the tests currently used are:

Laboratory Examinations:

• Giemsa staining of smears of conjunctival cells to demonstrate the chlamydial inclusion body.
• Cell cultures and microscopy.
• Microbiological testing: Polymerase chain reaction (PCR) and nucleic acid amplification tests (NAATs) are two common molecular techniques used in laboratory confirmation of an active Chlamydia trachomatis infection. Affected individuals provide conjunctival swabs or scrapings, which are examined for the presence of C. trachomatis DNA. These methods are usually considered in research settings since they are expensive and complex for routine clinical use.
• Serological testing: Antibodies against Chlamydia trachomatis can be found in serum samples using serological assays such as enzyme-linked immunosorbent assays (ELISAs) or immunofluorescence assays (IFAs). Nonetheless, epidemiological research rather than clinical diagnosis is the main application for serological testing.

Clinical Evaluation:

• Trachoma severity grading: Based on clinical indicators seen during the inspection, the World Health Organization (WHO) created a streamlined WHO grading system to categorize trachoma severity. Five categories, which include trachomatous trichiasis (TT), corneal opacity (CO), trachomatous inflammation follicular (TF), trachomatous inflammation intense (TI), and trachomatous scarring (TS), are used in this approach to classify trachoma.[54]
• Trichiasis assessment:[47] A direct flashlight examination is frequently used to find ingrown eyelashes touching the cornea to determine the presence and severity of trichiasis or eyelash misalignment. The number and position of trichiatic eyelashes are recorded to help with surgical planning.

 Radiography and Imaging Techniques:

• Radiographic imaging: Radiographic testing such as optical coherence tomography (OCT) or ultrasonography can be utilized to evaluate structural abnormalities in the eye when there is corneal opacity or scarring.
• Extra diagnostic testing: Conjunctival photography and mobile health technology are examples of supplementary testing that can be used in some situations to record clinical observations, track the course of an illness, and assess treatment effectiveness. Modern techniques helpful for trachoma diagnosis include photography,[55] artificial machine learning approaches,[56] and automated deep learning methods.[57]

Treatment / Management

The SAFE strategy(Surgery, Antibiotics, Facial cleanliness, and Environmental improvement) recommended by WHO encompasses surgery for trichiasis, antibiotics, facial hygiene, and environmental improvement.[58]

• Antibiotics should be administered to the patient and all the family members.[59]
  • A single dose of azithromycin (20 mg/kg up to 1g) is the treatment of choice. Since azithromycin has a convenient dosing regimen and is very effective, it is the recommended antibiotic when taken orally in single doses or as part of a mass drug administration (MDA) approach.
  • Erythromycin 500 mg twice daily for 14 days or doxycycline 100 mg twice daily for 10 days may be considered (use tetracyclines with caution in pregnancy/breastfeeding/children).
  • 1% tetracycline ointment may be used topically. However, it is less effective than oral treatment.
• Facial cleanliness is important.[60]
• Environmental improvement includes proper sanitation, access to clean drinking water, control of flies, and other factors.[61]
• Surgery may be required to relieve entropion and trichiasis and maintain functional and complete lid closure (see Image. Repair of trachomatous eyelids).[62] 

Management of Trichiasis and Cicatricial Entropion[63][64][63]

Trachoma is the most common infectious cause of blindness worldwide. Conjunctival scarring, with ensuing trichiasis and entropion, results in corneal scarring and eventual blindness. The proper management of trichiasis and cicatricial entropion in trachoma is vital to prevent visual disability. 

Treatment of lashes

There is a movement to teach simple procedures to ancillary medical team members in areas where this disease is endemic so that early intervention may be instituted and corneal injury and scarring prevented.[65] 

• Simple epilation
• Destruction of eyelash follicles
  • Radiofrequency ablation of follicles
  • Cryotherapy to lash roots
  • Electrocautery
  • Laser (argon, other types) treatment of lash roots
  • Irradiation (infrequently used now)
• Surgical excision of roots of eyelashes

Surgical Repair of Trichiasis and Entropion (see Image. Repair of trachomatous eyelids)[66][67]

• Tarsal rotation with bilamellar tarsal rotation or anterior lamellar tarsal rotation
• Tarsal repositioning with tarsal advancement with or without tarsal rotation
• Posterior lamellar lengthening with the advancement of the posterior lamella with or without an interpositional mucous membrane or tarsal graft
• Surgery to the anterior lamellar and eyelid margin
  • anterior lamellar repositioning 
  • eyelid margin split and eversion
  • anterior tarsal wedge resection (or grooving) and eversion
• Tarsectomy

Differential Diagnosis

The clinical characteristics of trachoma can be mimicked by several ocular disorders, making the differential diagnosis difficult. To guarantee proper management and avoid needless therapy, it is imperative to consider these alternative diagnoses.[68] 

• Allergic Conjunctivitis: The symptoms of allergic conjunctivitis can mimic the clinical signs of trachoma, including redness, itching, tearing, and swelling of the eyelids. Allergic conjunctivitis is usually bilateral and linked to past exposure to allergens such as dust, pollen, or pet dander.

• Bacterial Conjunctivitis (see Image. Bacterial conjunctivitis): Acute bacterial conjunctivitis and trachoma share similar clinical manifestations, such as crusting on the eyelids, discharge, and redness. Bacterial conjunctivitis frequently manifests acutely, with symptoms that appear quickly and go away on their own. Repeated infections and persistent inflammation typify trachoma.

• Viral Conjunctivitis: Adenovirus or herpes simplex virus-induced viral conjunctivitis can mimic trachoma symptoms such as photophobia, tearing, and redness. Nonetheless, systemic symptoms such as fever and malaise are commonly linked to viral conjunctivitis, which may aid in distinguishing it from trachoma.

• Dry Eye Syndrome: Trachoma-like symptoms such as redness, ocular discomfort, and a feeling of a foreign body may coexist with symptoms of dry eye syndrome. However, insufficient tear production or instability of the tear film, which results in dryness and pain on the ocular surface, are the hallmarks of dry eye syndrome.

• Pterygium and pinguecula: Pterygium and pinguecula are benign growths on the conjunctiva that resemble trachoma and can cause redness and irritation. These lesions are usually unilateral and situated next to the limbus, differentiating them from the diffuse conjunctival inflammation in trachoma. 

• Giant Papillary Conjunctivitis (GPC): This is frequently linked to contact lens wear or ocular prostheses. GPC is an inflammatory conjunctivitis characterized by the production of giant papillae. Although GPC might have symptoms such as redness and itching similar to trachoma, it is usually bilateral and has a history of ocular surface irritation.

• Atopic keratoconjunctivitis (AKC): This is a persistent inflammatory condition that affects the cornea and conjunctiva and is linked to atopic dermatitis. Individuals suffering from AKC may exhibit signs of inflammation of the conjunctiva, including redness, itching, and photophobia, which can be mistaken for trachoma. On the other hand, AKC is usually bilateral and can be linked to additional systemic atopic symptoms.

• Other less frequent ocular manifestations that share several signs and symptoms of trachoma include chronic follicular conjunctivitis, parinaud oculoglandular conjunctivitis, silent dacryocystitis, contact lens-related problems, and other causes of entropion and trichiasis.

Staging

The World Health Organization (WHO) recommends a simplified grading system for trachoma.[69] 

• Trachomatous inflammation, follicular (TF): The central region of the upper tarsal conjunctiva has five or more lymphoid follicles, each measuring at least 0.5 mm in diameter.

• Trachomatous inflammation, intense (TI): There are marked inflammatory changes in the conjunctiva, such as the presence of inflammatory thickening throughout the entire tarsal conjunctiva or a marked inflammatory thickening of the tarsal conjunctiva that obscures over half of the typical deep tarsal vessels.

• Trachomatous scarring (TS): The tarsal conjunctiva has scarring. This scarring can appear as fine, white, horizontal lines parallel to the lid edge or as linear lines. In addition, scarring may result in trichiasis (misaligned eyelashes) and deformity of the conjunctival surface, and transparency may result from scarring.

• Trachomatous trichiasis (TT): The existence of at least one eyelash touching the globe or proof that inverted eyelashes have recently been removed. Recurrent episodes of infection, inflammation, and scarring are linked to TT, which can result in corneal abrasions and abnormalities of the eyelids.

• Corneal opacity (CO): The most advanced stage of trachoma, CO is marked by corneal opacification, which, if ignored, can cause blindness and vision impairment.

Prognosis

The stage of the disease, comorbidities such as trichiasis and corneal opacities, access to healthcare, and the use of therapy and prevention strategies are some of the variables that affect the prognosis of trachoma. Due to international efforts to contain and eradicate the disease, such as the adoption of the SAFE approach (Surgery, Antibiotics, Facial Cleanliness, and Environmental Improvements), the prognosis for trachoma has generally improved recently. Several studies have shown significant reductions in the prevalence of active disease as a result of practicing this strategy.[70][71]

• Early Stage Trachoma: With prompt and adequate therapy, the prognosis is generally good for trachoma patients in their early stages (TF and TI). Azithromycin and topical tetracycline are examples of antibiotics that can successfully eradicate Chlamydia trachomatis infections and lower the chance of the illness worsening. Programs for health education that encourage maintaining a clean face and making environmental modifications aid in reducing the spread of the disease among communities and preventing reinfection.

• Advanced Stage Trachoma: If problems such as trichiasis and corneal opacities occur, the prognosis for advanced trachoma with scarring (TS) may not be as good. If left untreated, trichiasis, by misaligned eyelashes, can cause corneal abrasions, ulcerations, and blindness. Blindness can be avoided, and results can be significantly improved with surgical correction of trichiasis using techniques such as posterior lamellar tarsal rotation (PLTR) or bilamellar tarsal rotation (BLTR).

• Issues and the Extended Prognosis: The long-term prognosis of trachoma can be greatly impacted by comorbidities such as corneal opacities, corneal neovascularization, and irreversible vision loss. If left untreated, corneal opacity and scarring resulting from recurring infections and persistent inflammation can cause blindness or visual impairment. Nonetheless, some degree of vision restoration might be achievable with the appropriate medical and surgical procedures, including corneal transplantation in extreme circumstances.

• Public health interventions and international initiatives: Worldwide efforts to manage and eradicate trachoma have improved the disease's prognosis. Globally, trachoma prevalence and blindness have significantly decreased due to initiatives like the International Trachoma Initiative (ITI)[72] and the WHO Alliance for the Global Elimination of Trachoma by 2020.[73][74] The implementation of mass drug administration (MDA) campaigns, surgical outreach initiatives, and community-based treatments has resulted in enhanced patient outcomes and improved access to care.[75]

Although trachoma is still a serious public health issue in many areas, especially those with limited resources, improvements in diagnosis, prevention, and treatment have improved the prognoses and outcomes for those who are afflicted with the illness. To accomplish worldwide trachoma elimination and avoid needless blindness in afflicted populations, sustained funding for trachoma control programs, research, and advocacy initiatives is needed.[76]

Complications

If undiagnosed or improperly managed, trachoma can cause several issues that can eventually lead to blindness and permanent vision impairment.[77] Recurring infections, persistent inflammation, and disease-related tissue scarring frequently bring on these side effects. Key trachoma complications include the following (see Image. Trichiasis):

• Trichiasis: This is the misalignment of the lashes, which causes the cornea's surface to wear down with each blink. Corneal abrasions, ulcerations, and scarring can result from misdirected eyelashes that irritate and rub the cornea over time. Trichiasis can lead to corneal opacities and blindness if treatment is not received.

• Entropion: When the eyelid rotates inward, the lashes scrape on the eye's surface, resulting in discomfort, abrasions to the cornea, and perhaps blindness if treatment is not received. Entropion is a consequence of advanced trachoma in which the eyelids compress inward due to scarring and recurrent infections.

• Distichiasis: This can be seen when an extra row of lashes develops on the edge of the eyelid and points in the direction of the eye. These unusual eyelashes can cause pain, redness, and even corneal injury by irritating the cornea. It may happen as a result of severe trachoma-related eyelid deformation and scarring.

• Dry eye syndrome: This can be brought on by trachoma's damaging effects on the cornea and conjunctiva, which reduce tear production and compromise the integrity of the tear film. Symptoms of dry eyes include redness, burning, itching, and impaired vision. Additionally, chronic dryness increases the risk of infections and other issues in the eye.

• Superadded bacterial infection: The trachoma-related chronic inflammation and scarring can impair the eye's immune system, increasing the risk of secondary bacterial infections. If left untreated, these infections can worsen trachoma symptoms and result in consequences, including conjunctivitis, corneal ulcers, and even blindness (see Image. Bacterial conjunctivitis). Effective management of these superadded bacterial infections frequently requires antibiotic treatment.

• Corneal Opacities: Usually a consequence of trachoma, corneal opacities are caused by long-term inflammation and corneal scarring. These opacities may cause reduced visual acuity and possibly irreversible vision loss by interfering with light's ability to enter the eye. Dense corneal opacities can obstruct the pupil and cause central vision impairments in severe situations.

• Corneal Neovascularization: A complication of trachoma may be corneal neovascularization, chronic inflammation, and vascularization of the cornea. Neovascularization of the cornea can alter the eye's natural optical characteristics, compromising corneal transparency and perhaps causing visual impairment.

• Conjunctival Scarring: Recurrent episodes of inflammation in trachoma may cause the conjunctiva to fibrosis and scar, altering the architecture and texture of the surrounding tissue. Scarring on the conjunctiva may worsen ocular surface dryness, reduce the tear film's stability, and increase the risk of corneal problems and subsequent infections.

• Blindness: Trachoma can result in irreversible blindness if ignored or improperly handled, especially in situations of severe trichiasis, corneal opacities, or other issues impacting visual function. For those who become blind from trachoma and their communities, the disease can have a significant negative impact on their socioeconomic status and quality of life.

Deterrence and Patient Education

Patient education should be centered around the avoidance of overcrowding and poor hygiene. Hand-eye contact should be kept to a bare minimum. Frequently scratching the eyes should be avoided. Practicing good hygiene, particularly regularly washing hands, should be encouraged. Education should include the value of maintaining good facial hygiene, which includes frequent face washing with soap and water to stop the transmission of Chlamydia trachomatis-containing ocular secretions. Populations in endemic regions should be encouraged to dry their faces with clean towels or tissues and refrain from sharing personal objects like washcloths and towels. Frequent hand washing should be stressed to prevent the bacteria from being transferred from the feces to the mouth. This is especially important before handling food and after using the restroom. To lower environmental contamination and the risk of trachoma transmission, enhancements to the water, sanitation, and hygiene (WASH) infrastructure, including access to clean water sources, sanitation facilities, and waste management systems, should be implemented. The upgrading of sanitation infrastructure and the promotion of appropriate waste disposal techniques as part of community-led environmental sanitation projects are fundamental.

Individuals living in at-risk areas should be informed about trachoma's warning signs and symptoms, such as redness, irritation, discharge, and blurred vision, to encourage treatment-seeking behavior and early detection. Patients need to be well informed on the significance of obtaining treatment for eye infections and other ocular diseases from qualified medical professionals, highlighting the availability of efficient medications such as antibiotics. Community-based health education programs involving the community in prevention and control initiatives can help prevent trachoma and treat patients. Culturally relevant resources and communication techniques need to be considered.

Infected people should immediately be quarantined from the rest of their family members, friends, and associates. Once the diagnosis has been made, the patient should be educated to properly understand the disease, its means of spread, and preventive measures. Patients should also be warned about the possible complications of non-compliance to treatment or treatment failure.

Fundamental initiatives are needed to enable people and communities to adopt proactive measures toward trachoma prevention and control by implementing comprehensive deterrence and patient education programs guided by national and international recommendations. The aim of eliminating trachoma worldwide and enhancing the health and well-being of those afflicted with the illness depends on these initiatives.

Pearls and Other Issues

The most common infectious cause of blindness in the world, trachoma mainly affects people living in underdeveloped areas with limited access to healthcare and sanitary facilities. Chlamydia trachomatis, the bacteria that causes the disease, is spread by contact with ocular and nasal secretions, contaminated hands, and fomites. Focal conjunctivitis (TF) and severe inflammation (TI) are the initial symptoms of trachoma. Blindness caused by trachoma is the most common cause of blindness by infection. Scarring (TS) and potentially blinding consequences, including trichiasis and corneal opacities (TT), come next. The SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) forms the basis of trachoma control techniques. This approach involves mass pharmacological administration of antibiotics, surgical correction of trichiasis, and hygiene promotion.

Patients with trachoma may require referral to ophthalmologists or other qualified eye care professionals for additional assessment and treatment, especially if they have corneal opacities or trichiasis. Individuals suffering from active trachoma might require antibiotic therapy to eradicate the infection and stop the disease's advancement, whereas those experiencing complications would need surgery to save their vision.

In endemic areas, trachoma management attempts may be hampered by insufficient resources, cultural hurdles, and lack of access to healthcare. Underreporting of trachoma cases and delays in putting control measures in place might be caused by inadequate surveillance and monitoring systems. The success of mass drug administration programs may be jeopardized by irregular or incomplete adherence to treatment plans and antibiotic resistance.

Blindness caused by trachoma is preventable. Enhancing hygiene, increasing sanitation, and enacting environmental modifications are the main strategies for primary trachoma prevention to lessen the bacterium's spread. Raising awareness of trachoma, enabling early identification, and encouraging behavior change depend on health education and community involvement. Comprehensive trachoma control initiatives backed by national and international partnerships are essential to guarantee ongoing efforts to eradicate the disease. Simple techniques of epilation, treatment of trichiasis, and simple surgical procedures should be taught to clinicians and supporting medical staff in areas where this disease is endemic.

Enhancing Healthcare Team Outcomes

Trachoma is a very common infection that is often first seen by the primary care provider or the emergency department provider. These clinicians should always consult with the ophthalmologist before starting any treatment. The disease needs to be dealt with in time to avoid morbidity. Managing patients at risk and those with infection with trachoma requires a cohesive and interprofessional healthcare team to provide patient-centered care, enhance outcomes, ensure safety, and optimize team performance. Physicians, nurses, pharmacists, laboratory staff, and transfusion specialists play pivotal roles in this collaborative approach.

Coordination among healthcare professionals is vital for better patient outcomes. Ophthalmologists, opticians, dermatologists, nurses, and pharmacists must work together to tackle the disease and all the possible complications. Even after treatment, the patient should be closely followed until the symptoms have subsided and the visual acuity is normal. Surgeons also need to be involved since surgical interventions may be required to avoid complications. Interprofessional communication is the key to managing the problem at its core appropriately.

An interprofessional team approach is necessary. Effective communication among team members is paramount. Physicians and nurses must promptly recognize trachoma symptoms, such as irritation of the eyelids and eyes, redness of the eyes, itching, swelling of the eyelids, discharge from the eyes, eye pain, and photophobia. Laboratory staff should ensure accurate cross-matching and compatibility checks. Open and clear communication facilitates rapid diagnosis and treatment decisions, prevents errors, and provides a coordinated response. The clinicians will decide the course of treatment and prescribe appropriate therapy. Nursing can assist in patient education about the disease and assess therapeutic effectiveness and patient compliance. Pharmacists should verify dosing and perform medication reconciliation to ensure the absence of drug-drug interactions. Any concerns from nursing or pharmacy should be reported to the treating clinicians as soon as possible. Trachoma management will be optimized by this interprofessional, collaborative approach, leading to better patient outcomes.

Education and training keep the team updated on best practices. Ongoing professional development ensures that healthcare practitioners can diagnose trachoma promptly and respond effectively with appropriate treatment options. A patient-centered approach places the patient's well-being and preferences at the forefront of all decisions. In managing trachoma infection and reducing the risk of infection, an interprofessional healthcare team can ensure proper education, provide comprehensive responses, minimize complications, and prioritize patient safety and care quality.