Presentation notes

Trachoma is an eye disease caused by infection with the bacterium Chlamydia

trachomatis. It is the leading cause of infectious blindness globally, being
responsible for 1.3 million cases of blindness (1).
At a recent WHO meeting it was estimated that trachoma is endemic in 55
countries, mainly in Africa and Asia. Active trachoma (follicular trachoma,
inflammatory trachoma; TF/TI), which occurs most frequently in children, is clinically
diagnosed by signs of follicles and papillae on the conjunctival epithelium of the
upper lid (2).
These occur as a result of the inflammatory response following infection with C.
trachomatis. Repeated rounds of infection may result in scarring leading to
distortion of the eyelids and upper lid entropion (in-turning of the eyelids). As a
result of this in-turning, eyelashes rub on the globe, a condition known as trichiasis.
Trichiasis can lead to corneal opacity and eventually blindness.
Trachoma is an inflammation of the tarsal conjunctiva and tarsal plate seen on
eversion of the upper eyelid . Inflammation is characterized by the formation of
follicles, white dots or bumps that contain cells . The inflammation may be intense
enough to thicken the conjunctiva, obscuring the normal pattern of conjunctival
blood vessels and even obscuring follicles.
The chronic inflammation when repeated throughout life leads to scarring of the
tarsal plate and conjunctiva of the inside of the eyelid . This turns the eyelid margin
inward (ENTROPION) and maybe severe enough to turn the eyelashes inwards .
When the eyelashes rub on the eye, the condition is called TRACHOMATOUS
TRICHIASIS, TT (Figs 1c and 1d) . This is mainly a problem of the upper eyelid .
The purpose of the surgery is to correct the entropion and trichiasis by rotating the
eyelid margin outward, directing the eyelashes away from the globe . There may be
other causes of trichiasis and of entropion besides trachoma (metaplastic
eyelashes) -> Congenital metaplastic eyelashes (distichiasis) may rarely occur where a partial or
complete second row of lashes emerges behind the meibomian gland orifices.
When the eyelid is abnormal, with distorted glands and abnormal secretions as well
as an abnormal eyelid margin and trichiasis, rubbing of the eyelashes on the cornea
disturbs the normal corneal surface and causes scarring (CORNEAL OPACITY) . This
leads to gradual loss of vision and eventually to blindness . Surgery can restore a
modest amount of vision but cannot help those with severe vision loss . In these
cases, surgery prevents pain and further vision loss .

In 1997, WHO formed an Alliance to work towards the Global Elimination of

Trachoma by 2020 (GET2020). The Alliance promotes the use of the SAFE strategy
for trachoma control. This involves Surgery to correct trichiasis, Antibiotics to treat
infection, Facial cleanliness and Environmental improvement to interrupt
transmission of C. trachomatis. The appropriate targeting of the SAFE strategy

is dependent upon reliable information on the distribution of active trachoma and

trichiasis within a country, based specifically upon the district prevalence of the
disease (3).
Currently available maps of global trachoma distribution indicate the broad
areas/countries where endemic trachoma is found; however, they do not provide an
indication of the levels of trachoma endemicity within and between countries.
In recent years the number of individuals (mainly children) with active trachoma has
declined significantly from 146 million in 1996 to 40 million in 2007, indicating that
the A, F, and E components are effective [1,8]. In contrast, the estimates of the
number of people (mainly adults) living with untreated TT have not shown such
encouraging declines: 10.6 million in 1996, 7.6 million in 2003, and 8.2 million in
2007 [1,8]. Available data suggest that current surgical activity is probably keeping
up with incident TT but may not be clearing the backlog. For example, in Ethiopia
(the country with the most cases of TT) 1.3 million people were estimated to have
TT in 2006, but only around 300,000 operations were performed in the last 5 y [1,9].
The reasons for this treatment gap are complex and multiple. Firstly, there may be
insufficient services to address the backlog in many regions. Many of the health
workers trained in TT surgery have been lost from programmes, may have
conflicting clinical priorities, or do not have the instruments or consumables to
perform surgery [10,11]. Secondly, services may not be accessible to patients.
Several studies have shown financial constraints, transport difficulties, and lack of
time to be barriers to attending for surgery [7,12 14]. Thirdly, in many regions
many patients (often the majority) refuse the offer of surgery, even when major
barriers are addressed by the provision of free surgery at community level [7,13
15]. It is likely that in the next 5 y at least, the overwhelming majority of people
with TT will not receive surgical treatment, irrespective of whether the TT is minor or
major
Manyindividualswith trichiasis, particularlythose with milddisease, decline
surgery, even whenthisis provided free and close tohome [1316].Lack of
time andfear ofsurgeryare leadingreasons for poorsurgicaluptake,
suggesting aneed for non-surgical,community-based management
strategiesfor those declining surgery [8,13,17].Poor surgical
outcomes(recurrent trichiasis oran unsatisfactory cosmetic appearance)
may also deterpeople fromaccepting surgery[5,1820].
. There is broad consensus that major TT should be treated surgically. However, for
the management of minor TT the reality is often different, with many patients and
clinicians preferring to defer surgery until the TT becomes more problematic. In
some countries, such as The Gambia, there has been a policy of epilation (repeated
removal of lashes with forceps) for minor trichiasis and surgery for major trichiasis,
Bc of the prevalence of unoperated TT, the limited capacity of current surgical
services, concerns over programmatic surgical outcomes, and the high rates of
refusal, epilation might be an acceptable alternative to surgery for the management
of minor TT.ch predated the WHO guideline

Gambian study 1:
S. A cohort of Gambians with trichiasis in one or both eyes who had declined
surgery was observed. Clinical examinations were performed at baseline and 4
years later. Conjunctival swab samples were collected for Chlamydia trachomatis
PCR and bacteriology. RESULTS. One hundred fifty-four people were examined at
baseline and 4 years later (241 nonsurgical eyes). At baseline 124 (52%) eyes had
major trichiasis (5 lashes), 75 (31%) minor trichiasis (1 4 lashes), and 42 (17%) no
trichiasis. By 4 years, trichiasis had developed in 12 (29%) of 42 previously
unaffected eyes. Minor trichiasis progressed to major in 28 (37%) of 75 eyes. New
corneal opacification more commonly developed in eyes that had major (10%)
compared to minor (5%) trichiasis at baseline. Bacterial infection was common
(23%), becoming more frequent with increasing trichiasis. C. trachomatis infection
was rare (1%). Conjunctival inflammation was common (29%) and was associated
with progressive trichiasis and corneal opacification. CONCLUSIONS. Trichiasis
progressed in the long-term in this environment, despite a low prevalence of C.
trachomatis. Blinding corneal opacification develops infrequently, unless major
trichiasis is present. Epilation and early surgery need to be formally compared for
the management of minor trichiasis. The pathologic correlates and promoters of
conjunctival in- flammation need to be investigated. (Invest Ophthalmol Vis Sci.
2006;47:847 852) DOI:10.1167/iovs.05-0714
Gambian study 2:
Methods: A cohort of people in the Gambia who had undergone surgery for
trachomatous trichiasis 3 4 years earlier was re-assessed. They were examined
clinically and the conjunctiva was sampled for Chlamydia trachomatis polymerase
chain reaction (PCR) and general bacterial culture. Results: In total, 141/162 people
were re-examined. Recurrent trichiasis was found in 89/214 (41.6%) operated eyes
and 52 (24.3%) eyes had five or more lashes touching the globe. Corneal
opacification improved in 36 of 78 previously affected eyes. There was a general
deterioration in visual acuity between surgery and follow up, which was greater if
new corneal opacification developed or trichiasis returned. Recurrent trichiasis was
associated with severe conjunctival inflammation and bacterial infection. C
trachomatis was detected in only one individual. Conclusions: Recurrent trichiasis
following surgery is a common potentially sight threatening problem. Some
improvement in the cornea can occur following surgery and the rate of visual loss
tended to be less in those without recurrent trichiasis. The role of conjunctival
inflammation and bacterial infection needs to be investigated further. Follow up of
patients is advised to identify individuals needing additional surgical treatment.