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Updated: May 18 2022


  • Snapshot
    • An 8-year-old boy is brought by his parents to the pediatrician with symptoms of eye redness and irritation. He recently emigrated from Ethiopia to the United States. His parents report that other children in their community also experienced similar symptoms, and are worried that their child may go blind. Physical examination is notable for multiple dome-shaped, yellow-white follicles in the tarsal conjunctiva. He is prescribed oral azithromycin.
    • Trachoma is an ocular surface infection caused by Chlamydia trachomatis and is a leading cause of preventible blindness worldwide.
    • Diagnosed clinically based on presentation and physical exam findings.
    • Treatment is typically with azithromycin.
  • Epidemiology
    • Prevalence
      • estimated 21 million people worldwide with active trachoma
    • Demographics
      • most common in young children
        • prevalence of active trachoma decreases with age
    • Location
      • endemic in remote, resource-limited areas of North Africa, the Middle East, northwest India, and parts of Southeast Asia
    • Risk factors
      • endemic regions
      • poor access to water
      • crowded living conditions
      • poor facial hygeine
    • Pathophysiology
      • infection with Chlamydia trachomatis serotypes A, B, and C
      • infection of the conjunctival epithelium leads to an immune response with follicles
        • repeated infections lead to tissue destruction with fibrosis and scarring
          • scarring may cause inward turning of the lashes (trichiasis), resulting in corneal erosions, ulcerations, and opacification from scarring
      • transmission
        • direct personal contact
          • ocular and nasal secretions on the fingers
        • fomites (i.e. shared towels)
        • flies that come into contact with the eyes or nose of an infected individual
          • passive vectors
  • Presentation
    • Symptoms
      • itching and irritation of eyes and eyelids
      • mucopurulent eye discharge
      • eyelid swelling
      • eye pain
      • photophobia
    • Physical exam
      • follicular conjunctivitis (active disease)
        • dome-shaped, yellow-white elevations of lymphoid cell collections
          • can be seen on the everted upper eyelid
        • Herbert pits
          • depressions in the upper margin of the cornea caused by large conjunctival follicles
            • pathognomonic for trachoma
      • cicatricial disease (from recurrent infection and inflammation)
        • conjunctival scarring
        • fibrotic contraction of the eyelid margin
          • may cause trichiasis and subsequent corneal irritation
        • corneal opacification
          • secondary to recurrent corneal irritation
  • Differential
    • Viral conjunctivitis
      • key differentiating factors
        • acute and self-limited
        • watery discharge
    • Bacterial conjunctivitis caused by other species (e.g. Streptococcus pneumonia, Moraxella)
      • key differentiating factor
        • acute
    • Corneal abrasion
      • key differentiating factor
        • history of trauma to the eye
    • Clinical, based on presentation and physical exam findings
  • Treatment
    • Medical
      • azythromycin
        • indications
          • new or recent-onset of active disease
        • route of administration
          • oral azithromycin
            • single dose
          • topical azithromycin
            • twice daily for 3 days
        • mass antibiotic therapy has been effective in trachoma elimination efforts
      • topical tetracycline
        • indications
          • alternative treatment when azithromycin is not available
    • Surgical
      • bilamellar tarsal rotation (BLTR) or posterior lamellar tarsal rotation (PLTR)
        • indication
          • cicatricial disease
  • Complications
    • Corneal abrasions
    • Blindness
  • Prognosis
    • Repeated infections are common in endemic areas
    • Corneal scarring and opacification may occur in untreated cases, leading to blindness
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