Trachoma – Causes, Symptoms, Prognosis, Treatment, Remedies

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Trachoma is a disease of the eye. It is caused by an infection caused by Chlamydia trachomatis, a bacterium.

Table of Contents

Introduction, pathology, risk factors

Following the infection of the eye from the bacterium, on the inner surface of the eyelids, there occurs a roughening. Eventually there is eye pain. It will often lead to the breakdown of the outer surface of the eyes. The ultimate consequence may be blindness.
Read – Eye Diseases Causes, Pathogenesis, Symptoms, Treatment, Herbs

When the trachoma is not treated properly the eyelids turn inwards. This will cause permanent blindness. Repeated trachoma infections too will have the same impact.

How does trachoma infection spread?
When one gets into direct or indirect contact with the eyes or nose of a person affected by trachoma infection, one gets trachoma. The bacteria, thus spreads either directly or indirectly.

Indirect contact – It occurs through clothes or flies that have come into contact with eyes or nose of an infected person.
Read – Anatomy of Eye: Netra Rachana: Ayurveda Perspective

What increases spread of trachoma?

Poor sanitation
Unclean toilets
Unclean water
Crowded places and living conditions
Children spread the disease faster than adults
Read – Classification of Eye Diseases As Per Ayurveda

Risk Factors of trachoma

Poverty
Poor sanitation
Lack of latrines
Flies
Crowded living conditions
Age – children of 4-6 years of age, where disease is active
Sex – women’s rate of contracting trachoma is 2-6 times higher than men (read more)

Trachoma prevention tips

How can we prevent trachoma?
Cleaning face and hands – Keeping the face and hand clean by regular face washing and hand washing, will help in preventing trachoma and also to prevent its re-infection.
Controlling flies – flies are major source of transmission of trachoma. Reducing their population will eliminate this main source of transmission.
Proper waste management – Excreta are breeding grounds for flies. Therefore, the human and animal wastes need to be disposed in a proper way.
Improved access to clean water – is a key measure. Having source of fresh water nearby can improve hygienic conditions.
SAFE – Following SAFE strategy recommended by WHO.
Timely treatment in manifested cases – Timely treatment in earlier conditions with antibiotics, this decreases the number of people exposed to the infection. All those who are diagnosed with trachoma should be treated at once. The whole groups wherein the disease is known to be susceptible too shall be treated. Azithromycin and topical tetracycline are commonly used in treating trachoma.

Once the scarring of eyelids occurs, the disease will require surgery. Surgery will help in correcting the position of eyelashes and also to prevent blindness.
Read – Watery Eyes: Causes, Ayurvedic Treatment, Remedies

Trachoma home remedies

Are there any home remedies for trachoma?
I personally feel that home remedies shall not be used in trachoma. Trachoma is the leading cause for blindness and shall be reported to the doctor as early as possible and proper remedy sought for.

Ethnobotanical and Traditional Medicine as probable remedies for Chlamydia Trachomatis infections

In a ncbi publication, eight plant species have been mentioned as useful for treating Chlamydia infections. They are –

Aloe marlothii – Mountain Aloe
Eucomis pallidiflora subsp. pole-evansii – Giant Pineapple Lily
Gethyllis namaquensis (Schonland) Oberm,
Hypoxis obusta Burch, ex Ker Gawl,
Kleinia longiflora DC,
Protea caffra subsp. caffra
Tribulus terrestris L
Ziziphus mucronata Willd
Read – Computer Vision Syndrome: Causes, Ayurvedic Remedies, Tips

Do we have a lot of people suffering from trachoma? (Incidence of Trachoma)
Trachoma is included under ‘neglected tropical diseases’.
An estimated 80 million people worldwide have an active trachoma infection.
In some areas 60-90% of children carry the infection of trachoma. Trachoma commonly affects women than men.
Trachoma contributes to decreased vision in about 2.2 million people. Out of these people at least 1.2 million people become completely blind.
It is said that globally about 230 million people are at risk of getting trachoma even as the disease spreads over about 53 countries of Africa, Asia and America.
The estimated economic losses in a year, in USA are counted in billions.
(read more)

Symptoms, complications

What are the signs and symptoms of Trachoma?
Just before seeing the signs and symptoms let us learn some important aspects of the disease which form the backdrop of those symptoms.

Following an incubation period of 6-12 days the symptoms of conjunctivitis appear. Alternatively there is some irritation similar to ‘pink eye’. Multiple episodes of repeated infection can cause blinding endemic trachoma. If the infection doesn’t keep recurring, the inflammation will gradually go away.
Read – Alaji Eye Disorder Definition, Location, Symptoms, Treatment

Active Trachoma – is the name given for the acute inflammation of conjunctiva in trachoma. It is usually seen in children, mainly pre-school children. In this condition, there are white lumps on the under surface of upper eyelid (conjunctival follicles).

There may also be non-specific inflammation and thickening, often associated with papillae. The follicles may also appear at the junction of sclera and cornea (limbal follicles). This condition is irritating and will have watery discharges from the eye. If secondary infection by bacteria occurs, then the discharges will be purulent.
Read – Chaturvidha Netra Srava – 4 types of eye discharges, symptoms, treatment

Cicatricial Trachoma – is the name given to the later structural changes which occur following active trachoma. In this condition scarring of eyelid occurs. This leads to distortion of the eyelid and buckling of the eyelid. The lashes turn towards the eyeball and rub against it. This condition is called trichiasis. This will lead to opacities of cornea, scarring and consequential blindness.
Read – Kaphaja Upanaha (Netra Roga) – Definition, Symptoms, Treatment

Classical symptoms of trachoma
Related to the eye

Discharges
Swelling of eyelids
Eyelashes direct towards the eyeball – Trichiasis
Light sensitivity, especially intolerance to bright light

Other systemic symptoms

Swelling of lymph nodes in front of the ears
Complications related to ear, nose and throat
Increased heart rate
Read – Triphala Home Remedy For Eye Care

Does trachoma present with any complications?
Yes, trachoma, if untreated or with repeated recurrences will produce complications.

Major complication of trachoma is the corneal ulcer. This occurs due to the rubbing by concentrations or trichiasis with superimposed bacterial infection.

Complications –

Scarring of eyelids
Eyelid deformities – entropion (inward folding of eyelid) and trichiasis (ingrown eyelashes)
Corneal scarring or cloudiness
Partial or complete vision loss
Read – Blepharitis: Inflamed Eyelids Ayurvedic Treatment, Remedies

Causes, diagnosis, classification

What causes trachoma?
Causative agents – Trachoma is caused by the infection caused by Chlamydia trachomatis, including its serotypes A, B and C.

The infection spreads by –

Direct spread – direct contact with the eye, nose and throat secretions from affected individuals
Spread through fomites – Contact with inanimate objects carrying infections agents (fomites). These include towels, washcloths etc
Mechanical transmission – as caused by flies

Susceptibility in Children – Children are most susceptible to infection. On the other hand, severe symptoms and blinding effects are often seen in adults.

Poor hygiene – Blinding endemic trachoma occurs in areas with poor personal and family hygiene.
Read – Netra Sandhigata Rogas – Disorders Affecting The Junctions Of The Eye

Indirect factors –

Poverty
Lack of water facilities and lack of clean water, availability of unclean water
Absence of latrines or toilet, untidy latrines and toilets
Presence of flies
Living in close proximity to cattle
Living in crowded places
Dirty faces in children (most common)

Note – It is important to remember that most of the transmission of trachoma occurs within the four walls of the home, within the family.
Read – Nidana: Meaning, Word Derivation, Definition

How do we diagnose trachoma?
Trachoma and its stages and symptoms can be diagnosed on clinical examination. McCallan’s and WHO classification of trachoma are the accepted guides in this direction.

WHO classification of Trachoma

The Simplified WHO Grading System for diagnosis of Trachoma is as explained below –

Grade	Stage of Trachoma	Abbreviated as	Predominant features
1	Trachomatous inflammation, Follicular	TF	5 or more follicles of more than 0.5 mm on the upper tarsal conjunctiva
2	Trachomatous inflammation Intense	TI	Papillary hypertrophy Inflammatory thickening of the upper tarsal conjunctiva obscuring more than half the deep tarsal vessels
3	Trachomatous Scarring	TS	Presence of scarring in tarsal conjunctiva
4	Trachomatous Trichiasis	TT	At least one in-grown eyelash touching the globe (eyeball) or evidence of epilation (removal of eyelash)
5	Corneal Opacity	CO	Corneal opacity blurrig a part of the pupil margin

McCallan’s classification of trachoma

Stage	Name of the stage	Predominant features
1	Incipient Trachoma	Hyperemia of palpabral conjunctiva Presence of immature follicles
2	Established Trachoma	Appearance of mature follicle and papillae Progressive corneal pannus
3	Cicatrising Trachoma	Scarring of palpabral conjunctiva Scars easily visible as white bands
4	Healed Trachoma	Disease is cured or is not marked Sequelae to cicatrisation cause symptoms

Prevention, treatment

How can Trachoma be prevented?
Related to Environmental improvement (to reduce transmission of causative agent)

This includes –

Modifications and betterment in usage of water
Modifications and measures to control flies
Modifications in use of latrines and providing better sanitary conditions
Modifications in health education
Modifications related to proximity to domesticated animals
Read – Ayurvedic Healthy Daily Routine Charak Samhita Sutrasthana – Chapter 5

Other measures –

Insecticide sprays
Measures to control the environmental factors that limit facial cleanliness (the above said preventive measures are effective in this aspect)

Use of Antibiotics
According to the guidelines of WHO, a region should receive ‘community based mass antibiotic treatment’ when prevalence rate of active trachoma is more than 10% among children of 1-9 years age group.

Subsequently for the next three years, annual treatment shall be administered. At the same time, reassessment of prevalence should be done.

Annual treatment should be done until the prevalence rate drops to less than 5%. When prevalence of trachoma is low, this treatment should be limited to family level.
Read – How to Live Healthy Everyday With Ayurveda

What does some studies related to trachoma focus upon?

Studies show that usage of insecticide spray resulted in significant reduction of trachoma and fly density.
Health education also resulted in reduction of active trachoma, when implemented seriously.
Improved water supply did not result in reduction of trachoma incidence.
Children with visible nasal and ocular discharges and flies on their faces are twice at the risk of having active trachoma in comparison to the children with clean faces.
Environmental changes make a good impact on the transmission of eye infections which occur by means of less facial cleanliness.
Read – Complete Guide to Fungal Infections, Its Types And Preventions

How can Trachoma be managed?
Antibiotic treatment – It reduces the risk of active trachoma in individuals with Chlamydia trachomatis.

Below mentioned are the choices of antibiotics –

Oral dose of Azithromycin
Topical use of Tetracycline

Surgery – Surgery is preferable to treat trichiasis and protect the eyeball from being damaged.
Read – Sushruta’s 8 Types Of Surgical Procedures – Astavidha Shastra Karma

Lifestyle Measures

Facial cleanliness – Maintenance of facial cleanliness is very important. Presence of nasal and ocular discharges, unclean faces with flies on them, especially in children is a risk factor and can cause active trachoma. This can be achieved by –

Intensive community based health education programs to promote face-washing (reduces prevalence of active trachoma)
Encouraging face wash to the infected people (prevents re-infection)

WHO recommended SAFE strategy –
S – Surgery to correct advanced stages of trachoma
A – Antibiotics to treat active infection, using Azithromycin
F – Facial cleanliness to reduce disease transmission
E – Environmental change to increase access to clean water and improved sanitation
Read – Tested Remedies For Eye, Ear, Nose, Throat Problems: Ramdas Pai

prognosis, epidemiology, history

What prognosis does Trachoma carry?
If trachoma is not treated timely and comprehensively, the symptoms will worsen and lead to blindness. Blindness occurs due to ulceration and scarring of cornea. In complicated conditions, surgery will be needed to fix eyelid deformities.
Read – How To Make Prognosis Of Disease According To Ayurveda?

What does epidemiology of trachoma tell us?
As of 2011, 21 million people approximately are affected by trachoma actively. Around 2.2 million people among them are permanently blind or have severe visual impairment.
An additional 7.3 million people are reported to have trichiasis. Until now, at least 51 countries are classified as endemic for blinding trachoma. Among the Africa is considered as the worst affected area. Over 85% of all known active cases of trachoma are available in Africa alone, mainly Ethiopia and South Sudan.
It is found that around 158 million people are living in areas where trachoma is more common and around 229 million live in areas where it could potentially occur.
Among the developed countries, Australia is the only country to have trachoma. It was found in half of Australia’s remote communities in 2008.

Eradication of Trachoma
WHO Alliance for the Global Elimination of Trachoma by 2020 (launched by WHO, in 1996)
2020 target for trachoma elimination – WHO, in the year 2006, set a target of year 2020 to eliminate trachoma as a public health problem
2020 insight – strategic plan containing plans and actions to achieve global elimination of blinding trachoma by 2020 proposed by ICTC (International Coalition for Trachoma Control)
SAFE program – for blindness prevention which also includes sanitation to reduce open presence of human feces (recommended by ICTC and 2020 insight)
Countries certified to have eliminated trachoma as a public health problem by 2018 – Cambodia, Oman, Nepal, Mexico, Morocco, Ghana and Laos. Campaign – The campaign of Azithromycin donation by Pfizer company has found to reduce the early death rate in very poor children up to 25%.
Read – Ayurvedic Preventive Healthcare: Swastha Urjaskara Chikitsa

What does history have to tell about Trachoma?
Trachoma is one of the earliest known eye diseases. It was identified around 15 B.C. in Egypt. It was present in ancient Mesopotamia and China too.

It was a problem in 19^th century Europe, especially after Egyptian campaigns and Napoleonic wars. It spread from army barracks to the town life. With stringent measures, trachoma was controlled in Europe by early 20^th century.
Most victims of trachoma live in underdeveloped and poor countries today, mainly Africa, Middle-East and Asia.

In 1913, President Woodrow Wilson signed an act designating funds for trachoma eradication. Immigrants through Ellis Island, New York had to be checked for trachoma. During this time, trachoma was treated with topical application of copper sulphate.
Read – Ayurveda Eye Treatment Types, Methods – Ashtanga Hrudaya Sutrasthana 23

By late 1930’s sulfonamide antibiotics were used to treat trachoma.
USA declares that blindness due to trachoma has been eliminated from United States. The last cases were found among Native America populations.
Trachoma disappeared from industrialized world by 1950’s due to improved sanitation and overall living conditions.

In 1956-63, epidemiological studies were conducted by the Trachoma Control Pilot Project in India under the Indian Council for Medical Research. India declared itself free of infective trachoma in 2017.

Currently 8 million people (globally) are visually impaired due to trachoma and 41 million suffer from active infection, in poorest regions of Africa, Asia and Middle East, also in some parts of Australia and Latin America.

Among the developed countries, Australia (Aboriginal people living in remote communities) is the only country cited to have blinding trachoma according to World Health Organization.
Read – Netra Tarpana Treatment For Eye Care Benefits, How To Do?

How did Trachoma get its name?
The term Trachoma Greek word trakhoma or trakhus which means ‘rough’

What has ‘WHO’ to tell about trachoma?
According to WHO, it is the leading infectious cause of blindness worldwide. It causes blindness or visual impairment in about 1.9 million people. It causes about 1.4% of all blindness worldwide. Blindness from trachoma is irreversible .

It is a public health problem in 37 countries. 158 million people live in trachoma endemic areas and are at risk of trachoma blindness (April 2018 data)

In endemic areas, active trachoma is common in preschool aged children. Here the prevalence rates are higher than 60-90%.
Women are blinded up to 4 times than men. This is due to their close contact with infected children.

Africa remains the most affected continent and also the one with most intensive efforts. The economic burden of trachoma on individuals and communities is enormous. The economic cost in terms of lost productivity from blindness and visual impairment is estimated at USD 2.9-5.3 billion annually. The burden increases to USD 8 billion when trichiasis is included.

‘WHO’ recommends SAFE strategy for elimination of trachoma and have been implemented by many countries. The World Health Assembly adopted resolution WHA51.11 in 1998, targeting the global elimination of trachoma as a public health problem. The elimination strategy is summarized by the acronym ‘SAFE’ (explained earlier). (read more)

Data reports for 2017 submitted by member states to ‘WHO’ states that more than 231,000 people were provided surgery for Trachomatous trichiasis and 83.5 million people in endemic communities were treated with antibiotics to eliminate it.

‘WHO’ aims to eliminate trachoma as a public health problem. In 1996, it launched the WHO Alliance for the Global Elimination of Trachoma by 2020.
Read – Tarpana Putapaka – Ayurveda Eye Care – Ashtanga Hrudaya Sutrasthana 24

Trachoma Ayurvedic relation

Reference for Trachoma in Ayurveda?
Yes, we do have a condition called as Pothaki explained in the context of vartma gata rogas i.e. disorders of the eyelids in Ayurvedic treatises. This condition closely resembles trachoma in its clinical picture.

Other conditions explained in Ayurveda which resemble trachoma –