Conjunctivitis and trochoma

               Conjunctivitis
Conjunctivitis: An inflammation of the mucous membrane lining the inner surface of the eyelids and the cornea (conjunctiva).
Epidemiology
> Conjunctivitis is the most common eye disease worldwide
>The disease is highly contagious
> Conjunctivitis is caused by:
       Viruses such as herpes simplex, Molluscum contagiosum and measles virus
        Bacteria such as Neisseria gonorrhoeae, Streptococcus pneumoniae, Staphylococcus aureus and Chlamydia trachomatis serotypes A-C.
       Fungal such as Candida albicans
       Parasites such as Ascaris lumbricoides, Schistosoma haematobium and Taenia solium

Transmission is by:
     √Contact with ocular discharge
     √Contact with secretions from upper respiratory tract of infected person through contaminated fingers, clothing and other articles
     Flies may transmit the disease from infected person to another (mechanical
transmission)
√The disease is common in children

The predisposing factors include
√ Poor personal hygiene
√Inadequate water supply
√Overcrowding
√Poor environmental hygiene

Clinical Features and Diagnosis of Conjunctivitis
Important Symptoms
√Foreign body sensation
√Scratching or burning sensation
√Sensation of fullness around the eye
√Itching
√Photophobia

Associated Features
• Oedema of eyelids
• The eyes are watery and feels ‘gritty’
• There is no actual pain or loss of vision
• If there is pain the cornea is probably also affected
• Normally both eyes are affected

Most Important Signs
√ Hyperaemia
√Tearing
√Exudation (purulent drainage)
√ Pseudoptosis (drooping of the upper lid)
√ If trachoma is left untreated it can lead to blindness
     Note:
Other conditions causing a red eye must be excluded particularly a foreign body to
the eye.

Diagnostic Methods
√Do clinical examination to rule out other courses of red eyes.
√ Take pus swab for microscopic examination (Gram stain or Giemsa) and culture if the discharge is purulent

Treatment of Conjunctivitis
√ Cleaning the infected eyes regularly by soap and water (do not put soap in the eyes).
√Hand washing is essential to avoid transmitting infection to unaffected eye or to others in the household.
√Apply Chloramphenicol eyes ointment or 1% Tetracycline eye ointment for five days.
√ Eye drops are more convenient for the patient but is short lived.
√ If no response, refer to district hospital for further evaluation and management.
√If gram stain shows gram negative diplococci, add systemic antibiotic to cover Gonorrhea.
√Most of Conjunctivitis cases are caused by virus from systemic viral infection such as
measles virus.
√They are only treated by frequent eye washing and antibiotics are not indicated, but if there is secondary bacterial infection apply antibiotic (i.e. presence of purulent discharge from eyes)

Prevention and Control of Conjunctivitis
√Personal hygiene-hand washing
√ Care and treatment of infected eyes
√Proper refuse disposal to prevent fly breeding
√ Health education at the community and schools on personal hygiene and danger of improper refuse disposal
√Improve water supply

Epidemiology of Trachoma of Trachoma
Trachoma: A chronic inflammation of the conjunctiva and cornea caused by a certain serotypes of Chlamydia trachomatis
        It is characterized by vascular invasion of the cornea (pannus) and later blindness

Epidemiology
      √Trachoma is a very important cause of blindness
    √It is more common in dirty, dry, densely populated areas
    √Transmission of trachoma occurs through contact with ocular discharges of infected persons
   √ This can be either directly via fingers contaminated with discharge or indirectly
through fomites and flies
√ Chlamydia trachomatis is present in large numbers during the early stages of the disease
√ The early stages are the most infective
√ Transmission is high among children and in endemic areas; they get the infection at an early age
√Disease normally progresses very slowly and blindness by the age of 10 is common
√ Secondary bacterial infection and Vitamin A deficiency exacerbate the disease and predispose to scarring, leading to blindness

Clinical Features and Management of Trachoma

Clinical Features
The incubation period of trachoma is 5 to 12 days, after which the affected individual experiences symptoms of conjunctivitis, or irritation similar to ‘pink eye’.
√ The conjunctival inflammation is called ‘active trachoma’ and usually is seen in children,
especially preschool children.
√ The active trachoma is characterized by white lumps in the undersurface of the upper eye lid (conjunctival follicles or lymphoid germinal centres) and by non-specific inflammation and thickening often associated with papillae.
√Follicles may also appear at the junction of the cornea and the sclera (limbal follicles).
Trachoma Manifest in Four Stages
       1 Stage I (Trachomatous Inflammation – Follicular – TF).
      o Early trachoma begins with red watery eyes like ordinary Conjunctivitis.
      o After a month or more, small pinkish-grey lumps, called follicles, form inside the upper lids.
      o White of the eye becomes mildly inflamed.
      o There is little pus unless bacterial superinfection has started.
     o The pre-auricular glands also begin to enlarge.
     o Confirmation can be made by demonstrating the chlamydiae inclusion bodies in scrapings from the conjunctiva stained with any Romanowsky stain and/or Lugol's solution (in the laboratory)

• Stage II (Trachomatous Inflammation – Intense – TI)
         o Intense diffuse inflammatory infiltration, oedema and vascular papillary hypertrophy
         o The top edge of the cornea looks grayish because it has many tiny red blood
vessels in it (pannus).
         o Note that a combination of follicles and pannus is almost diagnostic for trachoma.
  
  Stage II of TrachomaPannus

Stage III (Trachomatous Scarring (TS)
      o After several years the follicles begin to disappear leaving whitish scars on the conjunctiva.
      o In the cornea, the small vessels retrogress.
      o A diffuse haze remains on the cornea.
      o Some vision may remain unless gross damage, like rupture of the cornea from corneal scars, has occurred.
      o The scars are on the inner side of the conjunctiva.

  Stage IV (Trachomatous Trichiasis – TT)
      o Scar tissues always retract so the eyelid becomes thick and turned inward - This is known as entropion.
      o These scars make the eyelids thick and narrow and may keep them from opening all the way or they may pull the eyelashes down into the eye, scratching the cornea wherever the patient blinks.
      o This is called trichiasis.
The combination of entropion and trichiasis will completely destroy the cornea resulting into blindness.

Management of Trachoma
Diagnosis
√ In most endemic areas, trachoma will be a clinical diagnosis.
√A diagnosis is made by examining the eyes and the inner surfaces of the eyelids
especially the upper lids.
√ Diagnosis can also be made in a well equipped laboratory by obtaining swabs for microscopy and culture for infected discharges.

Treatment
√Chlamydia trachomatis is sensitive to
              o Tetracycline
                o Azithromycin
                  o Erythromycin
                    o Doxycycline
√ The treatment of choice is 3% tetracycline topical eye ointment.
√ This is stronger than the usual 1% tetracycline eye ointment used for general eye infections.
√Azithromycin is the recommended single dose in adults to treat ocular chlamydial infection while in children 20mg/kg as single dose of azithromycin in recommended.
√Patient in stage IV of the disease with entropion must be treated surgically.
√ It is essential to do this as soon as possible because every blink worsens the damage.
√ These patients need to be referred but before that remove the in-turned eyelashes by pulling them out with forceps.

Prevention and Control of Trachoma
√ Trachoma is an example of a disease which is caused by lack of water.
√ The quantity of water is more important than the quality.
√Health education on the disease prevention especially personal hygiene.
√Improvement of sanitation reduces bleeding sites for flies.
√ Flies act as mechanical vector.

By: Welfare Jambo

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