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The Trachoma Story

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The Trachoma Story Questions about the cause, the effect, the diagnosis, the infectivity, the clinical pattern, the prevention, and the treatment of trachoma are answered by an ophthalmologist from his experience and from the literature. The Trachoma Story By ARTHUR A. SINISCAL, M.D. T lIE IMPORTAN-CE of trIachoma "as a well kniowni in the civilizations of the four great sourice of hlumtiani suii ngeiiiir, as a cause of river valleys-the Ilwaicr Ho anid the Yanig(tze blinidniess, anid as a niatioinal economnic loss over Kian(r, the IJiduts anid Ganges, the Euphlrates large tracts of the world's surface is seconid to aiid Tigris, anid the :Nile-many centuries be- nlonle amllonicg the diseases of the eye, or inideed, fore Chlrist. It was recogniized anid treated in monll (liseases of all kinids." aInIcienit Egyp)t, Greece, aind Romile, as well as Tlhus Sir Stewar-t Duke-Elder, a distin- in cotuntries of Bliblical famiie. The Moslem guislhed4 B3ritislh oplhthalnmologist, assessed tra- coniquests p)robably led to its spread to Europe elhomia in a textbook published in 1934 (1). As as early as tlle eightlh cenitury (4), anid, unii- late as 1950, it was estimllated that 15 to 20 per- dooubtedly, Napoleon's campaigni to Egypt in cenit of the world populationi suffered fromi this 1798-1802 was responisible in large measure for disease (2). its dispersion aiiiongt the Euiropeanis () Throughout the wvorld, traclhoiniatologists, B3elieved to lhavle been ilitlodiUCe(l inito the oplhtlhalmuologists, sociologists, ptublic hiealtl Uniited States duIIrinig coloniial tiimes by Euri-o- workers, aid otliers are strlivingr earnestly to im- pean inuniiigrianits (6), the disease was spread prove the liealtlh anid socioecoiomic coii(litionls thromughout a cenitral belt reaching fr-omii the Al- of those afflicted witlh trachlomlla. Buit tlhey e(,llelly AMounltaills to IK-anisas aiid Oklahoma, w'ave n1o imlaglic wand; wlhat they accomplish, amolg the Indianiis as well as others. Akccor-d- tlhey accomplish tlhrou(gli steady, organiized ef- inig to Cosgrove (7), the tr-achlomiia foundi(i in fort, whlicll depenids ini tUrnll uponi public under- Missouri anid.A,rkanisas o01iriginated fr oiii persoims standing anid sLupport. The followinge pagres wlho camIie inito these States fr'omii Tennliessee an11td tell of iinediciiie's planned attack atgaiiist this Kenitucky. The trachomna ini New AMexico anolil anicienit inifection. Arizoina anid probably Califforniia is believedi to According to MNouftinhlo, (3), tr-aclhoma was hIave coiie fr om i Mexico (8). Today, tr-achioinia is fouIInd( oni everyv contineleit (4). It is COmmlllOnl ill nost of sil,wlelre it Dr. Sin iscal since 1944 has been medical director of affects fromii 3) to 60 p)elrent of tIme poulaltion. the Alissouri Trachoma Hospital in Rolla, a service It is somi-iewhalt comniiioni in Emrope, whlsere it alf- of the division of health, Missouri Department of fects approxillately 5 PelrCenlit of the popllat ion. Public Health and Welfare. More prevalelit ill the 11a11kallk States alnd ill northiernii Emropean conititles thi i elsewvhere oni Vol. 70, No. 5, May 1955 497 that continent, it is present also in France, the trachoma is indistinguishable morphologically Netherlands, Germany, Austria, Hungary, from that of the virus causing inclusion Italy, Ireland, Great Britain, Norway, Sweden, blennorrhea of infants and swimming pool con- and Denmark. junctivitis of adults (also called para- Once a serious public hiealth problem in the trachoma). Some workers have regarded the United States, particularly in the central por- agents of these infections as belonging to the tion where it is considered endemic, trachoma Rickett8sa group, but Bengtson's (9) research is now relatively rare. It is still present, how- has shown that the trachoma bodies are rather ever, in Missouri and Arkansas and, to a lesser distinct from the rickettsiae. Generally speak- extent, in southern Illinois. In Missouri, ac- ing, the view is taken that the trachoma body tive cases are found in the southern half of the is a virus, but the question has not yet been State, particularly in the cotton-growing low- finally settled. The dividing line between bac- lands and in remote regions of the Ozark hill teria and rickettsiae or between rickettsiae and country. Accounting for 1 out of 4 pensioners viruses is not sharp. on the State's blind pension roll 25 years ago, A great majority of scientists now believe trachoma now is the disease of only 1 out of that trachoma is due to the organism discovered every 10 blind pensioners. by Prowazek and Halberstaedter. In 1907, Questions asked most frequently about tra- they described cytoplasmic inclusions, the choma are given here with the answers availa- presence of which in the epithelial cells of the ble from the experience of many workers. Al- conjunctiva and the cornea manifests the first though much is known about the cause, the diag- detectable sign of the disease in the laboratory. nosis, the clinical manifestations, and the pre- Thygeson (10) has pointed out that these intra- vention and treatment of this disease, not every cellular parasites are relatively large particles question can yet be answered . finally or and that their life cycle is very similar to that completely. of the psittacosis and lymphogranuloma venereum viruses. What Is Trachoma? There is need for more research on the causa- Trachoma is an infectious disease of the ex- tive agent or agents of trachoma. The exact ternal lining membranes (or conjunctiva) of nature of the organism will remain obscure the eyeball and eyelids. It causes an inflam- until it is definitely isolated and successfully mation of chronic duration, characterized by cultivated. burning, itching, excessive lacrimation, and photophobia. Generally insidious in onset, it How Are the Eyes and Eyesight Affected? develops usually at a slow pace and is somewhat If the infection is allowed to progress without resistant to treatment. The disease is localized treatment for several months or longer, a strictly to the conjunctiva of the eyelids and- lymphoid infiltration in the conjunctiva and in eyeball and to the tarsus and the cornea. The the subepithelial tissue will result in hyper- pathological changes in the tarsus and the cor- trophy and thickening of the conjunctiva and nea are deep seated and usually irreversible eventually in connective tissue formation and when once established. Persistent duration of scarring. Even the tarsal plates are involved inflammatory symptoms may lead to blindness, and may become buckled or deformed as a re- which results from corneal opacification andl sult of cicatrization. Follicles may or may not disintegration and, further, from cicatrized de- develop, but the absence of these should not formities of the eyelids and eyeball. rule out the presence of the disease (11, 12). The most serious pathological complication What Is the Cause of Trachoma? of trachoma is considered to be the formation The etiological agent is believed to be a large of pannus, which is a vascular invasion under virus or inclusion body of the group which in- the epithelium of the cornea. When pannus is cludes the psittacosis and lymphogranuloma allowed to progress centrally, the pupil becomes venereum viruses. The inclusion body of obscured by this veil-like opacity. Trichiasis, 498 Public Health Reports cicatrizatioii of corineal follicles; (e) finding ,Of the inclusioni bodies. A study by Rice and Siiti (17) of the rec- * ~~ords for 1,154 cases of trachioina found that 88 l)eprelr t shiowed the presence of pannus involve- niienit of the corniea. .According.to Cosgrove (7), a definiite diagniosis of trachoia cannot be miiade without pannuts unless a provedl case lias , beeni seenIin the sae family. Recently, iow- ever, Julianielle anid Smiithi (18) observed that alppr-oximnately 37 percent of ear-ly trachoma cases do niot shiow aniy pannus, anid Mitsuii (19) States that eveni a microscopic pannuiis cani be absent in the earliest stage in some cases of trachionia. AMitsuii observes that in J apan, miciroscopic l)palnus can be seen in about 50 L)er- cenit of trachioinia cases during the acute stage, anid that marginial punctate infiltration of the cornea can I)e seeni in a smtaller percentage of catses. (Cuenod and Naataf (20), who stress the value of slit-lampj) b)iomicroscopy in their monograplh Florid pannus covering complete upper half of oi corineal studies (21), state that pannus is one cornea, as seen in advanced stage of tra- of the most constant patlogical signs of tra- choma. Pannus is pathognomonic of the bf disease. clioma, but tlat tley believe it possible for true tiraclhoina to occuir without paiinits, especially at conditioni of inigrowinig eyelaslhes, resuilts fromii cicattrization of the lid structtues; it cauises the eyelashes to rub against the cornea, tlhereby de- stroying the epitlhelitunm anid predisposling to tiiicerationi, p)erforation, anml denise corneal scarri-iing. Blindiiess iimay -be due to diffuse corneal scars in genieral, or to pannus formiationi over the pupillary airea, or occasionally to sec- _ _ ondairy uveitis followinig perfoIrationi of the chamber and prolapse of its conitents, resulting__ eventually in phtlhisis bulbi. Is Pannus Essential to the Diagnosis? Altiouigh the presenice of typical trachionia- tons palilIiius is a solid basis for making( a diag nosis of trachona, its absence does niot abso- Ilutely rule ouit the diagnosis. Somne observer-s (13-16) believe that any one or imiore of the followinig signis slhould be sufficient to establish a diagnosis of traclhoma: (a) presence of typi- cal follicles; (b) presence of painnuis; (c) pres- ence of cicatrization; (d) puinctate depressions Trachoma granules in the conjunctiva, as seen at the periphery of the cornea resuilting from in the florid stage of the disease. Vol. 70, No. 5, May 1955 499 the early stage. Nataf (22) states further that, occur in other conjunctival diseases, but in an in hiis opinion, it is possible for certain forms of endemic area of trachoma, one would be remiss the infection to occur without pannus but that in his duties if he neglected to take cognizance diagnosis in such cases should be made with of them.
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