Paratrachoma is a form of conjunctivitis in adults, characterized by damage to the mucous membrane of the eye with chlamydia infection. The main symptoms of the disease: increased tearing, photophobia, hyperemia, burning sensation and pain in the eyes. To make a diagnosis, the technique of fluorescent antibodies, enzyme immunoassay, polymerase chain reaction, biomicroscopy, ultrasound, ophthalmoscopy, visometry, perimetry, tonometry is used. Conservative therapy is based on the use of antibacterial agents, NSAIDs, glucocorticosteroids, moisturizing and antihypertensive drugs, vitamins of group A, C, R.
Paratrachoma, or adult chlamydial conjunctivitis, is an acquired disease, the prevalence of which in ophthalmology is steadily increasing every year. The share of pathology in the overall structure of conjunctivitis ranges from 10 to 30%. Primary infection often occurs at the age of 20-30 years. In 2/3 of cases, the disease is characterized by a unilateral lesion. Acute form occurs in 65%, chronic – in 35% of patients. The persistence of the virus in the body is manifested by periodic relapses of the disease. The ratio of morbidity among men and women is 1/3. Geographical features of the distribution have not been studied.
The development of pathology is caused by infection with Chlamydia trachomatis, which is the main representative of the urogenital strain. Paratrachoma is often one of the manifestations of urogenital chlamydia infection, which may have an asymptomatic course. The development of clinical manifestations is caused by the impact of unfavorable exogenous or endogenous factors (hypothermia, uncontrolled intake of antibacterial agents, immunodeficiency). Infection occurs when an infection is transferred from the genitals. The probability of infection is high when visiting public saunas, swimming pools, baths. Cases of infection of medical personnel during the examination of patients with chlamydia are described.
Infection with Ch. trachomatis leads to damage to the urogenital tract, conjunctiva of the eyes, less often – joints. The incubation period lasts 10-14 days. Due to the ability to form specific L-forms, microorganisms can persist for a long time in the cells of the eyeball in an inactive state. Adverse effects lead to the reversion of bacteria from L-forms to active strains and their intensive reproduction. The occurrence of chlamydial conjunctivitis causes serotype D-K, which also plays a leading role in the etiology of paratrachoma in newborns.
The defeat of the conjunctiva can be realized in a domestic way. Bacteria enter the mucous membrane of the eyeball through hands, personal hygiene items, after direct contact with infected genital secretions. It has been proven that chlamydia remain viable in water for a long time. Even an asymptomatic carrier of genitourinary chlamydia can lead to infection of the eyes of a healthy person. The risk of infection increases significantly with the oral form of sexual intercourse. Pathology occurs in isolation or against the background of Reiter’s syndrome, which develops by an autoimmune mechanism.
Paratrachoma is an acquired disease, but D–K serotypes are able to potentiate the development of the disease in the neonatal period. In accordance with the clinical classification , the following forms of pathology are distinguished:
- Spicy. In this variant, swelling increases sharply, leading to narrowing of the eye slit. Hyperemia of the palpebral conjunctiva extends to the transitional folds. After 2-3 days, loose follicles are formed, which are considered as paratrachoma-specific inclusions.
- Chronic. Symptoms occur only after exposure to adverse factors. A recurrent course is characteristic, leading to secondary complications from the organ of vision.
The disease can be asymptomatic for a long time. In acute form, the first signs of the disease appear 1-2 weeks after infection. With paratrachoma, only one eye is more often affected. Patients complain of the release of a small amount of mucopurulent masses, which are subsequently replaced by an abundant purulent secret. Patients note swelling and hyperemia of the conjunctiva, photophobia, a feeling of pain and burning in the eyes. On 3-5 days from the moment of the development of the first symptoms, regional lymph nodes increase on the side of the lesion. Palpation of lymph nodes is painless, the skin above them is not changed.
The chronic form of the disease is prone to slow progression. Exacerbations occur regularly, which are manifested by increased lacrimation, photophobia, redness of the orbital conjunctiva. The development of relapses is associated with the influence of external factors – wearing contact lenses, hypothermia, uncontrolled intake of antibacterial or antiviral agents. It is very difficult to establish a link between the chronic variant of the disease and chlamydia. Instillations of NSAIDs or antibacterial agents allow to stop clinical manifestations for a short period of time. Scarring of the conjunctiva at the site of the appearance of specific inclusions does not develop.
The acute form of pathology is complicated by lymphadenopathy, in which the anterior lymph nodes are most often affected. The appearance of noise and pain in the ear in combination with hearing loss indicates the development of tubootitis. Less often there is a clinic of isolated eustachiitis. In 52% of cases, dry keratoconjunctivitis occurs after a trachoma. The spread of infection to the palpebral conjunctiva in the chronic variant leads to blepharitis. Patients with paratrachoma have a high probability of developing infectious and inflammatory diseases of the anterior eye (keratitis, retinitis). Involvement in the pathological process of the uveal tract leads to iridocyclitis, chorioiditis.
To confirm the diagnosis, a physical examination of the patient is carried out, special examination methods are prescribed. Pronounced puffiness of the eyelids, narrowing of the eye slit is visually determined. In order to identify the causative agent of paratrachoma:
- Scraping off the conjunctiva. With a specific staining according to Romanovsky-Giemse, a lesion of the mucous membrane by the causative agent of the disease is detected. The technique is uninformative with respect to L-forms.
- The method of fluorescent antibodies (MFA). It has the highest informative value, since it makes it possible to qualitatively and quantitatively determine the surface and intracellular antigens of microorganisms.
- Enzyme immunoassay (ELISA). Allows you to identify specific antibodies to the pathogen antigens. An increase in the antibody titer of at least 1 is considered to be diagnostically significant:4.
- Polymerase chain reaction (PCR). PCR-based test systems are a highly informative way of diagnosing a disease, in which the DNA of the pathogen is determined.
The main method of instrumental research is biomicroscopy of the eye. Biomicroscopically, hyperemia and infiltration of the conjunctiva are detected. The pathological process extends to the area of transitional folds. A typical sign of paratrachoma is the formation of loose follicles in the lower transitional fold with a tendency to merge into two, less often into three rollers. In the upper part of the articulation of the cornea and sclera, there is swelling, infiltration and vascularization of the limb. Fine-point infiltrates are detected on the surface of the cornea, the color of which does not change when stained with fluorescein. Additionally, the following is shown:
- Visometry. In most cases, visual dysfunction does not occur. A decrease in visual acuity is observed only with a complicated course of pathology.
- Ophthalmoscopy. When examining the fundus in patients with lesions of the posterior parts of the eyeball, the ophthalmologist determines a slight accumulation of exudate, small-point areas of hemorrhage.
- Ultrasound of the eyes. Organic changes of the eyeball are revealed with the size of the anteroposterior axis of the eye unchanged. When the lens is affected, ultrasound is the method of choice in the examination of the vascular membrane.
- Contactless tonometry. When the pathological process spreads to the drainage system, an increase in intraocular pressure is detected. If there is insufficient effect from hypotensive therapy, tonography is performed.
Additionally, a gynecologist’s consultation is indicated for women, and a urologist for men. With concomitant symptoms from the musculoskeletal system, an examination by a rheumatologist is necessary.
Treatment of paratrachoma
The main goal of paratrachoma treatment is complete eradication of the pathogen from the body. If the damage to the organ of vision occurs a second time against the background of urogenital chlamydia or Reiter’s syndrome, the main pathology should be eliminated first of all. Conservative therapy is based on the use of:
- Antibacterial drugs. Azithromycin instillations have the greatest effectiveness in the treatment of chlamydia infection. The drug is used in a short course lasting 3 days. If necessary, the course is repeated after 1 week. Additionally, the use of antibacterial ointments (tetracycline, ofloxacin ointment) is shown.
- Nonsteroidal anti-inflammatory drugs. They are prescribed in the presence of signs of a local inflammatory process. Instillations of NSAIDs make it possible to eliminate edema and prevent violation of the outflow of intraocular fluid.
- Glucocorticosteroids. Hormonal agents are indicated for severe paratrachoma or in the absence of an effect from the use of NSAIDs. They are used in the form of drops or retrobulbar injections.
- Moisturizers. Artificial tear preparations and their analogues are used to prevent dry eye syndrome. With xerophthalmia, it is necessary to use moisturizing gels or ointments daily.
- Antihypertensive drugs. Hypotensive therapy is indicated with an increase in intraocular pressure. Instillation of drugs should be combined with anti-inflammatory therapy.
- Vitamin therapy. They are used to increase the overall reactivity and resistance of the body. The intake of vitamins of group C, A, R is indicated.
Prognosis and prevention
With timely treatment, the prognosis for life and visual functions is favorable. Visual dysfunction occurs only with secondary damage to the posterior segment of the eyeball. Specific preventive measures have not been developed. Non-specific prevention is reduced to the prevention of the development of chlamydia (refusal of casual sexual intercourse, the use of barrier contraception, regular examination by a gynecologist / urologist, abstinence from sexual activity throughout the entire period of treatment). It is necessary to use only individual personal hygiene items.