TRACHOMA (Pothaki)
According to Ayurveda:
Pothaki is a Kaphaja Lékhana Sadhya Vyadhi. It is one of the Pilla roga.
खाविण्यः कण्डुरा गुब्यों रक्तसर्षपसन्निभाः।
पिडकाच रुजावत्यः पोथक्य इति संज्ञिता: ll (S.U.3/11)
It is a vartmagata roga in which the pidakas resemble red mustard seed. The pidakas are hard (heavy). painful, associated with itching and discharge. The condition having the above features is called as Pothaki.
पोथक्यः पिटिका: श्वेता: सर्पपाभा घनाः कफात् ।
शोफ उपदेह रुकू कण्डू पिच्छिलाश्रु समन्विताः ।
(A.H. U. 8/9)
Pothaki is a condition in which hard follicles with coating, resembling the seeds of white mustard originates in vartma due to vitiation of kapha dosha. The associated symptoms are oedema, sticky discharge, pain and itching.
Chikitsa:
Two methods of treatments are indicated in pothaki:
1. Blood letting
2. Scraping.
Initially blood letting is indicated. This is to be followed by scraping the part slowly.
According to Acharya Vagbhata;
The management of Pothaki is as follows
1. Lekhana.
2. Pratisarana with shunti, saindhava and pippali.
3. Prakshalana with ushnambu.
4. Sechana with kashaya prepared out of khadira, adhaki and shigru.
5. Aschótana with kashaya prepared out of haridra, daruharidra and yashtimadhu mixed with honey.
6. Aschótana with decoction of tender leaves of amra and jambu.
7. Anjana prepared from vidanga, laksha, daruharidra, twak, haratala, manashila and honey.
According to Modern:
Definition:
It is a chronic keratoconjunctivitis primarily affecting the superficial epithelium of
conjunctiva and cornea simultaneously.
It is characterized by a mixed follicular and papillary response of conjunctival tissue.
Etiology:
(1) Causative organism- Bedsonian organism, Chlamydia trachomatis belonging to PLT (Psittacosis Lymphogranuloma Trachoma) group.
It is epitheliotrophic and forms intracytoplasmic inclusion bodies called H.P. bodies
(Halbertstaedter Prowazeke)
(2) Predisposing factorsa.
Age – usually infancy & childhood
b. Sex – female
c. Race – more in jews and less in negroes
d. Climate – dry and dusty
e. Socio-economic status – poor class owing to unhygienic condition, over crowding etc.
f. Environmental factors – exposure to dust, smoke, sunlight etc.
(3) Source of infection- conjunctival discharge of the affected person.
(4) Mode of infection
a.Direct spread through contact by air borne or water borne modes.
b. Vector transmission through flies.
c. Material transfer through contaminated fingers of doctors, nurses and contaminated
tonometers, common towel, hanker chief, bedding and surma rods.
Incubation period: 5-21 days
Pathology:
It is a chronic inflammatory disease which involves epithelial and subepithelial layer of
conjunctiva.
In early stage – epithelial hyperplasia of palpebral conjunctiva.
Lymphocytic infilteration in subepithelial layer
Increased vascularisation and formation of follicles and papillae.
In the healing stage, it is initiated by cicatrization which is directly proportional to the extent of secondary infection.
Results of cicatrization on the following:
(1) Subconjunctival tissue – shallowing of fornix, symblephron.
(2) Bulbar conjunctiva – dryness, keratinization of conjunctival surface
(3) Limbus – Herbert’s pit
(4) Cornea – scarring of corneal tissue, corneal astigmatism (curvature of cornea disturbe)
(5) Angle of A.C. – secondarily rise of IOP.
After Trachoma:
The conjunctiva can never be reformed.
(1) Herbert’s pits are always present.
(2) Palpebral conjunctiva looses its transparency.
(3) Ghost vessels are present – these are remainant of blood vessels formed during the active stage of disease. These are empty vessels with no blood inside.
Symptoms:
(1) In absence of sec. infection –
a. mild F.B. sensation,
b. occasional lacrimation,
c. slight stickiness of the lid,
d. scanty mucoid discharge.
(2) In presence of sec. infection – symptoms of muco-purulent conjuncitivitis develop.
Signs:
(A) Conjunctival sign
a.Congestion of upper tarsal and fornix conjunctiva.
b. Conjunctival follicles – look like sago grains (common on upper tarsal conjunctiva and
fornix, sometimes even on bulbar conjunctiva)
Follicles – scattered aggregation of lymphocytes and other cells in the adenoid layer
Central part – mononuclear histocytes + few lymphocytes + Leber cells
(large multinucleated cells)
Cortical part – actively proliferating lymphocytes.
Most peripheral part – blood vessels.
Presence of Leber cells + signs of necrosis makes confirmation of Trachoma.
c. Papillary hyperplasia- reddish, flat top raised areas and give red and velvery appearance
to tarsal conjunctiva.
Central part- numerous dilated blood vessels.
Cortical part- lymphocytes and conjunctival hypertrophic epithelium.
d. Conjunctival scarring – irregular, star shaped or linear.
Arlt’s line – linear scar present in sulcus subtarsalis.
e. Concretions due to accumulation of dead epithelial cells and mucus in the depressions
called glands of Henle.
(B) Corneal signs:
a. Superficial Keratitis in upper part.
b. Herbert follicles – follicles present in Limbal area.
c. Pannus – infilteration of cornea associated with vascularisation seen in upper part.
Vessels are superficial and lie between epithelium and bowman’s membrane. Later on
Bowman’s membrane is also destroyed.
i. Progressive pannus – infileration of cornea is ahead of vascularisation.
ii. Regressive pannus – (pannus siccus) vessels extend a short distance beyond the
area of infilteration.
d. Corneal ulcer
e. Herbert pits – oval or circular shaped pitted scars left behind healing of Herbert follicles
in the limbal area.
f. Corneal opacity – it is the end of trachomatous corneal lesions. May involve the papillary area.
Grading of Trachoma:
Mc Callan’s classification (1908) –
Stage I – Incipient trachoma or stage of infilteration (hyperemia of palpebral conjunctiva + immature follicles)
Stage II- established trachoma or stage of floride infileration(mature follicles, papillae, progressive corneal pannus)
Stage III- cicatrizing trachoma or stage of scarring(scaring of palpebral conjunctiva)
Stage IV- healed trachoma or stage of sequel
(disease is quiet and cured but sequel due to cicatrization give rise to symptoms.)
Complication:
(1) Trichiasis – forward, upward, downward direction of eyelashes is normal, but in trichiasis it turns into forward, downward, backward. (infection when affects the hair follicles or cicatrization may distort the direction of cilia.)
(2) Entropion – inward rolling of the lid margin. (inner surface of tarsal plate affected and thickened due cicatrization leads to entropion.)
(3) Symblepheron and shallowing of fornix.
(4) Corneal haze and astigmatism. (cornea get flattened – astigmatism, and vessels – haze)
(5) Corneal vascularization – pannus
(6) Conjunctival xerosis – keratinization of bulbar conjunctiva leads to dryness.
(7) Exposure keratitis – eyelid shortening (inflammation of cornea upto 1/6 of cornea)
(8) Trachomatous ptosis – due to follicles, papillae lid becomes heavy and drop
(9) Dacryocystitis, dacryoadenitis – inflammation of lacrimal sac or gland.
(10) Corneal ulcers and corneal opacities – exposure keratitis and follicles rub the corneal surface due to blinking.
(11) Degenerative changes – concretion formation (calcified degeneration) in palpebral conjunctiva.
Treatment:
(1) Prophylaxis at family level –
a. Don’t use same surma stick without washing.
b. Don’t use saree to wipe tears.
c. Avoid doping children with opiates (fly control)
(2) Prophylaxis at school level
a. Prevent the child from going to school.
b. Proper sanitary measure, avoiding flies etc.
(3) Endemic area- tab. Azithromycin single dose of 2 gms orally.
Treatment-
(1) 20% Sulphacetamide (Phenosulf) drops Q.I.D. for 2-3 months.
(2) 1% tetracycline/ 1% erythromycin eye ointment at night.
(3) systemic – tetracycline tab / tab. Erythromycin 500 mg O.D. for 3 days
Tab. Doxycyline 100 mg B.I.D.
Tab. Azithromycin 1 gms O.D.
In complication – go for surgical treatment.
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