A71.1 Active stage of trachoma

Name of the Condition

• Active stage of trachoma

Summary

Active stage of trachoma is a phase of the chronic infectious eye disease caused by Chlamydia trachomatis. It is characterized by ongoing inflammation of the conjunctiva, often with visible follicular changes and discharge. This stage indicates active infection and requires intervention to prevent progression to scarring and vision impairment.

Causes

Active stage of trachoma is caused by infection with Chlamydia trachomatis, a bacterium transmitted through direct or indirect contact with eye or nasal discharge from infected individuals. Flies can act as vectors, spreading the bacteria in environments with poor hygiene and crowded conditions.

Risk Factors

• Living in areas with inadequate sanitation and limited access to clean water.
• Close contact with infected individuals, especially in households or communities.
• Lack of facial cleanliness, particularly in children.
• Exposure to flies and other vectors in endemic regions.

Symptoms

• Eye irritation, redness, and discharge.
• Swelling of the eyelids (chemosis).
• Formation of follicles on the inner eyelid (trachomatous inflammation—follicular, or TF).
• Scarring of the eyelid (trachomatous scarring, or TS).
• Inward turning of the eyelashes (trachomatous trichiasis, or TT).

Diagnosis

Diagnosis is based on clinical examination of the eye, focusing on signs of follicular inflammation, discharge, and scarring. In endemic areas, rapid diagnostic tests may be used to confirm infection.

Treatment Options

• Antibiotics: Oral or topical antibiotics to eliminate the bacterial infection.
• Hygiene measures: Improved facial cleanliness and environmental sanitation to reduce transmission.
• Surgical intervention: For advanced cases with trichiasis or scarring, eyelid surgery may be necessary.

Prognosis and Follow-Up

With prompt treatment, the active stage can be resolved, preventing progression to severe scarring and vision loss. Follow-up is essential to monitor for recurrence or complications, especially in endemic areas.

Complications

• Corneal opacity and vision impairment.
• Trichiasis leading to corneal damage.
• Permanent blindness if left untreated.

Lifestyle & Prevention

• Practice facial cleanliness, especially for children.
• Improve environmental sanitation and access to clean water.
• Avoid contact with infected individuals or contaminated surfaces.
• Use fly control measures in endemic regions.

When to Seek Professional Help

Seek medical attention if eye irritation, redness, or discharge persists, or if there are signs of scarring or inward-turning eyelashes.

Tips for Medical Coders

Document clinical findings such as follicular inflammation, discharge, or scarring to support the diagnosis. Ensure the code A71.1 is used for the active stage, with clear differentiation from initial or cicatricial stages when applicable.