The Blinding Cycle

A 28-year-old woman presents to a district health clinic in the Amhara region of Ethiopia with a three-month history of bilateral eye irritation, mucopurulent discharge, and photophobia. She works as a community health worker in a rural village where access to clean water requires a two-hour daily walk. She lives in a compound household with her parents, two siblings, and four young children. Several of the children have had similar eye symptoms for the past year. She reports no prior eye surgery or trauma and no systemic symptoms.

On examination, visual acuity is 20/25 bilaterally with no correction. There is mild conjunctival injection and a scant mucopurulent discharge in both eyes. Slit-lamp biomicroscopy of the everted upper eyelids reveals the finding shown in the image below. The lower tarsal conjunctiva and cornea are clear. There is no eyelid scarring, no in-turned eyelashes, and no corneal opacity on this examination. Regional lymphadenopathy and systemic examination are unremarkable.

A survey conducted in this community three months ago found that 38% of children aged 1 to 9 years had the same finding on upper tarsal conjunctival examination. The district health officer is asking for guidance on both individual management and community-level response.