Eyes - trachoma

About trachoma

Trachoma is a bacterial infection of the eye that can cause complications including blindness. It is caused by Chlamydia trachomatis. This preventable disease is linked to poor hygiene and is often associated with poverty. Lack of facial cleanliness is the main factor that allows the transmission of the infection. People need some 150 to 200 episodes of infection and re-infection to cause severe conjunctive scarring and in-turned eye lashes that lead to blindness. Trachoma is also sometimes known as sandy blight.

This communicable disease is still common in a number of remote Aboriginal communities. More than 40 developing countries throughout Africa and Asia are also affected by trachoma, particularly in rural areas where hygiene tends to be poor, but 15 countries have eliminated trachoma in the last few years.

During the 20th century, there was considerable improvement in living conditions around the world. Separate rooms for sleeping, running water and plumbed sewerage meant that trachoma disappeared from all developed countries – except in outback Australia.

Australia is the only Western nation still affected by trachoma. In 2009, the Australian Government made a commitment to eliminate blinding trachoma from Australian Aboriginal communities by 2020. This target was missed but elimination by 2024 is the new target.

How trachoma is spread

Trachoma is a communicable disease caused by the bacterium Chlamydia trachomatis. It is usually transmitted by:

• direct contact such as touching infected eye secretions
• other forms of direct contact such as touching infected nasal secretions
• indirect contact such as touching contaminated items – for example, towels, sheets, blankets or clothing.

A single episode of chlamydial conjunctivitis, “inclusion conjunctivitis”, will resolve spontaneously over a month or two and leave little or no impact. An individual may need to have 150 to 200 episodes of reinfection to sustain the intense inflammation for sufficiently long to lead to severe scarring that leads to trichiasis and blindness.

Symptoms of trachoma

Signs and symptoms begin within five to 12 days following infection and may include:

• eye irritation, redness and discharge (conjunctivitis)
• swelling of the eyelids
• inflammation inside the upper eyelid and lymphoid follicles (lumps caused by an immune system reaction)
• scarring and distortion of the upper eyelid develops over time from repeated episodes of reinfection
• development of eyelashes that turn into the upper lid and then rub on the cornea
• abnormal growth of corneal blood vessels
• cornea scarring (transparent membrane that covers the eye surface).

People with trachoma may not experience symptoms (asymptomatic) and the condition may go unrecognised, unless it’s specifically looked for.

Complications of trachoma

Without medical treatment, recurrent infections and inflammation can cause corneal scarring and eyelid deformities. A common late complication is eyelid inversion (entropion) – the lashes turn inwards (trichiasis) and continually rub against the cornea. This irritation can cause corneal scarring and then vision loss and blindness in the long term.

The incidence of trachoma is high among Aboriginal populations

Trachoma remains in a number of remote Aboriginal communities in Australia. Depending on the area, community disease rates range from less than 5% to more than 20%. However, the overall rate or trachoma has decreased significantly and many communities now no longer have trachoma.

Risk factors of trachoma

Trachoma is linked to poor personal and community hygiene, and is often associated with poverty.

Particular risk factors include:

• inadequate personal hygiene, especially a dirty face
• lack of understanding about the importance of environmental cleanliness and personal hygiene, especially about facial cleanliness in children
• inadequate housing and the lack of safe and functional bathrooms
• lack of prompt repair and planned maintenance of housing and services
• crowded living conditions, such as having children share the same bed
• poor water supply (about one Aboriginal person in six doesn’t have a drinkable water supply in the Northern Territory)
• living inland, since coastal populations can clean themselves by swimming in the sea
• young age, since the infection is more common among preschool children.

Diagnosis of trachoma

Tests used to diagnose trachoma may include:

• medical history
• physical examination including an eye examination (including everting or flipping the eyelid)
• eye swab for laboratory testing, but the diagnosis is normally made by clinical examination.

Treatment for trachoma

Treatment depends on the severity of the condition, but may include:

• antibiotic medications – a single oral dose of an antibiotic (azithromycin) is the first line of treatment in uncomplicated cases. This medication kills off the bacteria so that the body’s natural healing processes can repair the eye. Antibiotics must be given to all household members where trachoma is found. In areas where there is widespread infection, the whole community may need to be treated. Treatment may need to be repeated every six to 12 months.
• surgery – this is used to correct the eyelid deformity and evert (turn outwards) the injured eyelashes in older people.

Prevention of trachoma

A clean face and clean environment are the main prevention strategies to combat trachoma (no visible secretions from the eyes or nose). The Australian guidelines (prepared by Communicable Disease Network Australia) closely follow those outlined in SAFE, the World Health Organization’s proposed form of trachoma control. SAFE stands for Surgery, Antibiotics, Facial cleanliness and Environmental improvement.

Prevention of trachoma in remote communities is proving to be difficult. During the 1970s, the Australian Government treated nearly 40,000 Australians affected with trachoma. In November 2006, the National Trachoma Surveillance and Reporting Unit (NTSRU) was established to combat trachoma among remote Aboriginal communities.

The proper implementation of the full SAFE Strategy has significantly reduced trachoma in many communities. The overall prevalence of trachoma in children between five and nine years old in endemic areas in 2009 was 14% and, in 2021, this had been reduced to 3.3%. However, according to the NTRSU, 11% of communities had rates over 20%.

Where to get help

• Your GP (doctor)
• Ophthalmologist or optometrist
• Indigenous Eye Health Unit, The University of Melbourne Tel. (03) 8344 9320
• Royal Australian and New Zealand College of Ophthalmologists Tel. (02) 9690 1001