International Coalition for Trachoma Control

Co authored by Esmael Habtamu, Research Fellow: International Centre for Eye Health, London School of Hygiene and Tropical Medicine and Matthew J Burton, Professor of International Eye Health & Wellcome Trust Senior Research Fellow in Clinical Science

Trichiasis, the advanced stage of trachoma, is a painful condition, which some patients describe as feeling like a thorn stabbing the eye. The eyelashes turn inwards and scratch the cornea which causes great pain and can lead to irreversible sight loss from scarring of the cornea. Our research in Ethiopia shows that the knock on effects of surgery on people’s quality of life are far reaching, significantly improving wellbeing in many facets of their lives including their economic productivity. This underlines the importance of treating the 3.2 million people currently in need of surgery – many of whom have too long been overlooked by development interventions.

Recognising that clinical outcomes do not provide the full picture of a condition’s impact on an individual and their family, measuring quality of life has become an important aspect of health intervention measurements. Trachoma has major personal, social and economic consequences for individuals, families and communities. It typically affects the poorest people, keeping them trapped in a cycle of poverty as the disease passes from one generation to the next.

In a recent case-control study in Ethiopia, we found that people living with trichiasis were from significantly poorer households than their neighbours without the condition. Trachoma is a preventable disease but, unlike cataract, once it has advanced to a stage where it causes significant vision loss, sight cannot be fully restored. The impact of this on the individual can be devastating.

In our recent case-control study in Ethiopia, we found strong evidence that trichiasis markedly impairs quality of life, affecting people’s physical and mental health as well as their ability to engage in social and economically productive activities. Quality of life was scored between 0 (lowest) and 100 (highest). People with trichiasis reported substantially lower levels of vision (Mean score, 45.9 vs 95.4) and overall health satisfaction (Mean score, 38.2 vs 71.7) than those without the condition. 59% also reported that they felt embarrassed, 91.3% worried that they might lose their remaining eye sight, 68.1% suffered sleep disturbances and 7% had been troubled in their marriage – confirming that trichiasis has a considerable impact on self-esteem. Other studies indicated that people with trichiasis reported social withdrawal or stigmatization.

Furthermore, trichiasis significantly reduced an individual’s capacity to carry out productive activities. People with trichiasis were less likely than unaffected individuals to participate in productive and social activities. They were also more likely to report difficulty in performing productive and social activities; and seek assistance in performing productive  and social  activities than those without the condition, which in turn would have negative consequences for their household incomes.

Trichiasis is treated with corrective eyelid surgery to turn the eye lashes away from the cornea to reduce the risk of blindness. Our recent longitudinal studies show that the resulting benefits of this treatment go beyond preventing the risk of blindness to improving people’s overall wellbeing, health perception and daily functioning. 

We measured the vision and health-related quality of life of 1,000 people with trichiasis before they underwent surgery and one year after they had undergone it and compared them to 200 participants who did not have trachoma or trichiasis. The results show that, a year after corrective eyelid surgery, quality of life improved substantially by up to 42 points on a 0 – 100 quality of life scale. Although larger gains were seen among people whose vision improved after the surgery, substantial improvement also occurred for patients whose vision did not improve or whose vision continued to deteriorate (potentially from other ocular conditions). People suffering from trichiasis on both eyes, advanced trichiasis or vision obscuring corneal opacity reported significantly larger quality of life gains as a result of surgery compared to other participants. 

In a separate analysis, we found strong evidence that trichiasis surgery substantially improves the ability to take part in productive activities such as farming (5.7%) fetching wood (23.6%) and processing agricultural products (18.1%). Similarly, there was a significant increase in the proportion of people who could perform activities without assistance with the largest increases seen in animal rearing (37.8%) and farming (23.2%). 

There is a clear case for investment in trichiasis surgery. Scale up of surgical programs will not only reduce the burden of blindness but also to improve people’s overall wellbeing and ability to be economically productive, contributing to improved household income and wealth. A number of large scale programs currently underway – including the DFID SAFE Trachoma Program, the Queen Elizabeth Diamond Jubilee Trust Trachoma Initiative, the ENVISION Morbidity Management and Disability Prevention (MMDP) Project and the SightFirst program and many programs supported by individual member organizations of the International Coalition for Trachoma Control – are making great inroads to tackle the problem. However, our research makes a clear case for more investment to reach all of the 3.2 million people that remain in need of surgery to avoid blindness due to trachoma. 

As a disease that affects the poorest and most marginalized communities, effectively treating and working to prevent trachoma will support the Sustainable Development Goals’ commitment to end extreme poverty and to leave no one behind. Action is urgently needed if we are to fulfil global commitments to ensure global prosperity and reach everyone, everywhere. 

 This blog was written by Esmael Ali, Research Fellow: International Centre for Eye Health, London School of Hygiene and Tropical Medicine

Further reading

Palmer SL, Winskell K, Patterson AE, et al. ‘A living death’: a qualitative assessment of quality of life among women with trichiasis in rural Niger. International health 2014; 6(4): 291-7.

Habtamu E, Wondie T, Aweke S, et al. Impact of Trichiasis Surgery on Quality of Life: A Longitudinal Study in Ethiopia. PLoS Negl Trop Dis 2016; 10(4): e0004627.

WHO Alliance for the Global Elimination of Trachoma by 2020. Eliminating Trachoma: Accelerating Towards 2020, 2016.

Habtamu E, Wondie T, Aweke S, et al. Trachoma and Relative Poverty: A Case-Control Study. PLoS Negl Trop Dis 2015; 9(11): e0004228.