H. R. TAYLOR, M.R.A.C.O., D.O. Assistant Director, National Trachoma and Eye Health Program; Research Associate, Melbourne University Department of Ophthalmology

SUMMARY The early findings of the National Trachoma

and Eye Health Program show that the blindness rate for Australian Aborigines living in Central Australia is eighteen per thousand. Most blind- ness occurs in those over sixty years of age, when one in four Aborigines is blind. The commonest cause of blindness is senile cataract. Ocular trauma, corneal opacities and Labrador keratopathy are seen commonly, as is Trachoma- tous blindness. Pseudo-exfoliation is a frequent finding, but is not often associated with glau- coma.

INTRODUCTION The Australian Aborigines suffer from chronic

ill health. Chronic infections, including trepone- mal, are frequent. Malnutrition, obesity, diabetes and vascular disease are also common. Of particular interest is the continuing high incidence of eye di, cease.

The National Trachoma and Eye Health Program has been reassessing the eye diseases which are commonly found in Australian Aborigines. The programme has already found most Aborigines in Central Australia show some signs of trachoma. This paper presents the frequency and causes of blindness found in Australian Aborigines.

Past investigators, including Black and Cldand (1936) ;l Schneider (1946) ;2 Father Frank Flynn (1957)3 and Ida Mann (1966-68)45 have drawn attention to the high prevalence of blindness in Australian Aborigines. I t is dis-

Paper Read to Annual Congress, Australian College of Ophthalmologists, March 28, 1977, Melbourne.

Address for reprints: Dr. H. R. Taylor, National Trachoma and Eye Health Program, 27 Commonwealth Street, Sydney, New South Wales, 2010, Australia.

BLINDNESS IN AUSTRALIAN ABORIGINES

Age

0-20 , . 20-29 _ . 30-39 . . 40-49 . _ 50-59 . . 60f . . , . Overall . .

tressing that the prevalence and causes of blindness have not changed significantly over the last thirty years.

INCIDENCE AND CAUSES OF BLINDNESS The Program to date has examined more

than 12,500 Aborigines in Central Australia. Two hundred and twenty people have been found whose vision is 6/60 or less in each eye. These people are classified as blind. This gives a frequency of blindness of 18 : lOOO Aborigines; that is, almost 2% of all Aborigines living in Central Australia are blind. In Australian whites, the blindness figures are approximately 1:lOOO or 0.1”/c?6

Percentage of Total -__ -__- Binocular Monocular

0 . 0 2 0 . 3 0 . 3 1 . 5 0 . 1 1.9 1 . 1 6.6 5 . 5 1 4 . 7

25.1 22.5

1 . 8 2 . 5 - -

TABLE 1 Age Distribution of Blindness in 12,500 Aborigines

A better understanding of the magnitude of the problem is obtained by considering the occurrence of blindness in each age group, (Table I). The frequency of binocular and monocular blindness increases with age, and there is a dramatic increase in blindness in the elderly. For every four people of sixty years or more, one is blind, and another has a blind eye.

To guide attempts to reduce this high prevalence of blindness, a special study is being conducted, investigating the causes of blindness in Australian Aborigines. As data collection and processing are not yet complete, the figures presented are interim results from the examina- tion of only 1,300 Aborigines. Of these 1,300, 28 had binocular blindness, the causes of which are shown in Table 2.

155

By far the most common cause of blindness is senile cataract, this being nearly always nuclear sclerosis. Fourteen people had bilateral cataracts causing blindness, and another three were blinded with cataract in one eye, while the fellow eye of one had an opaque cornea, a pterygium covered the pupil in another, and in the third, the fellow eye was phthisical.

Ocular trauma caused blindness in seven people. In all these cases the cause of blindness was anterior segment disease.

TABLE 2 Cuuses of ninoeulur IllindnPsn in 1300 Aboriqmes

Cataract . . . . . . . . . . 14 Coriieal scar . . . . . . . . . . 4 I’hthisis . . . . . . 3 J,ahrador kerato’pathy . . . . . . . 3 nacilo1na . . . . . . . . 2 Interstitis1 kerkiktis . . . . . . . . 1 I’terygiuin arid cataract . . . . . . 1

Total . . . . . . . . . . . . 28 -

There were two causes rarely seen in Aus- tralians of European stock. One is trachoma, which blinded two people, and the other, Labrador keratopathy, which blinded three.

Labrador keratopathy is a superficial corneal degeneration characterised initially by a fine frosting of epithelium in the palpebral aperture. It may extend to cover the optical axis, and may be associated with spheroidal droplet degenera- tion. I t is thought to result from years of exposure to a hot, dry, gritty atmosphere. In all, eight of 28 blind people had Labrador kerato- pathy.

TABLE 3 Causes of Alonocular Blindness in I100 Aborigmes

Smile &:wart 13 Traumatic cataract Corneal scar . . Phthisis . . Trachoma Iirtrrstitisl kerktitis Optic atrophy . . Chorioretiiiopathy

Total . .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

.. . .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. . 5

. . 8 . . 4

.. 3

. . 2

. . 1 . . 1

37

Also in the group of 1,300 Aborigines there were 37 who had monocular blindness, that is, the vision in one eye was 6/60 or less, (Table 3 ) .

Again, senile cataract was the commonest cause of blindness. Very importantly, 12 of the 13 with senile cataract had vision of 6/24 or less in their fellow, or better eye, as did the three with trachoma, and one of those who had a traumatic corneal scar.

Sixteen cases of monocular blindness were due to trauma; the effects of trauma being shown as traumatic cataracts, corneal scars, phthisis and optic atrophy.

Ocular trauma is a significant cause of blind- ness, and occurs at all ages. Corneal abrasions or penetrating injuries which may not cause irrevocable visual impairment if adequately managed, are a potent cause of blindness in areas where medical, let alone ophthalmic, services are not readily available, and where the normal protective processes are diminished by trachoma.

One in twenty people over the age of sixty are blind, or ne]arly blind, from trachoma.

ANTERIOR SEGMENT EYE DISEASE To try to get a better understanding of the

nature and development of anterior segment blindness, a further survey is being undertaken. People of various age group are randomly selected and examined on the slit lamp. A special

TARLE 4 Anterior Seament Disease in 32 Aborigines*

Xormal . . . . . . Corneal opacity . . . . Yterygium . . . . Labrador keratopatii’y . . Trachomatous bliridiiess . . Cataract . . . . Pseudo-exfoliation . . . .

Piumber seen . . . .

~ ~ _ _ 15-34 35-44 45-51 ______ I I A g e

-1- I-

I I ~~

* Some people showed multiple pathology.

__ _- 85-64 I 65 +

1 0 3 2 1 3 2 3 1 2 3 3 1 1

history of general, environmental and personal factors, including ocular trauma and occupation, is taken. Preliminary results are shown in Table 4. Every person examined has shown signs of trachoma.

Eyes without anterior segment disease become more infrequent as age increases. Corneal opacities are seeln at all ages, and usually result from trauma. They may range from a scar from a corneal foreign body to a vascularised leucoma. Labrador keratopathy, trachomatous blindness and cataracts are usually confined to the elderly.

The finding of pseudo-exfoliation aroused much interest, particularly as some authors feel the condition may be inherited from Viking ancestors.7 Pseudo-exfoliation is found com- monly in full-blood Aborigines in Central Aus- tralia.’

156 AUSTRALIAN JOURNAL OF OPHTHALMOLOGY

Table 5 sets out the prevalence of pseudo- exfoliation found in 2,500 Aborigines in South Australia. The prevalence increase steadily with age to 16.5% in those over the age of sixty. This is three times that found in Europeans,? and three hundred times that found in the Bantu.lO Surprisingly, pseudo-exfoliation was not commonly associated with glaucoma. Only S% of people with pseudo-exfoliation had an elevated intra-ocular pressure and enlarged cups of the'optic disc.

What I have attempted to do, is to outline again, the desperate state of ocular health that exists in the Australian Aborigines. I must stress that one in four Aborigines over the age of sixty is blind. Aborigines make up but 1% of the Australian population, but blind Aborigines account for one sixth of people blind in Aus- tralia. Most of the blindness of white Australians is not preventable. Almost all the blindness in

TABLE 5 Prevalence of Pseudo-Exfoliation of the Len8 in an Aboriginal Population of 2500

and was given glasses. I was with him in the Army plane that flew him back to Giles after the surgery. His excitement in being able to see his own country again overcame his fear of flying, and he was received by the community with great joy.

Eight days ago, I was in Giles again. I arrived at the camp and enquired about Russett and the other post-surgical patients. I was directed to a group sitting under a tree. As I neared it, I saw Russett, who was two or three hundred yards away, hurrying towards me. He saw that I had noticed him, and he started to wave to me. He rushed over to me, picking his way through a stony creek bed, and embraced me. He was still wearing his glasses.

This elderly blind man that I had seen and operated on in November was now a new man. He knew it, and the community knew it. He was my patient, and he accepted me as his doctor. There are many other patients like him in Central Australia in need of a similar ophthalmic service.

Age

<30 . . . . 31-40 .. . . 41-50 . . . 5 1 - 6 0 . , . . 61+ . . . .

Overall . .

Prevalence

0 0 . 4 1 . 6 2 .8

16 .5

1 . 3

Aborigines is due to preventable, or remediable causes; over half the blindness being due to cataract. Surely there is an obligation here for

I would like to end with a story which I think is very important.

In early November last year, I went to Giles as part of the National Trachoma and Eye Health Program. Giles is on the edge of the Gibson Desert, two days' drive from Alice Springs, and three days' drive from Kalgoorlie. There I met an elderly, blind. Pitjantatjara man called Russett. He was in his late sixtim and his blindness was due to cataracts.

In late November he had a cataract extraction performed at Amata in the Army Field Hospital,

us.

REFERENCES BLACK, E. L., and CLELAND, J. B. (1936), Pathological

lesions in Australian Ahorigines in Central Australia and Flinders Ranges, 1. crop. Med. Hyg., 41: 69.

SCHNEIDER, M. (1946), A sociological study of the Aborigines in the Northern Territory and their eye disease, Med. J. Aust., 1: 99.

'FLY", F. (1957), Trachoma among natives of the Northern Territory of Australia, Med. J. Aust., 11: 269.

'MANN, I. (1966), Culture, Race, Climate and Eye Disease, Charles C. Thomas, Springfield.

'MANN, I., and ROUNTREE, P. (1968), Geographic ophthalmology, a report on a recent survey of Australian Aboriginals, Amer. J. Ophthal., 66: 1020.

' ANDERSON, J. R. (1939), Blindness in private practice, Med. 1. Aust., 2: 680.

' AASVED, H. (1%9), The geographical distribution of fibrillopathia epitheliocapsularis, Acta Ophthal. (Kbh.), 47: 792.

*TAYLOR, H. R., HOLLOWS, F. C., and MORAN, D. (1977), Pseudo-exfoliation of the lens in Australian Aborigines, Brit. J . Ophthal., 61: In the press.

' AASVED, H. (1971), The frequency of fihrillopathia epitheliocapsularis in patients with open angle glaucoma, Acta Ophthal. (Kbh.), 49: 194.

"LUNTZ, M. H. (1972), The prevalence of pseudo- exfoliation syndrome in an urban South African clinic population, Amer. J. Ophthal., 74: 581.

BLINDNESS IN AUSTRALIAN ABORIGINES 157