Tumor necrosis factor alpha (TNF-␣) may play a central role in the disease pathogenesis which occurs as a consequence of chlamydial infection. To investigate the importance of TNF-␣ gene promoter polymorphisms and TNF-␣ levels in tear fluid in scarring trachoma, a large matched-pair case-control study was performed in The Gambia. The-308A allele was present in a higher proportion of patients (28.4%) than controls (18.4%), with an increasing association for homozygotes (2 for trend, P ؍ 0.032; allele frequency, 0.163 in patients and 0.099 in controls; 2 , P ؍ 0.025). For the-238A allele, the association was similar but not significant. The disease association was highly significant when the number of either-308A or-238A sites in an individual was considered (P ؍ 0.003). TNF-␣ promoter alleles are tightly linked to some HLA class I and II alleles, but multivariate analysis confirmed that the disease associations were independent of HLA, although a class I allele, A*6802, is also associated with disease. TNF-␣ was more frequently detected in tear samples from patients (27.6%) than from controls (15.9%), increasingly so for higher levels of detectable TNF-␣ (P ؍ 0.015). Among patients, detectable TNF-␣ in tears was highly associated with the presence of ocular chlamydial infection (P < 0.001). The results indicate that TNF-␣ plays a major role in the tissue damage and scarring which occurs as a consequence of Chlamydia trachomatis infection.