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Kreis AJ, Gower EW, Kropp M, Kello AB, Nouhoum G, Resnikoff S, Talero SL, Solomon AW. The prevention and management of postoperative trachomatous trichiasis: A systematic review. Surv Ophthalmol 2024; 69:93-102. [PMID: 36878359 DOI: 10.1016/j.survophthal.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
Among ocular infections, trachoma is the main cause of blindness. Repeated conjunctival Chlamydia trachomatis infections lead to trichiasis, corneal opacification, and visual impairment. Surgery is often needed to relieve discomfort and preserve vision; however, a high postoperative trachomatous trichiasis (PTT) rate has been observed in various settings. We wanted to know why, whether PTT rates could be reduced, and how to manage the PTT that occurs. We performed a search of the literature. Of 217 papers screened, 59 studies were identified for inclusion as potentially relevant, the majority having been excluded for not directly concerning PTT in humans. Preventing PTT is a major challenge. Only one published trial, the STAR trial in Ethiopia, has reported a cumulative PTT rate <10% one year after surgery. The literature on the management of PTT is sparse. Though no PTT management guidelines are available, high-quality surgery with a low rate of unfavorable outcomes for PTT patients is likely to require enhanced training of a smaller group of highly-skilled surgeons. Based on the surgical complexity and the authors' own experience, the pathway for patients suffering from PTT should be studied further for improvement.
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Affiliation(s)
- Andreas J Kreis
- Experimental Ophthalmology, University of Geneva, Geneva, Switzerland; Department of Ophthalmology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Emily W Gower
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Martina Kropp
- Experimental Ophthalmology, University of Geneva, Geneva, Switzerland; Department of Ophthalmology, University Hospitals of Geneva, Geneva, Switzerland
| | - Amir B Kello
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Guirou Nouhoum
- Techniques and Technologies of Bamako, Institut d'Ophtalmologie Tropicale d'Afrique, University of the Sciences, Bamako, Mali
| | - Serge Resnikoff
- Organisation pour la Prévention de la Cécité, Paris, France; School of Optometry & Vision Science (SOVS), University of New South Wales, Sydney, Australia
| | - Sandra L Talero
- Research Department of Development and Innovation, Superior School of Ophthalmology, Barraquer Institute of America, Bogotá, Colombia
| | - Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Shrestha R, Merbs SL, Bayissasse B, Sisay A, Beckwith C, Courtright P, Gower EW. Characteristics and perspectives of patients with postoperative trichiasis in Hadiya Zone, Ethiopia. Int Health 2022; 14:i49-i56. [PMID: 35385867 PMCID: PMC8986352 DOI: 10.1093/inthealth/ihac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/08/2021] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Postoperative trachomatous trichiasis (PTT) is a challenge for trichiasis surgery programs. Little is known about PTT patients’ perceptions regarding outcomes and future disease management. This study aimed to understand the characteristics of PTT patients, how they managed trichiasis and their perceptions of prior surgeries and future surgery uptake. Methods Patients with PTT were identified during an existing trichiasis screening program in Hadiya Zone, Ethiopia. A vision assessment and evaluation of the eyelids were conducted to determine distance vision, presence and severity of trichiasis and eyelid contour abnormalities. A questionnaire was administered to obtain information regarding patients’ perceptions of surgery and PTT management approaches. Descriptive statistics were used to characterize PTT and determine associations between PTT severity and patient perceptions. Results Among 404 participants, most were female (79.7%) and aged 40–60 y (62.6%). In total, 514 eyelids had PTT, and nearly half had severe PTT (46.9%). Although >50% of participants were currently epilating to manage their PTT, the majority (82.8%) indicated that they wanted repeat surgery. Most participants indicated that pain persisted despite epilation. The majority (75.1%) indicated satisfaction with their prior surgery and 59.6% indicated that they would recommend surgery to others. Conclusions This study, which included a large proportion of severe PTT cases, indicated that individuals were generally satisfied with prior surgery and would prefer to have surgery again for PTT management.
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Affiliation(s)
- Riju Shrestha
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shannath L Merbs
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | - Paul Courtright
- Sightsavers, Haywards Heath, UK.,Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Emily W Gower
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Ophthalmology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Diab MM, Allen RC. Recurrent upper eyelid trachomatous entropion repair: long-term efficacy of a five-step approach. Eye (Lond) 2021; 35:2781-2786. [PMID: 33235346 PMCID: PMC8452750 DOI: 10.1038/s41433-020-01306-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 10/05/2020] [Accepted: 11/06/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To describe the lid characteristics of recurrent upper eyelid trachomatous entropion and to report the long-term outcomes of a five-step surgical approach based on the principles of upper eyelid crease lamellar splitting and retractor release with redirection. SUBJECTS AND METHODS Retrospective case review of adult patients with recurrent upper eyelid trachomatous entropion who had undergone surgical correction using the five-step surgical technique between March 2014 and March 2018. Cases with primary entropion and/or <2 years of follow-up were excluded from this series. MAIN OUTCOME MEASURES Eyelid deformities (type of trichiasis, anterior lamellar laxity, lid margin abnormality, lid retraction and lagophthalmos), recurrence of entropion and trichiasis, cosmetic satisfaction, and surgical complications. RESULTS Forty-two upper eyelids in 33 patients met inclusion criteria. Preoperative anterior lamellar laxity was present in 36 eyelids (85.7%), lid retraction in 31 eyelids (73.8%) with a mean preoperative MRD1 of 6.48 ± 1.1 mm, atrophic tarsus in 28 eyelids (66.7%), lid margin notching in 22 eyelids (52.4%), and lagophthalmos in 15 eyelids (35.7%). The surgical success rate was 92.9% (95% CI 0.805-0.985). There was no documented recurrence of entropion over a mean follow-up period of 31.79 months. Postoperative trichiasis without entropion occurred in three eyelids, which required repeat epilation. CONCLUSIONS The five step-approach based on the principles of lamellar splitting is effective in correction of recurrent trachomatous entropion with long-term stability. The procedure addresses the fundamental changes frequently seen in recurrent cases, in particular anterior lamellar laxity, scarred shortened posterior lamella, and trichiasis.
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Affiliation(s)
- Mostafa M. Diab
- grid.411170.20000 0004 0412 4537Department of Ophthalmology, Faculty of Medicine, Fayoum University, Al Fayoum, Egypt
| | - Richard C. Allen
- grid.39382.330000 0001 2160 926XDepartment of Ophthalmology, Cullen Eye Institute,Baylor College of Medicine, Houston, Texas USA
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Flueckiger RM, Stelmach R, Burgert-Brucker CR, Courtright P, Kabona G, Mosher AW, Mwingira UJ, Harding JC, Simon A, Ngondi J. Evaluating Precision of a Trachomatous Trichiasis (TT) Super Survey with Modulating Sample Sizes in Tanzania. Ophthalmic Epidemiol 2021; 29:394-400. [PMID: 34380006 DOI: 10.1080/09286586.2021.1950775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
As trachoma programs move towards eliminating trachoma as a public health problem, the number of surveys necessary to evaluate the status of trachomatous trichiasis (TT) increases. Currently, the World Health Organization endorses a district-level population-based prevalence survey for trachoma that involves a two-stage cluster design. We explored the validity of implementing this survey design in larger geographic areas to gain cost efficiencies. We evaluated the change in precision due to combining geographically contiguous and homogenous districts into single evaluation units (EUs) and modulating the sample size by running simulations on existing datasets. Preliminary findings from two opportunities in Tanzania show variability in the appropriateness in conducting this survey across larger geographies. These preliminary findings stress the importance of determining what is meant by homogeneity in terms of TT before combining multiple districts into a single EU.
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Affiliation(s)
- Rebecca M Flueckiger
- Global Health Division, International Development Group, RTI International, Washington, USA
| | - Rachel Stelmach
- Global Health Division, International Development Group, RTI International, Washington, USA
| | | | - Paul Courtright
- Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - George Kabona
- Neglected Tropical Disease Control Program, Ministry of Health and Social Welfare, Dar Es Salaam, Tanzania
| | - Aryc W Mosher
- Bureau for Global Health, United States Agency for International Development, Washington, USA
| | - Upendo J Mwingira
- Neglected Tropical Disease Control Program, Ministry of Health and Social Welfare, Dar Es Salaam, Tanzania
| | | | - Alistidia Simon
- Neglected Tropical Disease Control Program, Ministry of Health and Social Welfare, Dar Es Salaam, Tanzania
| | - Jeremiah Ngondi
- Global Health Division, International Development Group, RTI International, Dar Es Salaam, Tanzania
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Platt E, Doe M, Kim NE, Chirengendure B, Musonda P, Kaja S, Grimes CE. Economic impact of surgery on households and individuals in low income countries: A systematic review. Int J Surg 2021; 90:105956. [PMID: 33940199 DOI: 10.1016/j.ijsu.2021.105956] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/01/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com). METHODS We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. RESULTS 31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs. CONCLUSION Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.
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Affiliation(s)
- Esther Platt
- Imperial College Healthcare NHS Trust, South Wharf Road, Paddington, W2 INY, UK.
| | | | | | - Bright Chirengendure
- Consultant General Surgeon, Ndola Teaching Hospital, Zambia; Copperbelt Medical University, Zambia.
| | - Patrick Musonda
- Consultant General Surgeon, Ndola Teaching Hospital, Zambia.
| | - Simba Kaja
- Consultant Orthopaedic Surgeon, Ndola Teaching Hospital, Zambia.
| | - Caris E Grimes
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, SE5 9RJ, UK; Medway NHS Foundation Trust, Windmill Road, Gillingham, Kent, ME7 5NY, UK.
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Mwangi G, Courtright P, Solomon AW. Systematic review of the incidence of post-operative trichiasis in Africa. BMC Ophthalmol 2020; 20:451. [PMID: 33203380 PMCID: PMC7670604 DOI: 10.1186/s12886-020-01564-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 07/10/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Surgery for trichiasis is one of the pillars of the World Health Organization's strategy for global elimination of trachoma as a public health problem. A high incidence of post-operative trichiasis or other poor surgical outcomes could jeopardize these efforts. In this review, we aimed to summarize the reported incidence of post-operative trichiasis and other poor outcomes of trichiasis surgery in Africa. METHODS We conducted a systematic literature search using PubMed, Academic Search Premier, Africa-Wide Information, CINAHL and Health Source Nursing through EBSCOhost, Web of Science, and the Cochrane Central Register of Controlled Trials. Reference lists of included studies were also reviewed to identify further potentially relevant publications. All observational and interventional studies that measured post-operative trichiasis in Africa as an outcome of trichiasis surgery were included. RESULTS Thirty-five papers reporting on 22 studies (9 interventional,13 observational; total 13,737 participants) met the inclusion criteria. The reported incidence of post-operative trichiasis in the included studies ranged from 2% (at 6 weeks after bilamellar tarsal rotation) to 69% (at 3 weeks after anterior lamellar repositioning). The incidence varied by surgical procedure, study design, and length of follow-up. CONCLUSION Trichiasis surgical outcomes should be improved. National trachoma programmes could benefit from identifying and adopting strategies to improve the performance and quality of their surgical service.
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Affiliation(s)
- Grace Mwangi
- Department of Surgery, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa.
| | - Paul Courtright
- Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Ramyil A, Bascaran C, Bunce C, Alada J, Wade P, Mpyet C. Outcome of trachoma lid surgeries in Jigawa state, Nigeria. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1233683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Alice Ramyil
- Department of Ophthalmology, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Covadonga Bascaran
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Catey Bunce
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- University College London (UCL), London, UK
| | - Joel Alada
- Department of Ophthalmology, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Patricia Wade
- Department of Ophthalmology, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Caleb Mpyet
- Department of Ophthalmology, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
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Habtamu E, Rajak SN, Tadesse Z, Wondie T, Zerihun M, Guadie B, Gebre T, Kello AB, Callahan K, Mabey DCW, Khaw PT, Gilbert CE, Weiss HA, Emerson PM, Burton MJ. Epilation for minor trachomatous trichiasis: four-year results of a randomised controlled trial. PLoS Negl Trop Dis 2015; 9:e0003558. [PMID: 25768796 PMCID: PMC4358978 DOI: 10.1371/journal.pntd.0003558] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/22/2015] [Indexed: 11/19/2022] Open
Abstract
Background Trachomatous trichiasis (TT) needs to be managed to reduce the risk of vision loss. The long-term impact of epilation (a common traditional practice of repeated plucking of lashes touching the eye) in preventing visual impairment and corneal opacity from TT is unknown. We conducted a randomized controlled trial of epilation versus surgery for the management of minor TT (fewer than six lashes touching the eye) in Ethiopia. Here we report the four-year outcome and the effect on vision and corneal opacity. Methodology/ Principal Findings 1300 individuals with minor TT were recruited and randomly assigned to quality trichiasis surgery or repeated epilation using high quality epilation forceps by a trained person with good near vision. Participants were examined six-monthly for two-years, and then at four-years after randomisation. At two-years all epilation arm participants were offered free surgery. At four-years 1151 (88.5%) were re-examined: 572 (88%) and 579 (89%) from epilation and surgery arms, respectively. At that time, 21.1% of the surgery arm participants had recurrent TT; 189/572 (33%) of the epilation arm had received surgery, while 383 (67%) declined surgery and had continued epilating (“epilation-only”). Among the epilation-only group, 207 (54.1%) fully controlled their TT, 166 (43.3%) had minor TT and 10 (2.6%) had major TT (>5 lashes). There were no differences between participants in the epilation-only, epilation-to-surgery and surgery arm participants in changes in visual acuity and corneal opacity between baseline and four-years. Conclusions/ Significance Most minor TT participants randomised to the epilation arm continued epilating and controlled their TT. Change in vision and corneal opacity was comparable between surgery and epilation-only participants. This suggests that good quality epilation with regular follow-up is a reasonable second-line alternative to surgery for minor TT for individuals who either decline surgery or do not have immediate access to surgical treatment. Trachoma causes visual impairment through the effect of in-turned eyelashes (trichiasis) on the surface of the eye. Epilation is a common traditional practice of intermittent plucking of lashes touching the eye, however, its long-term effectiveness in preventing visual impairment is unknown. We conducted a randomized controlled trial of epilation versus eyelid surgery (the main treatment option) in 1300 people with mild trichiasis in Ethiopia. We defined mild trichiasis as fewer than six lashes touching the eye. We have previously reported results to two years and have now re-assessed these individuals at four years. Overall, we found no difference between the epilation and surgery groups in terms of change in vision and corneal opacity between baseline and four years. Most mild trichiasis participants randomised to the epilation arm continued epilating and controlled their trichiasis. This suggests that good quality epilation is a reasonable second-line alternative to surgery for mild trichiasis for individuals who either decline surgery or do not have immediate access to surgical treatment.
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Affiliation(s)
- Esmael Habtamu
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Carter Center, Addis Ababa, Ethiopia
| | - Saul N. Rajak
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | - Teshome Gebre
- International Trachoma Initiative, Addis Ababa, Ethiopia
| | | | - Kelly Callahan
- The Carter Center, Atlanta, Georgia, United States of America
| | - David C. W. Mabey
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peng T. Khaw
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
| | - Clare E. Gilbert
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helen A. Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Paul M. Emerson
- International Trachoma Initiative, Atlanta, Georgia, United States of America
| | - Matthew J. Burton
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- * E-mail:
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Rajak SN, Habtamu E, Weiss HA, Kello AB, Abera B, Zerihun M, Gebre T, Gilbert CE, Khaw PT, Emerson PM, Burton MJ. The outcome of trachomatous trichiasis surgery in Ethiopia: risk factors for recurrence. PLoS Negl Trop Dis 2013; 7:e2392. [PMID: 23991241 PMCID: PMC3749971 DOI: 10.1371/journal.pntd.0002392] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 07/17/2013] [Indexed: 11/23/2022] Open
Abstract
Background Over 1.2 million people are blind from trachomatous trichiasis (TT). Lid rotation surgery is the mainstay of treatment, but recurrence rates can be high. We investigated the outcomes (recurrence rates and other complications) of posterior lamellar tarsal rotation (PLTR) surgery, one of the two most widely practised TT procedures in endemic settings. Methodology/Principal Findings We conducted a two-year follow-up study of 1300 participants who had PLTR surgery, conducted by one of five TT nurse surgeons. None had previously undergone TT surgery. All participants received a detailed trachoma eye examination at baseline and 6, 12, 18 and 24 months post-operatively. The study investigated the recurrence rates, other complications and factors associated with recurrence. Recurrence occurred in 207/635 (32.6%) and 108/641 (16.9%) of participants with pre-operative major (>5 trichiatic lashes) and minor (<5 lashes) TT respectively. Of the 315 recurrences, 42/315 (3.3% overall) had >5 lashes (major recurrence). Recurrence was greatest in the first six months after surgery: 172 cases (55%) occurring in this period. Recurrence was associated with major TT pre-operatively (OR 2.39, 95% CI 1.83–3.11), pre-operative entropic lashes compared to misdirected/metaplastic lashes (OR 1.99, 95% CI 1.23–3.20), age over 40 years (OR 1.59, 95% CI 1.14–2.20) and specific surgeons (surgeon recurrence risk range: 18%–53%). Granuloma occurred in 69 (5.7%) and notching in 156 (13.0%). Conclusions/Significance Risk of recurrence is high despite high volume, highly trained surgeons. However, the vast majority are minor recurrences, which may not have significant corneal or visual consequences. Inter-surgeon variation in recurrence is concerning; surgical technique, training and immediate post-operative lid position require further investigation. Trachoma is the most common infectious cause of blindness worldwide. It causes trichiasis (inturning of the eyelashes to touch the eye), which can cause visual loss. Trachomatous trichiasis (TT) affects over eight million people, 1.2 of whom live in Ethiopia – the most affected country worldwide. Surgery is the mainstay of treatment for TT. However, results of surgery in the field are often very mixed. We investigated the surgical outcomes of one of the two most widely used surgical techniques (posterior lamellar rotation), in 1300 individuals in the Amhara Region of Ethiopia. We found that recurrence occurred frequently: 315/1276 (24.7%) participants. However, recurrence was rarely severe (greater than 5 lashes): 42 participants (3.3%). Recurrence occurred much more frequently in participants who had severe pre-operative disease and with specific surgeons. The high recurrence rates and inter-surgeon variation is concerning. Further research will be required to investigate factors such as surgical technique, surgeon training and immediate post-operative lid position, in order to improve surgical outcomes.
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Affiliation(s)
- Saul N Rajak
- The London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Barr K, Essex RW, Liu S, Henderson T. Comparison of trichiasis recurrence after primary bilamellar tarsal rotation or anterior lamellar repositioning surgery performed for trachoma. Clin Exp Ophthalmol 2013; 42:311-6. [PMID: 23952906 DOI: 10.1111/ceo.12197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 08/02/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND To compare the trichiasis recurrence rate following bilamellar tarsal rotation or anterior lamellar repositioning, performed as primary surgery for trachomatous trichiasis. DESIGN Retrospective consecutive case series. PARTICIPANTS All cases of trachomatous trichiasis undergoing primary surgical correction at Alice Springs Hospital, Alice Springs, Northern Territory, Australia, between 1 June 2001 and 11 June 2011 were included. METHODS Retrospective chart review. Key baseline, operative and outcome details were collected from the notes. MAIN OUTCOME MEASURE Recurrent trichiasis was defined as one or more lashes touching the cornea, resulting in recurrent symptoms of trichiasis and warranting further surgery in the opinion of the treating ophthalmologist. RESULTS Sixty-seven BTR and eighteen ALR procedures were performed, with BTR being performed from 2001 to 2008, and ALR from 2008 to 2011. The mean follow-up times were significantly different for the BTR group (1654 days) and for the ALR group (673 days)(P < 0.001). Kaplan-Meier survival analysis did not reveal any significant differences in recurrence rate between the two procedures overall (P = 0.935). Analysis of the 2008 calendar year (the only year where both procedures were performed and therefore had equal follow-up times) suggested that ALR might have a lower recurrence rate (1/10 ALR recurrences vs. 4/6 BTR recurrences, P = 0.181). CONCLUSIONS The results do not demonstrate a difference in the recurrence rate between the two techniques. Inconsistent follow times however leave uncertainty in this result, and a larger prospective randomised study is warranted to address this question.
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Affiliation(s)
- Kieran Barr
- Australian National University Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
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11
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Khanduja S, Jhanji V, Sharma N, Vashist P, Murthy GVS, Gupta SK, Satpathy G, Tandon R, Titiyal JS, Vajpayee RB. Trachoma prevalence in women living in rural northern India: rapid assessment findings. Ophthalmic Epidemiol 2012; 19:216-20. [PMID: 22775277 DOI: 10.3109/09286586.2012.657765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Rapid assessment of cicatricial trachoma in adult females aged over 15 years in a previously hyperendemic rural area in Haryana, North India. METHODS Ten disadvantaged villages each with a population of 3000-5000 were chosen by cluster random sampling. One thousand females, 500 between 15-30 years and the rest over 30 years in the underdeveloped parts of the villages, identified by observation and consultation, were examined for signs of trachomatous scarring (TS), trachomatous trichiasis (TT) and trachomatous corneal opacity (TCO). Examinations of both eyes were performed with the aid of a binocular loupe (2.5x magnification) for signs of trachoma, its complications and other ocular morbidities. RESULTS Bilateral examination was carried out in all participants. About two-thirds (n = 650; 65%) of subjects did not have any signs of trachoma. The percentages of trachoma stages TS, TT and TCO were found to be 26.4%, 5.4% and 3.2% respectively. Trichiasis was observed in 54 subjects, all in the age group >30 years, and highest in the age group 66-75 years (22.8%). Females in the age group >30 years had significantly higher cicatricial trachoma compared to females <30 years (p < 0.001). Overall 59.3% of affected females had not received any treatment. Epilation and entropion surgery had been performed in 30.3% and 10.4% of affected females, respectively. CONCLUSION The results of our rapid assessment suggest that the presence of cicatricial trachoma remains an important health issue in females over 15 years of age.
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Affiliation(s)
- Sumeet Khanduja
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Trachomatous trichiasis and its management in endemic countries. Surv Ophthalmol 2012; 57:105-35. [PMID: 22285842 PMCID: PMC3316859 DOI: 10.1016/j.survophthal.2011.08.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 11/20/2022]
Abstract
Trichiasis is the sight-threatening consequence of conjunctival scarring in trachoma, the most common infectious cause of blindness worldwide. Trachomatous trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, trichiasis, and ultimately blinding corneal opacification. The disease causes painful, usually irreversible sight loss. Over eight million people have trachomatous trichiasis, mostly those living in poor rural communities in 57 endemic countries. The global cost is estimated at US$ 5.3 billion. The WHO recommends surgery as part of the SAFE strategy for controlling the disease.We examine the principles of clinical management, treatment options, and the challenging issues of providing the quantity and quality of surgery that is needed in resource-poor settings.
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Rajak SN, Habtamu E, Weiss HA, Kello AB, Gebre T, Genet A, Bailey RL, Mabey DCW, Khaw PT, Gilbert CE, Emerson PM, Burton MJ. Absorbable versus silk sutures for surgical treatment of trachomatous trichiasis in Ethiopia: a randomised controlled trial. PLoS Med 2011; 8:e1001137. [PMID: 22180732 PMCID: PMC3236737 DOI: 10.1371/journal.pmed.1001137] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 10/19/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Trachoma causes blindness through an anatomical abnormality called trichiasis (lashes touching the eye). Trichiasis can recur after corrective surgery. We tested the hypothesis that using absorbable sutures instead of silk sutures might reduce the risk of recurrent disease among patients with major trichiasis in a randomised trial. METHODS AND FINDINGS 1,300 individuals with major trichiasis from rural villages in the Amhara Region of Ethiopia were recruited and assigned (1:1) by computer-generated randomisation sequence to receive trichiasis surgery using either an absorbable suture (polyglactin-910) or silk sutures (removed at 7-10 days) in an otherwise identical surgical technique. Participants were examined every 6 months for 2 years by clinicians masked to allocation. The primary outcome measure was recurrent trichiasis (≥one lash touching the eye) at 1 year. There was no difference in prevalence of recurrent trichiasis at 1 year (114 [18.2%] in the absorbable suture group versus 120 [19.7%] in the silk suture group; odds ratio = 0.90, 95% CI 0.68-1.20). The two groups also did not differ in terms of corneal opacification, visual acuity, conjunctival inflammation, and surgical complications. CONCLUSIONS There was no evidence that use of absorbable polyglactin-910 sutures was associated with a lower prevalence of trichiasis recurrence at 1 year postsurgery than silk sutures. However, from a programmatic perspective, polyglactin-910 offers the major advantage that patients do not have to be seen soon after surgery for suture removal. The postoperative review after surgery using absorbable polyglactin-910 sutures can be delayed for 3-6 months, which might allow us to better determine whether a patient needs additional surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT00522860.
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Affiliation(s)
- Saul N. Rajak
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Helen A. Weiss
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Asrat Genet
- The Amhara Regional Health Bureau, Bahir Dar, Ethiopia
| | - Robin L. Bailey
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David C. W. Mabey
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peng T. Khaw
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology and UCL Partners AHSC, London, United Kingdom
| | - Clare E. Gilbert
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Matthew J. Burton
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology and UCL Partners AHSC, London, United Kingdom
- * E-mail:
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Khandekar R, Thanh TTK, Luong VQ. The determinants of trichiasis recurrence differ at one and two years following lid surgery in Vietnam: A community-based intervention study. Oman J Ophthalmol 2011; 2:119-25. [PMID: 20927208 PMCID: PMC2903916 DOI: 10.4103/0974-620x.57311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim To compare determinants for recurrence of trichiasis at one and two years following lid surgery in Vietnam. Study Design Community-based intervention study. Methods This study was carried out between 2000 and 2003 in four trachoma-endemic districts of Vietnam. Trained trichiasis surgeons performed modified Cuenod Nataf lid surgery on 648 eyes of 472 patients with Trachomatous trichiasis (TT). Trained investigators collected information on ocular and lid status before surgery and at one and two years following surgery. Trichiasis recurrence was calculated after adjusting for one or both eyes of each operated individual. Results Fifty-six eyes developed recurrence at one year with adjusted prevalence of 8.8% (95% CI 6.60-11.01). One hundred and one eyes [15.9% (95% CI 13.04-18.72)] had recurrence two years following surgery. Female gender, older age group, study area, severe grade of trachomatous scarring (TS), past history of lid surgery, postoperative suture adjustment and surgeon were risk factors for recurrence at the end of one year. Study area and previous lid surgery were risk factors for recurrence in the second year. Recurrence at one year could be predicted if study area and severity of Trachomatous Scarring (TS) are known. Conclusions One and two year recurrence rates with modified Cuenod Nataf lid surgeries for TT in Vietnam were acceptably low. Early recurrence could be reduced by proper case selection. However, late recurrence seems to be dependent on interaction of risk factors. Only age of the patient was the reliable predictor of recurrence.
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Affiliation(s)
- Rajiv Khandekar
- British Columbia Center for Epidemiologic and International Ophthalmology, University of British Columbia, Canada
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Gower EW, Merbs SL, Munoz BE, Kello AB, Alemayehu W, Imeru A, West SK. Rates and risk factors for unfavorable outcomes 6 weeks after trichiasis surgery. Invest Ophthalmol Vis Sci 2011; 52:2704-11. [PMID: 21051704 DOI: 10.1167/iovs.10-5161] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Several studies of trichiasis recurrence suggest an association between surgical factors and long-term recurrence, yet data on short-term risk factors are limited. This study was conducted to evaluate risk factors for early trichiasis recurrence and other unfavorable short-term outcomes. METHODS Trichiasis patients presenting for surgery were evaluated for presence of active trachoma and signs of cicatricial outcomes of trachoma, including number of trichiatic lashes, epilation, and entropion. Surgical factors recorded included incision length, surgery duration, and the surgeon performing the operation. Participants were followed up for 6 weeks after surgery and evaluated for eyelid closure defect and trichiasis recurrence; in addition, in two thirds of the patients, eyelid contour abnormality and granuloma formation were evaluated. RESULTS First-time trichiasis surgery was performed on 2615 eyelids. Of these, 2601 eyelids without surgical failure were followed up 6 weeks after surgery. Of the eyelids treated, 2.3% had recurrent trichiasis and 1.3% had an eyelid closure defect. Data on eyelid contour abnormalities and granuloma formation were recorded for 1881 eyes, with rates of 1.2% and 10.5%, respectively. Associated risk factors differed by outcome. Surgeon was predictive of eyelid closure defect and granuloma formation. Eyelids with short incisions were nearly four times more likely to have recurrent trichiasis (95% confidence interval, 1.7-9.3). Baseline trichiasis severity was predictive of eyelid contour abnormalities and recurrent trichiasis. Epilation was associated with granuloma formation, but was protective against eyelid closure defect. CONCLUSIONS Surgical factors are important predictors of unfavorable outcomes in the weeks immediately after surgery. Although the overall rate of serious uncorrectable unfavorable outcomes was very low, the high rate of granuloma formation, which can be treated by removal, highlights the need for follow-up of patients after trichiasis surgery. (ClinicalTrials.gov number, NCT00347776.).
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Affiliation(s)
- Emily W Gower
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Baltimore, Maryland 21287, USA.
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Abstract
BACKGROUND Trachoma remains a significant cause of blindness in many parts of the world. The major route to blindness involves upper lid entropion leading to trachomatous trichiasis (TT), which promotes progressive corneal opacification. The provision of surgery to correct TT in the populations most severely affected is a major challenge for the global effort to eliminate trachoma blindness by the year 2020. Most attention has focused on increasing the quantity of TT surgery performed, and large numbers of non-doctor operators have been trained to this end. Surgical audit by those performing TT surgery is not a routine part of any national trachoma control programme, and no effective mechanism exists for identifying surgeons experiencing poor outcomes. The authors propose a methodology for surgical audit at the level of the individual surgeon based on Lot Quality Assurance. METHODS A set number of patients operated on previously for upper eyelid TT are examined to detect the recurrence of TT. The number of recurrent cases found will lead to categorisation of the TT surgeon to either 'high recurrence' or 'low recurrence' with reasonable confidence. The threshold of unacceptability can be set by individual programmes according to previous local studies of recurrence rates or those from similar settings. CONCLUSIONS Identification of surgeons delivering unacceptably high levels of recurrent TT will guide managers on the need for remedial intervention such as retraining.
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Affiliation(s)
- John C Buchan
- Kissy UMC Eye Hospital, PO Box 115, 41 East Kissy Bye-Pass Road, Freetown, PMB 8803, Sierra Leone.
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Hu VH, Harding-Esch EM, Burton MJ, Bailey RL, Kadimpeul J, Mabey DCW. Epidemiology and control of trachoma: systematic review. Trop Med Int Health 2010; 15:673-91. [PMID: 20374566 PMCID: PMC3770928 DOI: 10.1111/j.1365-3156.2010.02521.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Trachoma is the commonest infectious cause of blindness. Recurrent episodes of infection with serovars A-C of Chlamydia trachomatis cause conjunctival inflammation in children who go on to develop scarring and blindness as adults. It was estimated that in 2002 at least 1.3 million people were blind from trachoma, and currently 40 million people are thought to have active disease and 8.2 million to have trichiasis. The disease is largely found in poor, rural communities in developing countries, particularly in sub-Saharan Africa. The WHO promotes trachoma control through a multifaceted approach involving surgery, mass antibiotic distribution, encouraging facial cleanliness and environmental improvements. This has been associated with significant reductions in the prevalence of active disease over the past 20 years, but there remain a large number of people with trichiasis who are at risk of blindness.
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Affiliation(s)
- Victor H Hu
- London School of Hygiene and Tropical Medicine, UK.
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Nagpal G, Dhaliwal U, Bhatia MS. Barriers to Acceptance of Intervention among Patients with Trachomatous Trichiasis or Entropion Presenting to a Teaching Hospital. Ophthalmic Epidemiol 2009; 13:53-8. [PMID: 16510347 DOI: 10.1080/09286580500428518] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the barriers to therapeutic intervention in patients with trachomatous trichiasis or entropion. METHODS Prospective study over one year in 60 patients with trachomatous trichiasis or entropion presenting to a teaching hospital. The outcome measure was reported barriers to uptake of intervention using a questionnaire. The data were analysed using chi-square and Fisher's exact tests. Patient characteristics were correlated with barriers using univariate and multivariate analysis. RESULTS The major barriers (operative in > 60% of patients) were illiteracy (66.7%), ignorance regarding treatment (65.0%), and fear of surgery (63.3%). Duration of symptoms in 43 females and 17 males ranged from 0.5 to 240 months (mean 30.2 +/- 45.82). Females reported significantly more barriers (average 5.8 +/- 1.88) than males (average 4.6 +/- 1.97; p = 0.03). Shorter duration was significantly related to perceived expense (p = 0.008). Patients aged =55 years more often cited young children as a barrier (p = 0.02). CONCLUSIONS Encouraging patients who have undergone intervention to share their experiences with community members, providing intervention in patients' villages, community involvement with patients who live alone and making gender-sensitive medical programmes might be useful in reducing the fear of surgery and enhancing awareness and uptake of intervention. Future studies must identify barriers in their regions so that attempts can be directed to overcoming them so as to reduce the blinding and non-blinding burden of trachoma.
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Affiliation(s)
- Gaurav Nagpal
- Department of Ophthalmology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi-95, India
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Habte D, Gebre T, Zerihun M, Assefa Y. Determinants of uptake of surgical treatment for trachomatous trichiasis in North Ethiopia. Ophthalmic Epidemiol 2008; 15:328-33. [PMID: 18850469 DOI: 10.1080/09286580801974897] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgery for trachomatous trichiasis prevents blindness. However people still decline surgery despite the availability of services in nearby health facilities. OBJECTIVES To assess what proportion of cases of trichiasis had surgical treatment and to investigate the determinants of uptake of surgery. METHODS Eight villages in Enebse Sarmidir district of Amhara Region-Ethiopia were randomly selected and all self-reported cases of trichiasis were approached. Both operated and un-operated trichiasis cases were interviewed using structured questionnaires. RESULT The study employed a case control study design with patients with untreated trichiasis being cases (135) and those operated, controls (141). The main reasons given for not having surgery were burden of household tasks, indirect cost of surgery, lack of companion and fear of surgery. Uptake of surgery was found to rise with duration of illness (Chi Square for trend = 26.62, P < 0.05). Longer walking distance (more than one hour) to the nearby health facility was a negative predictor of uptake of surgical treatment (adjusted odd ratio 0.31, 95% confidence interval 0.15-0.67). CONCLUSION Behavior change communication interventions targeted on early uptake of surgery are very important. Village-based surgical service provision may be worthwhile in settings of high blinding trachoma burden.
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Affiliation(s)
- Dereje Habte
- Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.
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Abstract
Trachoma is a keratoconjunctivitis caused by ocular infection with Chlamydia trachomatis. Repeated or persistent episodes lead to increasingly severe inflammation that can progress to scarring of the upper tarsal conjunctiva. Trichiasis develops when scarring distorts the upper eyelid sufficiently to cause one or more lashes to abrade the cornea, scarring it in turn and causing blindness. Active trachoma affects an estimated 84 million people; another 7.6 million have end-stage disease, of which about 1.3 million are blind. Trachoma should stand on the brink of extinction thanks to a 1998 initiative launched by WHO--the Global Elimination of Trachoma by 2020. This programme advocates control of trachoma at the community level with four inter-related population-health initiatives that form the SAFE strategy: surgery for trichiasis, antibiotics for active trachoma, facial cleanliness, and environmental improvement. Evidence supports the effectiveness of this approach, and if current world efforts continue, blinding trachoma will indeed be eliminated by 2020.
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Affiliation(s)
- Heathcote R Wright
- Centre for Eye Research Australia, University of Melbourne, WHO Collaborating Centre for the Prevention of Blindness, East Melbourne, VIC, Australia.
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West S, Alemayehu W, Munoz B, Gower EW. Azithromycin prevents recurrence of severe trichiasis following trichiasis surgery: STAR trial. Ophthalmic Epidemiol 2007; 14:273-7. [PMID: 17994436 DOI: 10.1080/09286580701410323] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Trichiasis, the potentially visually disabling result of chronic trachoma, is a leading cause of blindness world wide. Surgery can repair trichiasis, but recurrence of severe trichiasis (lashes touching the cornea) following surgery is likely to have immediate vision threatening consequences. Azithromycin use post-surgery appeared to be beneficial against recurrences but there were a mix of severe, moderate, and mild trichiasis; the specific effect on prevention of severe, vision-threatening recurrence is unknown. This randomized, clinical trial determined if treating trichiasis surgical patients with oral azithromycin compared to usual care (topical tetracycline) resulted in a reduction in severe recurrence of trichiasis to one year. METHODS In a rural, trachoma hyperendemic district in Ethiopia, 1452 trichiasis patients age 18 or older presenting for surgery were randomly allocated to azithromycin, single 1 gram dose, versus topical tetracycline twice per day for six weeks. The outcome was recurrent severe trichiasis, defined as lashes touching the cornea, or more than 5 lashes touching the globe, to one year. RESULTS Patients randomized to receive azithromycin had significantly fewer severe recurrences, 4.2/100 person years overall, compared to those randomized to topical tetracycline, 7.9/100 person years (p < 0.01). CONCLUSIONS A single dose of azithromycin has been shown to reduce severe post-surgical trichiasis recurrence rates to one year and should become standard post surgical treatment.
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Affiliation(s)
- Sheila West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, The Johns Hopkins University, Baltimore, Maryland 21287, USA
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Dhaliwal U, Nagpal G, Bhatia MS. Health-related quality of life in patients with trachomatous trichiasis or entropion. Ophthalmic Epidemiol 2006; 13:59-66. [PMID: 16510348 DOI: 10.1080/09286580500473803] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the health-related quality of life in patients with trachomatous trichiasis or entropion, before and after intervention. METHODS A prospective, case-control, interventional study. Health-related quality of life was evaluated in 60 patients with trachomatous trichiasis or entropion, before and after intervention, and 60 age- and gender-matched controls without trichiasis or entropion, using the WHOQOL-Bref questionnaire. Thirty patients and controls had vision < 6/18, while 30 had vision = 6/18 in the better eye. The WHOQOL-Bref assesses four domains of quality of life: physical health (1), psychological health (2), social relationships (3), and environment (4). Domain scores of patients and controls and of patients before and after intervention were compared using Student's t-test. Patient characteristics were correlated with domain scores using Pearson's correlation. RESULTS Quality of life was poorer than that of controls in domains 1 and 2 for patients with vision < 6/18 in the better eye (p < 0.001, p = 0.001, respectively), and in domains 1, 2 and 4 for patients with vision = 6/18 (p < 0.001, p < 0.001, p = 0.01, respectively). Scores improved after intervention in all domains except domain 3, even though vision did not improve. CONCLUSIONS Patients with trachomatous trichiasis or entropion suffer in the physical, psychological and environmental domains of health-related quality of life even when vision is normal. Timely intervention is essential not only to prevent corneal blindness but also to reduce the suffering caused by the non-visual symptoms. Future studies must identify barriers to therapeutic intervention, and attempts should be directed at overcoming them so as to reduce the non-blinding burden of trachoma.
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Affiliation(s)
- Upreet Dhaliwal
- Department of Ophthalmology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi-95, India.
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Burton MJ, Kinteh F, Jallow O, Sillah A, Bah M, Faye M, Aryee EAN, Ikumapayi UN, Alexander NDE, Adegbola RA, Faal H, Mabey DCW, Foster A, Johnson GJ, Bailey RL. A randomised controlled trial of azithromycin following surgery for trachomatous trichiasis in the Gambia. Br J Ophthalmol 2005; 89:1282-8. [PMID: 16170117 PMCID: PMC1772881 DOI: 10.1136/bjo.2004.062489] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIM Trachomatous trichiasis frequently returns following surgery. Several factors may promote recurrence: preoperative disease severity, surgeon ability, surgical procedure, healing responses, and infection. This study investigates whether enhanced control of infection, both of Chlamydia trachomatis and other bacteria, with azithromycin can improve surgical outcome in a trachoma control programme. METHODS Individuals with trachomatous trichiasis were examined and operated. After surgery patients were randomised to the azithromycin or control group. The azithromycin group and children in their household were given a dose of azithromycin. Antibiotic treatment was repeated at 6 months. All patients were reassessed at 6 months and 12 months. Samples were collected for C trachomatis polymerase chain reaction and general microbiology at each examination. RESULTS 451 patients were enrolled. 426 (94%) were reassessed at 1 year, of whom 176 (41.3%) had one or more lashes touching the eye and 84 (19.7%) had five or more lashes. There was no difference in trichiasis recurrence between the azithromycin and control group. Recurrent trichiasis was significantly associated with more severe preoperative trichiasis, bacterial infection, and severe conjunctival inflammation at 12 months. Significant variability in outcome was found between surgeons. Visual acuity and symptoms significantly improved following surgery. CONCLUSION In this setting, with a low prevalence of active trachoma, azithromycin did not improve the outcome of trichiasis surgery conducted by a trachoma control programme. Audit of trichiasis surgery should be routine.
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Affiliation(s)
- M J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Melese M, West ES, Alemayehu W, Munoz B, Worku A, Gaydos CA, West SK. Characteristics of trichiasis patients presenting for surgery in rural Ethiopia. Br J Ophthalmol 2005; 89:1084-8. [PMID: 16113353 PMCID: PMC1772827 DOI: 10.1136/bjo.2005.066076] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To determine the characteristics of trichiasis patients presenting for surgery in Wolayta Zone of Ethiopia. METHODS Patients referred for trichiasis surgery by community health agents were evaluated by trained integrated eye care workers (IECWs) for the presence of trichiasis, locations of inturned lashes, severity of trichiasis, corneal opacity, and visual acuity. RESULTS 1635 individuals with trichiasis presented for surgery. 82% had bilateral trichiasis; 91% of patients reported trichiasis duration of >2 years. Epilation was practised by over three fourths of the study subjects. A high proportion of patients tested positive for ocular Chlamydia trachomatis at presentation. 17% had monocular blindness and 8% were binocularly blind. Corneal opacity was highly associated with the trichiasis duration and severity and visual loss was associated with corneal opacity. CONCLUSION Severe trichiasis reflects the magnitude of the trachoma problem in Ethiopia. Visual impairment due to trichiasis is highly associated with disease severity and duration. Early intervention to correct trichiasis before it become severe is recommended to prevent visual impairment.
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Affiliation(s)
- M Melese
- Project ORBIS, Addis Ababa, Ethiopia
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West ES, Alemayehu W, Munoz B, Melese M, Imeru A, West SK. Surgery for Trichiasis, Antibiotics to prevent Recurrence (STAR) Clinical Trial methodology. Ophthalmic Epidemiol 2005; 12:279-86. [PMID: 16033749 DOI: 10.1080/09286580591005769] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Trachoma is the leading infectious cause of blindness worldwide. Surgery is available to correct trichiasis, which results from repeated episodes of infection with C. trachomatis. However, trichiasis recurrence rates post-surgery are very high. Methods for reducing post-surgical trichiasis recurrence need to be explored. This paper outlines the design of the Surgery for Trichiasis, Antibiotics to prevent Recurrence (STAR) Clinical Trial currently underway in Ethiopia. The STAR trial, funded by The National Eye Institute, is a randomized, controlled clinical trial of antibiotic use at time of trichiasis surgery, comparing topical tetracycline to single-dose azithromycin for the surgical patient and single-dose azithromycin for the surgical patient and all household members. The primary outcome is trichiasis recurrence at one-year. Data from this trial will be critical in helping to determine future policy on antibiotic treatment for C. trachomatis following surgery.
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Affiliation(s)
- Emily S West
- Dana Center for Preventive Ophthalmology, Johns Hopkins University, Baltimore, MD 21205, USA.
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Kuper H, Solomon AW, Buchan JC, Zondervan M, Mabey D, Foster A. Participatory evaluations of trachoma control programmes in eight countries. Trop Med Int Health 2005; 10:764-72. [PMID: 16045463 DOI: 10.1111/j.1365-3156.2005.01451.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Trachoma is a major cause of blindness. The objective of this initiative was to conduct participatory process evaluations of the trachoma control programmes receiving support from the International Trachoma Initiative in eight countries. METHODS During each 2- to 4-week evaluation we analysed information collected at the central, district and community level through interviews, focus groups, questionnaires, direct observation of trachoma control activities, and existing data. RESULTS Mapping and assessment of disease prevalence had been completed in four of eight countries. Integration of trachoma control activities into national planning and district-level service provision varied. Intersectoral partnerships to implement the SAFE strategy (i.e. surgery, antibiotics, facial cleanliness and environmental change) were well established in a few countries. In all eight countries, the number of surgeries performed annually was insufficient; and quality of surgery was rarely monitored. Mass distribution of antibiotics was carried out well in extremely resource-poor settings and good coverage was achieved, although the strategy for antibiotic distribution varied. Inadequate water and sanitation remained a major problem in all programme areas. Monitoring of programme activities was generally inadequate. The Morocco programme is an example from which lessons and processes can be learnt and adapted to other programme countries. CONCLUSIONS Significant achievements have been made in implementing the SAFE strategy. Scaling up of activities to true national coverage should be planned and implemented provided the resources can be made available. Further standardization of how to assess, implement and monitor trachoma control activities will facilitate expansion of the programme.
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Affiliation(s)
- Hannah Kuper
- London School of Hygiene and Tropical Medicine, London, UK.
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Burton MJ, Bowman RJC, Faal H, Aryee EAN, Ikumapayi UN, Alexander NDE, Adegbola RA, West SK, Mabey DCW, Foster A, Johnson GJ, Bailey RL. Long term outcome of trichiasis surgery in the Gambia. Br J Ophthalmol 2005; 89:575-9. [PMID: 15834088 PMCID: PMC1772648 DOI: 10.1136/bjo.2004.055996] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Trichiasis surgery is believed to reduce the risk of losing vision from trachoma. There are limited data on the long term outcome of surgery and its effect on vision and corneal opacification. Similarly, the determinants of failure are not well understood. METHODS A cohort of people in the Gambia who had undergone surgery for trachomatous trichiasis 3-4 years earlier was re-assessed. They were examined clinically and the conjunctiva was sampled for Chlamydia trachomatis polymerase chain reaction (PCR) and general bacterial culture. RESULTS In total, 141/162 people were re-examined. Recurrent trichiasis was found in 89/214 (41.6%) operated eyes and 52 (24.3%) eyes had five or more lashes touching the globe. Corneal opacification improved in 36 of 78 previously affected eyes. There was a general deterioration in visual acuity between surgery and follow up, which was greater if new corneal opacification developed or trichiasis returned. Recurrent trichiasis was associated with severe conjunctival inflammation and bacterial infection. C trachomatis was detected in only one individual. CONCLUSIONS Recurrent trichiasis following surgery is a common potentially sight threatening problem. Some improvement in the cornea can occur following surgery and the rate of visual loss tended to be less in those without recurrent trichiasis. The role of conjunctival inflammation and bacterial infection needs to be investigated further. Follow up of patients is advised to identify individuals needing additional surgical treatment.
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Affiliation(s)
- M J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Abstract
Trachoma is the leading infectious cause of blindness worldwide. The World Health Organization (WHO) estimated that approximately 5.9 million persons are blind or have severe vision-loss as a result of trachoma, and another 10 million are at high risk. Trachoma preferentially affects the most deprived communities, and within these communities, women and children bear the brunt of the burden. In recent years, there has been a renewed focus on research and heightened enthusiasm for strengthening trachoma control programs in afflicted countries. WHO has convened an alliance of member countries, non-governmental organizations, and other partners for the Global Elimination of Blinding Trachoma by the year 2020, and endorsed the multi-faceted SAFE strategy for trachoma control. SAFE-Surgery, Antibiotics, Face-washing, and Environmental improvement-has incorporated sound research on elements likely to reduce trachoma, and trachomatis blindness, in endemic communities. This review summarizes current knowledge about trachoma and its causative agent, Chlamydia trachomatis, the epidemiology and risk factors for trachoma as a prelude to reviewing the SAFE strategy. While ongoing research to support the knowledge base for SAFE must continue to be a priority, the full implementation of SAFE is the best hope for countries to reduce the global burden of blindness from this preventable cause.
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Affiliation(s)
- Sheila K West
- Dana Center for Preventive Ophthalmology, Johns Hopkins University School of Medicine, Wilmer Room 129, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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A critical review of the SAFE strategy for the prevention of blinding trachoma. THE LANCET. INFECTIOUS DISEASES 2003; 3:372-81. [PMID: 12781509 DOI: 10.1016/s1473-3099(03)00659-5] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Trachoma is an ocular disease caused by repeated infection with Chlamydia trachomatis. It is the leading cause of infectious blindness globally, responsible for 5.9 million cases of blindness. Although trachomatous blindness is untreatable, it is eminently possible to prevent and the World Health Organization promotes the use of the SAFE strategy (surgery to treat end-stage disease, antibiotics to reduce the reservoir of infection, facial cleanliness, and environmental improvement to reduce transmission of C trachomatis) for this purpose. In this review we have assessed the evidence base supporting the elements of the SAFE strategy. We find strong support for the efficacy of the surgery and antibiotics components, although the optimal antibiotic regimens have not yet been established. The evidence for an effect of health education and environmental improvement is weaker, and depends mostly on cross-sectional observational studies.
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