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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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Adamu MD, Mohammed Jabo A, Orji P, Zhang Y, Isiyaku S, Olobio N, Muhammad N, Mshelia Auta L, Willis R, Bakhtiari A, Jimenez C, Solomon AW, Harding-Esch EM, Mpyet CD. Baseline Prevalence of Trachoma in 13 Local Government Areas of Borno State, Nigeria. Ophthalmic Epidemiol 2023; 30:628-636. [PMID: 36469560 PMCID: PMC10581670 DOI: 10.1080/09286586.2022.2053550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 12/14/2021] [Accepted: 03/09/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE We set out to determine the baseline prevalence of trachoma in 13 Local Government Areas (LGAs) of Borno State, Nigeria. METHODS A population-based cross-sectional survey was conducted in each of 13 LGAs from 2017 to 2019, with the support of Tropical Data (TD). World Health Organization (WHO)-recommended protocols were used. With a probability-proportional-to-size systematic sampling method, 25 villages were selected per LGA in 2017 and 30 villages per LGA in 2019; in each village, 25 households were enrolled for 2017 surveys, while 30 were enrolled for 2019 surveys. All present, consenting residents aged ≥1 year were examined by TD-certified graders for trachomatous inflammation-follicular (TF) and trachomatous trichiasis (TT) using the WHO simplified grading scheme. Additionally, we collected data on household-level access to water, sanitation and hygiene (WASH) facilities. RESULTS One LGA (Magumeri) had TF prevalence in 1-9-year-olds ≥10%; two other LGAs (Monguno and Kaga) had TF prevalence between 5.0% and 9.9%. The prevalence of TT unknown to the health system was ≥0.2% in six LGAs. The proportion of households with access to improved water sources ranged from 30% (Kwaya Kusar) to 95% (Monguno); household-level access to improved latrines was lowest in Shani (7%) and highest in Maiduguri (95%). CONCLUSION Active TT case finding and strengthening of TT surgical services are needed in six LGAs. Mass drug administration (MDA) of antibiotics is needed in three LGAs to reduce the prevalence of active trachoma to below elimination thresholds. The trachoma elimination programme should engage WASH agencies to augment access to improved WASH facilities.
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Affiliation(s)
| | | | - Philomena Orji
- Helen Keller International, Nigeria Country office, Abuja, Nigeria
| | - Yaobi Zhang
- Helen Keller International, Regional Office for Africa, Dakar, Senegal
| | | | | | - Nasiru Muhammad
- Department of Ophthalmology, Usmanu Danfodiyo University, Sokoto, Nigeria
| | | | - Rebecca Willis
- International Trachoma Initiative, Task Force for Global Health, Decatur, Georgia, USA
| | - Ana Bakhtiari
- International Trachoma Initiative, Task Force for Global Health, Decatur, Georgia, USA
| | | | - Anthony W. Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Emma M. Harding-Esch
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- London Centre for Neglected Tropical Disease Research, London, UK
| | - Caleb D. Mpyet
- Sightsavers Nigeria Country Office, Kaduna, Nigeria
- Department of Ophthalmology, College of Health Sciences, University of Jos, Jos, Nigeria
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Abstract
Trachoma is a neglected tropical disease caused by infection with conjunctival strains of Chlamydia trachomatis. It can result in blindness. Pathophysiologically, trachoma is a disease complex composed of two linked chronic processes: a recurrent, generally subclinical infectious-inflammatory disease that mostly affects children, and a non-communicable, cicatricial and, owing to trichiasis, eventually blinding disease that supervenes in some individuals later in life. At least 150 infection episodes over an individual's lifetime are needed to precipitate trichiasis; thus, opportunity exists for a just global health system to intervene to prevent trachomatous blindness. Trachoma is found at highest prevalence in the poorest communities of low-income countries, particularly in sub-Saharan Africa; in June 2021, 1.8 million people worldwide were going blind from the disease. Blindness attributable to trachoma can appear in communities many years after conjunctival C. trachomatis transmission has waned or ceased; therefore, the two linked disease processes require distinct clinical and public health responses. Surgery is offered to individuals with trichiasis and antibiotic mass drug administration and interventions to stimulate facial cleanliness and environmental improvement are designed to reduce infection prevalence and transmission. Together, these interventions comprise the SAFE strategy, which is achieving considerable success. Although much work remains, a continuing public health problem from trachoma in the year 2030 will be difficult for the world to excuse.
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Acheampong HO, Kumah DB, Addo EK, Asare AK, Agyei-Manu E, Mohammed AS, Baah-Konadu B, Osei Duah Junior I, Mintah P, Darrah S, Akuffo KO. Practice patterns in the management of amblyopia among optometrists in Ghana. Strabismus 2022; 30:18-28. [PMID: 35023425 DOI: 10.1080/09273972.2021.2022715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite internationally recognized guidelines, amblyopia management varies among eye care professionals worldwide. Hence, we sought to investigate the practice patterns of amblyopia management and the factors associated with the decision to treat amblyopia among optometrists in Ghana. A cross-sectional survey was conducted among registered optometrists in Ghana from January 2020 to October 2020. Data collection was done through the administration of online questionnaires via e-mail (google form). The structured questionnaires included demographic information, mode, and scope of practice, diagnostic criteria, examination procedures, treatment modalities, and prognosis. A p value of less than 0.05 was deemed statistically significant. The mean (±SD) age of all the 168 respondents was 32.6 (±6.1) years (range: 24-50 years). The majority of the optometrists (64.9%) treated amblyopia in their practice; with the most prevalent being refractive amblyopia (68.2%), followed by strabismic amblyopia (27.1%), then form-deprivation amblyopia (4.7%). Most (76.1%) amblyopic patients presented with symptomatic squinting. The most common ocular and medical history was anisometropia (90.0%), and the most common diagnostic procedures were patient history, visual acuity, and refraction. Optical correction (88.3%) was mainly prescribed for amblyopia treatment, followed by patching (58.5%). Nearly half of the respondent (45.0%) reported good prognosis after amblyopia treatment. After statistical adjustment, female optometrists were significantly associated with decreased odds of treating amblyopia (AOR = 0.36, p = .004). Refractive amblyopia is the main type of amblyopia managed by optometrists in Ghana. Hence, optical correction is the primary treatment regime. Current amblyopia management practice among optometrists adhere to recommended guidelines and our findings demonstrate uniformity in the standard of care.
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Affiliation(s)
- Hubert Osei Acheampong
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi.,Department of Anatomy and Cell Biology, School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - David Ben Kumah
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
| | - Emmanuel Kofi Addo
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi.,Department of Ophthalmology and Visual Sciences, Moran Eye Centre, University of Utah, Salt Lake City, Utah.,Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - Akosua Kesewah Asare
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi.,Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver
| | - Eldad Agyei-Manu
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi.,Usher Institute for Population Health Sciences and Informatics, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh
| | - Abubakar Sadik Mohammed
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
| | - Benjamin Baah-Konadu
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
| | - Isaiah Osei Duah Junior
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
| | - Prince Mintah
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
| | - Samson Darrah
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
| | - Kwadwo Owusu Akuffo
- Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi
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Mwangi G, Courtright P, Solomon AW. National approaches to trichiasis surgical follow-up, outcome assessment and surgeon audit in trachoma-endemic countries in Africa. Br J Ophthalmol 2020; 105:904-908. [PMID: 32713838 PMCID: PMC7611077 DOI: 10.1136/bjophthalmol-2019-315777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/02/2020] [Accepted: 06/25/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Poor outcomes of trichiasis surgery, including postoperative trichiasis, are common in many trachoma-endemic countries in Africa. To improve outcomes, WHO recommends regular follow-up and outcome assessment of surgical cases plus audit of trichiasis surgeons. AIMS To assess national approaches to trichiasis surgical follow-up, outcome assessment and audit, and identify national targets for good surgical outcome (defined as the percentage of patients undergoing surgery for trichiasis remaining free of post-operative trichiasis for a defined interval after surgery). METHODS A cross-sectional survey was carried out between May and July 2018, involving all 29 known-trachoma-endemic countries in Africa. An emailed questionnaire was used to collect information on national targets for surgical outcomes, policies, monitoring and strategies to address underperformance by surgeons. RESULTS All national programmes provided information; 2 of the 29 had not yet implemented trichiasis surgery as part of their trachoma elimination programme. Findings from 27 countries are therefore reported. Only four countries reported having a national policy for trichiasis surgery follow-up and outcome assessment and only two had a national policy for conducting audits of trichiasis surgeons. Only 9 of the 27 countries had a cut-off point at which poorly performing surgeons would be instructed to discontinue surgery until retraining or other interventions had been undertaken. DISCUSSION To address the challenge of post-operative trichiasis and other poor outcomes, national trachoma programmes should create and implement policies and systems to follow up patients, assess surgical outcomes and monitor the performance of individual surgeons through post-surgical audits.
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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, Observatory, 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, Wade P, Oyediji F, Mpyet C. An assessment of trichiasis surgery workforce in Jigawa State, Nigeria. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1259145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- A.V. Ramyil
- Depatment of Ophthalmology, Jos UniversityTeaching Hospital, Jos, Nigeria
| | - C. Bascaran
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Catey Bunce
- Department of Medical statistics, King's college London,, London, UK
| | - P. Wade
- Depatment of Ophthalmology, Jos UniversityTeaching Hospital, Jos, Nigeria
| | - F. Oyediji
- Depatment of Ophthalmology, Jos UniversityTeaching Hospital, Jos, Nigeria
| | - C. Mpyet
- Depatment of Ophthalmology, Jos UniversityTeaching Hospital, Jos, Nigeria
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Mpyet C, Muhammad N, Adamu MD, Muazu H, Umar MM, Alada J, Onyebuchi U, Olamiju F, Isiyaku S, William A, Willis R, Flueckiger RM, Pavluck A, Chu BK, Mohammed D, Olobio N, Solomon AW. Trachoma Mapping in Gombe State, Nigeria: Results of 11 Local Government Area Surveys. Ophthalmic Epidemiol 2016; 23:406-411. [PMID: 27726459 PMCID: PMC6839962 DOI: 10.1080/09286586.2016.1230633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Purpose To determine the need or otherwise for establishment of a trachoma elimination program in Gombe State, Nigeria, by estimating the population-based prevalence of trachoma in each Local Government Area (LGA) of Gombe. Methods Using a multi-stage, systematic, random, and quasi-random sampling approach and Global Trachoma Mapping Project support, we selected 25 clusters in each LGA. In each cluster, we selected 25 households and all consenting residents aged 1 year and older were examined for trachomatous inflammation–follicular (TF) and trichiasis, using the World Health Organization simplified grading scheme. Results No LGA in Gombe State had a TF prevalence ≥5% in 1–9-year-olds. All LGAs had trichiasis prevalences above the elimination threshold and should be targeted for community-based delivery of trichiasis surgery. Only three LGAs had household-level improved wash water access of greater than 80%. Access to improved sanitation facilities was also poor as household access to improved sanitation facilities was above 80% in only one LGA. Conclusion A trachoma program focused on delivery of trichiasis surgery is required in Gombe. Improvements in water and sanitation, through engagement with other sectors, are necessary.
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Affiliation(s)
- Caleb Mpyet
- a Department of Ophthalmology , University of Jos , Jos , Nigeria.,b Sightsavers , Kaduna , Nigeria.,c Department of Ophthalmology , Jos University Teaching Hospital , Jos , Nigeria
| | - Nasiru Muhammad
- d Ophthalmology Unit, Surgery Department , Usmanu Dan Fodiyo University , Sokoto , Nigeria
| | - Mohammed Dantani Adamu
- d Ophthalmology Unit, Surgery Department , Usmanu Dan Fodiyo University , Sokoto , Nigeria
| | | | | | - Joel Alada
- c Department of Ophthalmology , Jos University Teaching Hospital , Jos , Nigeria
| | - Uwazoeke Onyebuchi
- g National Trachoma Control Program, Department of Public Health , Federal Ministry of Health , Abuja , Nigeria
| | | | | | | | | | | | | | - Brian K Chu
- i Task Force for Global Health , Decatur , GA , USA
| | | | - Nicholas Olobio
- g National Trachoma Control Program, Department of Public Health , Federal Ministry of Health , Abuja , Nigeria
| | - Anthony W Solomon
- k Clinical Research Department , London School of Hygiene & Tropical Medicine , London , UK.,l London Centre for Neglected Tropical Disease Research , London , UK
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Courtright P, Mathenge W, Kello AB, Cook C, Kalua K, Lewallen S. Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used? HUMAN RESOURCES FOR HEALTH 2016; 14:11. [PMID: 26984773 PMCID: PMC4794905 DOI: 10.1186/s12960-016-0107-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/09/2016] [Indexed: 05/13/2023]
Abstract
With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.
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Affiliation(s)
- Paul Courtright
- />Kilimanjaro Centre for Community Ophthalmology International c/o Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Wanjiku Mathenge
- />Rwanda International Institute of Ophthalmology, Kigali, Rwanda
- />Dr. Agarwal’s Eye Hospital, Kigali, Rwanda
| | | | - Colin Cook
- />Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Khumbo Kalua
- />Blantyre Institute of Community Ophthalmology, Blantyre, Malawi
| | - Susan Lewallen
- />Kilimanjaro Centre for Community Ophthalmology International c/o Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
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Gichangi M, Kalua K, Barassa E, Eliah E, Lewallen S, Courtright P. Task Shifting for Eye Care in Eastern Africa: General Nurses as Trichiasis Surgeons in Kenya, Malawi, and Tanzania. Ophthalmic Epidemiol 2016; 22:226-30. [PMID: 26158581 DOI: 10.3109/09286586.2015.1040924] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE There are approximately 8 million people with trachomatous trichiasis globally; in the year 2009, less than 160,000 people had surgery. These numbers are too low in order to achieve the goal of elimination of blinding trachoma by the year 2020. Task shifting approaches have led to the training of general nurses in trichiasis surgery in eastern Africa. The overall aim of this study was to determine the attrition and productivity (and the factors associated with productivity) of trichiasis surgeons in Kenya, Tanzania, and Malawi. METHODS A 3-year cohort study of trichiasis surgeons. RESULTS The overall response rate was 86%. Defining high productivity as 50+ operations per year per surgeon, only 16.1% of the trichiasis surgeons were highly productive. Among the surgeons, 27.9% were no longer at their site and ceased providing surgery (attrition) over the 3 years of study. High productivity was associated with having been trained by an experienced trainer, supervised by a clinical officer, having more than three surgical sets, and having an outreach program. CONCLUSION Attrition of general nurses trained in trichiasis surgery was high. Surgical productivity of trichiasis surgeons remained too low. It is likely that other approaches are needed to address the burden of trichiasis in the three countries. In terms of recommendations, training of trichiasis surgeons should be done in a "package," including a plan for provision of surgical equipment, continuous support and supervision, and outreach.
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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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11
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Rajak SN, Habtamu E, Weiss HA, Bedri A, Zerihun M, Gebre T, Gilbert CE, Emerson PM, Burton MJ. Why do people not attend for treatment for trachomatous trichiasis in Ethiopia? A study of barriers to surgery. PLoS Negl Trop Dis 2012; 6:e1766. [PMID: 22953007 PMCID: PMC3429389 DOI: 10.1371/journal.pntd.0001766] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 06/22/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Trachomatous trichiasis (TT) surgery is provided free or subsidised in most trachoma endemic settings. However, only 18-66% of TT patients attend for surgery. This study analyses barriers to attendance among TT patients in Ethiopia, the country with the highest prevalence of TT in the world. METHODOLOGY/PRINCIPAL FINDINGS Participants with previously un-operated TT were recruited at 17 surgical outreach campaigns in Amhara Region, Ethiopia. An interview was conducted to ascertain why they had not attended for surgery previously. A trachoma eye examination was performed by an ophthalmologist. 2591 consecutive individuals were interviewed. The most frequently cited barriers to previous attendance for surgery were lack of time (45.3%), financial constraints (42.9%) and lack of an escort (35.5% in females, 19.6% in males). Women were more likely to report a fear of surgery (7.7% vs 3.2%, p<0.001) or be unaware of how to access services (4.5% vs 1.0% p<0.001); men were more frequently asymptomatic (19.6% vs 10.1%, p<0.001). Women were also less likely to have been previously offered TT surgery than men (OR = 0.70, 95%CI 0.53-0.94). CONCLUSIONS/SIGNIFICANCE The major barriers to accessing surgery from the patients' perspective are the direct and indirect costs of surgery. These can to a large extent be reduced or overcome through the provision of free or low cost surgery at the community level. TRIAL REGISTRATION ClinicalTrials.gov NCT00522860 and NCT00522912.
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Affiliation(s)
- Saul N. Rajak
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Esmael Habtamu
- The Carter Center, Bahir Dar, Ethiopia
- The Carter Center, Atlanta, Georgia, United States of America
| | - Helen A. Weiss
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amir Bedri
- Light For The World, Addis Ababa, Ethiopia
| | - Mulat Zerihun
- The Carter Center, Bahir Dar, Ethiopia
- The Carter Center, Atlanta, Georgia, United States of America
| | - Teshome Gebre
- The Carter Center, Bahir Dar, Ethiopia
- The Carter Center, Atlanta, Georgia, United States of America
| | - Clare E. Gilbert
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paul M. Emerson
- The Carter Center, Bahir Dar, Ethiopia
- The Carter Center, Atlanta, Georgia, United States of America
| | - Matthew J. Burton
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
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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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Surgery versus epilation for the treatment of minor trichiasis in Ethiopia: a randomised controlled noninferiority trial. PLoS Med 2011; 8:e1001136. [PMID: 22180731 PMCID: PMC3236738 DOI: 10.1371/journal.pmed.1001136] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 10/18/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Trachomatous trichiasis can cause corneal damage and visual impairment. WHO recommends surgery for all cases. However, in many regions surgical provision is inadequate and patients frequently decline. Self-epilation is common and was associated with comparable outcomes to surgery in nonrandomised studies for minor trichiasis (<six lashes touching eye). This trial investigated whether epilation is noninferior to surgery for managing minor trichiasis. METHODS AND FINDINGS 1,300 individuals with minor trichiasis from Amhara Regional State, Ethiopia were recruited and randomly assigned (1:1) to receive trichiasis surgery or epilation. The epilation group were given new forceps and epilation training. The surgical group received trichiasis surgery. Participants were examined every 6 months for 2 years by clinicians masked to allocation, with 93.5% follow-up at 24 months. The primary outcome measure ("failure") was ≥five lashes touching the eye or receiving trichiasis surgery during 24 months of follow-up, and was assessed for noninferiority with a 10% prespecified noninferiority margin. Secondary outcomes included number of lashes touching, time to failure, and changes in visual acuity and corneal opacity. Cumulative risk of failure over 24 months was 13.2% in the epilation group and 2.2% in the surgical group (risk difference = 11%). The 95% confidence interval (8.1%-13.9%) includes the 10% noninferiority margin. Mean number of lashes touching the eye was greater in the epilation group than the surgery group (at 24 months 0.95 versus 0.09, respectively; p<0.001); there was no difference in change in visual acuity or corneal opacity between the two groups. CONCLUSIONS This trial was inconclusive regarding inferiority of epilation to surgery for the treatment of minor trichiasis, relative to the prespecified margin. Epilation had a comparable effect to surgery on visual acuity and corneal outcomes. We suggest that surgery be performed whenever possible but epilation be used for treatment of minor trichiasis patients without access to or declining surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT00522912.
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Mganga H, Lewallen S, Courtright P. Overcoming gender inequity in prevention of blindness and visual impairment in Africa. Middle East Afr J Ophthalmol 2011; 18:98-101. [PMID: 21731318 PMCID: PMC3119299 DOI: 10.4103/0974-9233.80695] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Globally, and in Africa, after adjusting for age, women are about 1.4 times more likely to be blind than men. While women generally live longer than men, the lack of accessibility to and use of services is likely the most important reason for excess blindness in women in Africa. Aim: We sought to review the literature on vision loss in Africa and summarize the findings related to gender equity. Materials and Methods: Information from across sub-Saharan Africa was collected on the evidence of gender inequity and reasons for this inequity. Finally, the results were used to generate suggestions on how gender equity could be improved. Results: In all published surveys (except one), cataract surgical coverage among women was lower than cataract surgical coverage among men. Although data available are limited, similar findings appeared in the use of services for other disease conditions, notably, childhood cataract and glaucoma. Evidence suggests that a variety of approaches are needed to improve the use of eye care services. Three main strategies are needed to address gender inequity in vision loss in Africa. First, it is important to address transport needs. Second, counseling of patients and family members is required. Finally, programs need to put in place pricing systems that make the services affordable the population. Conclusions: VISION 2020 can be achieved in Africa, but investment is needed in a variety of strategies that will ensure that eye care services are affordable, accessible, and acceptable to women and girls.
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Affiliation(s)
- Herrieth Mganga
- Kilimanjaro Centre for Community Ophthalmology, Good Samaritan Foundation, Moshi, Tanzania
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Clearing the backlog: trichiasis surgeon retention and productivity in northern Ethiopia. PLoS Negl Trop Dis 2011; 5:e1014. [PMID: 21483713 PMCID: PMC3071367 DOI: 10.1371/journal.pntd.0001014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 01/17/2011] [Indexed: 11/25/2022] Open
Abstract
Background In 2006 there were an estimated 645,000 people in Amhara, Ethiopia, with trachomatous trichiasis (TT) who needed surgery. Despite an extensive integrated eye care worker training programme (IECW) and robust support for TT surgical services, productivity has not reached targets. We investigated why surgeon productivity was below target. Methodology/Principal Findings Confidential interviews were conducted in person with TT surgeons trained from 24 selected districts in Amhara Region and their supervisors. Determinants of attrition and productivity were investigated. We interviewed 225 people who had received IECW training; 139 (59%) had subsequently changed career/job. Staff retention was associated with good road access to their health centre, mobile telephone network and a shorter time from initial training. Amongst the 94 IECW still working in the programme, the average number of patients operated was 41/year, which was mostly (86%) done through outreach campaigns and only 14% of cases were performed in the static facilities where they routinely worked. Spot checks were made of surgical instruments and consumables: only 3/94 IECW had the minimum instruments and consumables to perform surgery. The main barriers to operating were lack of time, shortage of consumables, lack of patients, lack of support and equipment problems. Very few IECW received ongoing supervision or active management. Conclusions/Significance Surgeon attrition rates are high. Vertical surgery campaigns were effective in treating large numbers of cases, whilst static-site service productivity was low. Good health system management is key to building a well-staffed and well-run service. Blindness from trachoma is caused by the abrasive effect of trichiasis (in-turned eyelashes). Surgery is performed to correct this anatomical abnormality, and prevent blindness. Despite the progress made in many regions in controlling the active/infectious stages of this disease, the global prevalence of trichiasis remains about the same. Current surgical activity is barely keeping abreast of incident trichiasis; this is undermining all the other efforts to control trachoma. We examine staff retention and productivity in Amhara Region, Ethiopia, where many hundreds of health care workers have been trained to perform the surgery. We found that the majority of people trained to do the surgery are now not in a position to do so. Amongst the sub-set that is still active within the programme, surgical productivity is low, with most surgery performed during “outreach campaigns” Insufficient surgical instruments and consumables were frequent problems. Strengthened health-systems management can overcome many of the problems that are holding back the delivery of an effective trichiasis surgical service.
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Abstract
Susan Lewallen and Amir Bedri Kello argue that human resources management will be crucial in reaching the global goal of eliminating avoidable blindness by the year 2020.
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Affiliation(s)
- Susan Lewallen
- Kilimanjaro Centre for Community Ophthalmology, Good Samaritan Foundation, Moshi, Tanzania.
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Abstract
Trachoma is a significant public health problem that is endemic in 57 countries, affecting 40.6 million people and contributing to 4% of the global burden of blindness. Repeated episodes of infection from Chlamydia trachomatis lead to long-term inflammation, scarring of the tarsal conjunctiva and distortion of the upper eyelid with in-turning of eyelashes that abrade the surface of the globe. This constant abrasion, in turn, can cause irreversible corneal opacity and blindness. The Alliance for the Global Elimination of Trachoma by 2020 (GET2020) has adopted the SAFE (Surgery, Antibiotics, Facial cleanliness and Environmental improvement) strategy as the main action against trachoma. Trichiasis surgery reduces the risk of blindness by reversing the in-turning of eyelashes and also improves the quality of life from non-visual symptoms. However, future efforts need to aim at increasing accessibility to surgery and improving acceptance. Antibacterials are required to reduce the burden of infection. Oral azithromycin is as close to the perfect antibacterial as we will get for mass distribution: it is safe, requires only a single oral dose, treatment is usually repeated every 6-12 months, resistance is not seen as a problem, and cost is not a limiting factor with a large donation programme and newer generic versions of the drug. Future focus should be on the details of antibacterial distribution such as coverage, frequency of distribution and target population. The promotion of facial cleanliness through education may be the key to trachoma elimination as it will stop the frequent exchange of infected ocular secretions and thus reduce the transmission of infection. However, innovative methods are required to translate health education and promotion activities into sustainable changes in hygiene behaviour. Environmental improvements should focus on the barriers to achieving facial cleanliness and cost-effective means need to be identified. There are a number of countries already eligible for certification of trachoma elimination and if current momentum continues, blinding trachoma can be eliminated by the year 2020.
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Affiliation(s)
- Anu A Mathew
- Centre for Eye Research Australia, University of Melbourne, Melbourne, Victoria, Australia
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Courtright P. Eye care human resources: are there gender issues? COMMUNITY EYE HEALTH 2009; 22:30. [PMID: 19888369 PMCID: PMC2760282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Paul Courtright
- Kilimanjaro Centre for Community Ophthalmology PO Box 2254, Moshi, Tanzania
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Bibliography. Current world literature. Pediatrics and strabismus. Curr Opin Ophthalmol 2007; 18:434-6. [PMID: 17700239 DOI: 10.1097/icu.0b013e3282f0361d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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