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Zhu XW, Li R, Zhang JY, Ding X, Qiu T, Lin M, Shao CY, Li J, Liu H. Reducing tension step by step in epicanthus and lower eyelid incision for treating cilial entropion in children: A case series analysis. J Plast Reconstr Aesthet Surg 2024; 95:134-141. [PMID: 38908037 DOI: 10.1016/j.bjps.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE To evaluate the surgical outcomes of a modified technique for treating congenital cilial entropion in children, which involves reducing tension step by step in the epicanthus and lower eyelid incision. METHODS The observational group consisted of 153 pediatric patients (81 males and 72 females) who were treated using the modified technique, whereas the control group included 124 patients (68 males and 56 females) who were treated using the rotating suture surgery. All the participants were bilateral. Surgical outcomes were classified as good, fair, or poor, and the recurrence rate, scar condition, inferior eyelid position, and patient satisfaction were also assessed. RESULTS The mean follow-up period was 9.13 ± 3.50 months (range: 3-14 months) for the observational group and 6.93 ± 4.51 months (range: 3-14 months) for the control group. In the observational group, surgical success with "good" outcomes was achieved in 300 eyes (98.04%), compared to 224 eyes (90.32%) in the control group. No recurrence occurred in the observational group, whereas the recurrence rate in the control group was 4.43%. Postoperative scar formation was mild in the observational group. The average scar score was 1.27 ± 0.96 in the observational group and 2.70 ± 0.99 in the control group, with a statistically significant difference (P < 0.001). Neither overcorrection nor postoperative ectropion was observed in both groups. CONCLUSION The modified technique effectively corrected medial entropion and trichiasis in the lower eyelid, resulting in stable postoperative outcomes, mild scar formation, quick recovery, flexible eyelid motility, and stable ocular surface. Therefore, it can be widely applied to children with congenital entropion and trichiasis.
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Affiliation(s)
- Xiao-Wei Zhu
- Department of Ophthalmology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, No.1678, Dongfang Road, Shanghai 200120, China
| | - Rui Li
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No.639, Zhizaoju Road, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Disease and Ocular Oncology, Shanghai 200011, China
| | - Jia-Ying Zhang
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No.639, Zhizaoju Road, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Disease and Ocular Oncology, Shanghai 200011, China
| | - Xia Ding
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No.639, Zhizaoju Road, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Disease and Ocular Oncology, Shanghai 200011, China
| | - Ting Qiu
- Department of Ophthalmology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, No.1678, Dongfang Road, Shanghai 200120, China
| | - Ming Lin
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No.639, Zhizaoju Road, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Disease and Ocular Oncology, Shanghai 200011, China
| | - Chun-Yi Shao
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No.639, Zhizaoju Road, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Disease and Ocular Oncology, Shanghai 200011, China.
| | - Jin Li
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No.639, Zhizaoju Road, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Disease and Ocular Oncology, Shanghai 200011, China.
| | - Hong Liu
- Department of Ophthalmology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, No.1678, Dongfang Road, Shanghai 200120, China.
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Pak C, Hall N, Bekele DT, Kollmann KHM, Tadele T, Tekle-Haimanot R, Taye T, Qureshi B, Yalew W, Gower EW, Kempen JH. Impact of refresher training on the outcomes of trachomatous trichiasis surgery. Br J Ophthalmol 2024; 108:1049-1052. [PMID: 37775258 DOI: 10.1136/bjo-2022-322497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND/AIMS Trachomatous trichiasis (TT) is a severe consequence of chronic inflammation/conjunctival scarring resulting from trachoma, the leading infectious cause of blindness worldwide. Our prospective cohort study evaluated the effectiveness of refresher training (RT) for experienced surgeons (1-22 years) on the outcomes of upper lid (UL) TT surgery in rural Ethiopia. METHODS Patients undergoing UL TT surgery in at least one eye by a participating surgeon were included. Patients were split into two cohorts: patients enrolled prior to (C1) and after (C2) RT. RT consisted of a 1-week programme with practice on a HEAD START mannequin and supportive supervision in live surgery by expert trainers. Data were collected at preoperative enrolment, and at 6-month and 12-month follow-up visits. The primary outcome was development of postoperative TT (PTT). A series of multivariate generalised estimating equations were fit to model PTT involving potential covariates of interest. RESULTS A total of 261 eyes contributed by 173 patients were studied between 2017 and 2019. By 1-year postoperatively, 37/128 eyes (28.9%) in C1 and 22/133 eyes (16.5%) in C2 had developed PTT (p=0.03). Other than surgeon RT participation, no factors studied were associated with differences in PTT. CONCLUSION Our results indicate a significant reduction in the risk of PTT after experienced surgeons' participation in RT as compared with eyes receiving surgery before RT. This observation suggests a significant potential benefit of the RT with HEAD START mannequin practice and supportive supervision during surgery, and suggests RT may be a valuable strategy to improve surgical outcomes.
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Affiliation(s)
- Clara Pak
- University of Rochester School of Medicine and Dentistry, Rochester, Minnesota, USA
| | - Nathan Hall
- Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Demissie Tadesse Bekele
- MyungSung Christian Medical Center (MCM) Eye Unit of MCM Comprehensive Specialized Hospital and MyungSung Medical College, Addis Ababa, Ethiopia
- Christian Blind Mission, Bensheim, Germany
| | | | | | | | - Tarik Taye
- Grarbet Tehadiso Mahber, Addis Ababa, Ethiopia
| | | | | | - Emily W Gower
- Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - John H Kempen
- Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- MyungSung Christian Medical Center (MCM) Eye Unit of MCM Comprehensive Specialized Hospital and MyungSung Medical College, Addis Ababa, Ethiopia
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3
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Tabor Yimam A, Wassie GT, Alene GD. Postoperative trachomatous trichiasis and associated factors among adults who underwent trachomatous trichiasis surgery in Ambassel District, North-East Ethiopia. PLoS One 2024; 19:e0304407. [PMID: 38805451 PMCID: PMC11132444 DOI: 10.1371/journal.pone.0304407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/10/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND In Trachoma endemic countries, many people who underwent Trichiasis surgery faced a recurrence of the disease. Postoperative Trichiasis is a significant problem for patients and health care providers because it puts the eye at renewed risk of sight loss. Despite the low utilization of Trachomatous Trichiasis surgery and the high recurrence rate, evidence that elucidate why it recurs after surgery is limited. This study was aimed to assess the magnitude and associated factors of postoperative Trichiasis among 18 years and above individuals who underwent Trachomatous Trichiasis surgery between 2013 and 2019 in Ambassel District, Northeast Ethiopia, 2020. METHODS The community-based cross-sectional study design was conducted from March 10 to March 23/2020 in selected kebeles of Ambassel District. The required sample size (506) was calculated using EPI-INFO Version 7. A multi-stage sampling technique was used to employ study participants. Data were collected through the interviewer-administered structured pre-tested questionnaire and entered into EpiData version 3.1 and then exported to SPSS version 23.0 for analysis. Bi-variable and multivariable logistic regression models were fitted to identify associated factors of Postoperative Trachomatous Trichiasis. RESULTS Four hundred ninety two individuals participated in this study with a response rate of 97.2%. In Ambassel district, the prevalence of postoperative Trichiasis was 23.8% (95% CI = 19.9-27.8). Among associated factors of postoperative Trachomatous Trichiasis: age 50-59 (AOR = 3.34, CI = 1.38-8.1), 60-69 (AOR = 3.24, CI = 1.38-7.61), ≥70 years (AOR = 6.04, CI = 2.23-16.41), duration since surgery (AOR = 1.7, CI = 1.35-2.14), complication (AOR = 2.98, CI = 1.24-7.2), washing the face two times (AOR = 0.25, CI = 0.13-0.47), washing the face three and more times (AOR = 0.1, CI = 0.41-0.25), taking Azithromycin following surgery (AOR = 0.19, CI = 0.09-0.41), pre-operative epilation history (AOR = 2.11, CI = 1.14, 3.9) and having a knowledge about TrachomaTtrichiasis (AOR = 0.21, CI = 0.08-0.58) showed a statistical significant association. CONCLUSIONS The prevalence of postoperative Trichiasis in Ambassel District was higher than most Ethiopian studies. Age, frequency of face washing, medication following surgery, duration since the last surgery, knowledge about trachoma, pre-operative epilation history, and complication after surgery were identified to be independent factors. To minimize postoperative Trachomatous Trichiasis stakeholders need to consider health education for patients, provision of Azithromycin after surgery, and proper training for integrated eye care workers.
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Affiliation(s)
- Abdu Tabor Yimam
- Department of Epidemiology and Biostatistics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gizachew Tadesse Wassie
- Department of Epidemiology and Biostatistics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Getu Degu Alene
- Department of Epidemiology and Biostatistics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
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4
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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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5
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Sullivan KM, Harding-Esch EM, Batcho WE, Issifou AAB, Lopes MDFC, Szwarcwald CL, Vaz Ferreira Gomez D, Bougouma C, Christophe N, Kabore M, Bucumi V, Bella AL, Epee E, Yaya G, Trujillo-Trujillo J, Dejene M, Gebretsadik FS, Gebru G, Kebede F, Mathewos T, Cassama ETDS, Sanha S, Barasa E, Sultani HM, Watitu T, Tekeraoi R, Kalua KM, Masika MP, Traoré L, Minnih AO, Abdala M, Massangaie ME, Win Y, Apadinuwe SC, Mishra SK, Sharma S, Amza A, Kadri B, Nassirou B, Mpyet CD, Olobio N, Hussain A, Khan AA, Jambi G, Ko R, Kello AB, Badiane MD, Sarr B, Dalmar A, Elshafie BE, Kabona GE, Kaitaba O, Mwingira U, Simon A, Kanyi S, Awoussi MS, Togbey K, Baayenda G, Francis M, Tukahebwa EM, Bakhtiari A, Keil AP, Maselko J, Westreich D, Garae M, Taleo F, Al-Khateeb TQ, Mwale C, Solomon AW, Gower EW. Gender differences in the surgical management of trachomatous trichiasis: an exploratory analysis of global trachoma survey data, 2015-2019. Int Health 2023; 15:ii58-ii67. [PMID: 38048383 PMCID: PMC10695456 DOI: 10.1093/inthealth/ihad067] [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: 04/14/2023] [Revised: 06/28/2023] [Accepted: 07/26/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Trachomatous trichiasis (TT) is a painful, potentially blinding eye condition that can be managed through epilation or surgery. Women are affected by TT approximately twice as often as men and are believed to face gendered barriers to receiving surgical care to prevent vision loss. METHODS We used data from 817 cross-sectional surveys conducted during 2015-2019 in 20 African countries to estimate the prevalence difference (PD) between female and male eyes for four outcomes potentially indicating gender-related differences in TT management: (1) received surgery and developed postoperative TT (PTT), (2) never offered surgery, (3) offered surgery but declined it, and (4) offered epilation but never offered surgery. RESULTS The prevalence was modestly elevated among female eyes compared with male eyes for having PTT (PD:1.8 [95% confidence limits (CL): 0.6, 3.0]) and having declined surgery for the eye (PD: 6.2 [95% CL: 1.8, 10.7]). The proportion offered epilation was similar by gender (PD:0.5 [95% CL: -0.4, 1.3]), while never having been offered surgery was somewhat more prevalent among male eyes (PD: -2.1 [95% CL: -3.5, -0.7]). CONCLUSIONS Our results suggest potential gender differences in TT management. More research is needed to determine the causes and implications of the observed differences.
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Affiliation(s)
- Kristin M Sullivan
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emma M Harding-Esch
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Wilfrid E Batcho
- Programme National De Lutte Contre Les Maladies Transmissibles, Ministère De La Santé, Cotonou, Benin
| | | | | | - Celia Landmann Szwarcwald
- Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Clarisse Bougouma
- Direction de la Protection de la Santé de la Population, Ministère de la Santé, Burkina Faso
| | - Nassa Christophe
- Attaché de Santé en Épidémiologie, Programme National de Lutte Contre Les MTN, Burkina Faso
| | - Martin Kabore
- L'unité d'élimination du trachome, PNMTN, Ouagadougou, Burkina Faso
| | - Victor Bucumi
- Département En Charge des Maladies Tropicales, Négligées Ministère De La Santé Publique Et De La Lutte Contre Le Sida, Bujumbura, Burundi
| | - Assumpta L Bella
- Programme National de Lutte Contre La Cecite, Ministère de la Santé Publique, Yaoundé, Cameroun
| | - Emilienne Epee
- Department Of Ophthalmology, University of Yaoundé Yaounde Centre/Ministère de la Santé Publique, Yaoundé, Cameroun
| | - Georges Yaya
- Ministère de la Santé Publique, Bangui, Central African Republic
| | - Julian Trujillo-Trujillo
- Subdirectorate of Communicable Diseases, Ministry of Health and Social Protection, Bogotá, Colombia
| | | | - Fikre Seife Gebretsadik
- Neglected Tropical Disease Prevention and Control Program, Ministry of Health, Addis Ababa, Ethiopia
| | - Genet Gebru
- Neglected Tropical Disease Prevention and Control Program, Ministry of Health, Addis Ababa, Ethiopia
| | - Fikreab Kebede
- Neglected Tropical Disease Prevention and Control Program, Ministry of Health, Addis Ababa, Ethiopia
| | - Tsedeke Mathewos
- Neglected Tropical Disease Prevention and Control Program, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Salimato Sanha
- Programa Nacional De Sau´de De Visão, Minsap, Bissau, Guinea-Bissau
| | | | | | | | | | - Khumbo M Kalua
- Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Michael P Masika
- Department of Clinical and Medical Rehabilitation Services, Ministry of Health, Lilongwe, Malawi
| | - Lamine Traoré
- National Eye Health Program, Ministry of Health and Social Development, Mali
| | - Abdallahi O Minnih
- Département Des Maladies Transmissibles, Ministère De La Santé Nouakchott, Nouakchott, Mauritania
| | - Mariamo Abdala
- Direção Nacional de Saúde Pública, Ministerio Da Saude, Maputo, Mozambique
| | | | - Ye Win
- Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | | | - Sailesh Kumar Mishra
- National Society for Comprehensive Eye Care, Nepal Netra Jyoti Sangh, Kathmandu, Nepal
| | | | - Abdou Amza
- Programme National De Santé Oculaire, Ministère De La Santé Publique, Niamey, Niger
| | - Boubacar Kadri
- Programme National De Santé Oculaire, Ministère De La Santé Publique, Niamey, Niger
| | - Beido Nassirou
- Programme National De Santé Oculaire, Ministère De La Santé Publique, Niamey, Niger
| | - Caleb D Mpyet
- Department of Ophthalmology, University of Jos, Jos, Plateau, Nigeria
| | - Nicholas Olobio
- Neglected Tropical Diseases Division, Department of Public Health, Federal Ministry of Health, Abuja, Nigeria
| | - Arif Hussain
- Community Ophthalmology, College of Ophthalmology & Allied Vision Sciences (COAVS), Mayo Hospital Lahore, Lahore, Pakistan
| | - Asad Aslam Khan
- College of Ophthalmology and Allied Vision Sciences, Mayo Hospital, Lahore, Pakistan
| | - Garap Jambi
- Prevention of Blindness Committee, PNG Eye Care, Boroko, Papua New Guinea
| | - Robert Ko
- National Department of Health, Waigani, Papua New Guinea
| | - Amir B Kello
- AF/UCU UHC/Communicable and Noncommunicable Diseases Unit, ESPEN, World Health Organization, Brazzaville, Republic of Congo
| | - Mouctar D Badiane
- Programme National de Promotion de La Santé Oculaire, Ministère de la Santé et de L'Action Sociale, Dakar, Senegal
| | - Boubacar Sarr
- Ministère de la Santé et de l'Action Sociale, Senegal
| | | | - Balgesa E Elshafie
- National Program for Prevention of Blindness, Federal Ministry of Health, Khartoum, Sudan
| | - George E Kabona
- Neglected Tropical Diseases Control Program, Ministry of Health, Dodoma, Tanzania
| | - Oscar Kaitaba
- Neglected Tropical Diseases Control Program, Ministry of Health, Dodoma, Tanzania
| | - Upendo Mwingira
- Neglected Tropical Diseases Control Program, Ministry of Health, Dodoma, Tanzania
| | - Alistidia Simon
- Neglected Tropical Diseases Control Program, Ministry of Health, Dodoma, Tanzania
| | - Sarjo Kanyi
- National Eye Health Programme, Ministry of Health and Social Welfare, Banjul, The Gambia
| | | | - Kwamy Togbey
- Programme National des Maladies Tropicales Negligées, Ministry of Health, Public Hygiene and Universal Access to Care, Lomé, Togo
| | - Gilbert Baayenda
- Neglected Tropical Diseases Control, Ministry of Health, Kampala, Uganda
| | - Mugume Francis
- Neglected Tropical Diseases Control, Ministry of Health, Kampala, Uganda
| | - Edridah M Tukahebwa
- Vector-Borne and Neglected Tropical Diseases, Ministry of Health, Kampala, Uganda
| | - Ana Bakhtiari
- International Trachoma Initiative, Task Force for Global Health, Decatur, Georgia, USA
| | - Alexander P Keil
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joanna Maselko
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Westreich
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mackline Garae
- Department of Neglected Tropical Diseases, Vanuatu Ministry of Health, Port Vila, Vanuatu
| | - Fasiah Taleo
- Department of Neglected Tropical Diseases, Vanuatu Ministry of Health, Port Vila, Vanuatu
| | | | - Consity Mwale
- Kitwe Teaching Eye Hospital, Ministry of Health, Kitwe, Zambia
| | - Anthony W Solomon
- Global Neglected Tropical Diseases Programme, World Health Organization, Geneva, Switzerland
| | - Emily W Gower
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Adimassu NF, Assem AS, Fekadu SA. Postoperative trachomatous trichiasis: a systematic review and meta-analysis study. Int Health 2023; 15:623-629. [PMID: 36852770 PMCID: PMC10629961 DOI: 10.1093/inthealth/ihad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/04/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Trachomatous trichiasis is the potential stage of trachoma in which the eyelashes scratch the surface of the globe, ultimately causing corneal opacity, visual impairment and blindness. The aim of this systematic review and meta-analysis is to obtain the pooled prevalence and associated factors of postoperative trachomatous trichiasis (PTT) in World Health Organization (WHO) trachoma-endemic regions. METHODS An inclusive literature search was undertaken using PubMed, Cochrane Library, Science Direct and Google Scholar databases from 30 May 2022 to 28 June 2022. I2 statistics and funnel plots were used to determine heterogeneity and publication bias among included studies. A random effects model was used to estimate pooled prevalence, incidence and odds ratios (ORs) with the respective 95% confidence intervals (CIs) using RevMan 5.4 software. RESULTS Eighteen articles were included in this meta-analysis and systematic review. The pooled prevalence of PTT was 19% (range 18-21). PTT was lower among young adults compared with old adults (OR 0.63 [95% CI 0.44 to 0.92]), single-dose oral azithromycin as compared with tetracycline eye ointment users (OR 0.82 [95% CI 0.69 to 0.99]) and minor trichiasis before surgery as compared with major trichiasis (OR 0.63 [95% CI 0.47 to 0.85]). CONCLUSIONS The incidence of PTT was higher than the WHO's recommendation. Prescribing single-dose oral azithromycin after surgery, periodic training for trichiasis surgeons, close follow-up and health education after surgery are crucial to minimize the recurrence.Study protocol registration on PROSPERO: CRD42022336003.
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Affiliation(s)
- Nebiyat Feleke Adimassu
- Department of Optometry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abel Sinshaw Assem
- Department of Optometry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Sofonias Addis Fekadu
- Department of Optometry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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7
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Ibrahim ENA, Tharwat E, Khalil MMAA, Mohammed AR, Mohammed MF, Alkady AMM, Ezzeldin ER, Hassan Ahmed RE, Al-Faky YH, Hassanein M, Elsayed AN, Abd El-Salam ME. Modified Anterior Lamellar Recession for All Grades of Upper Eyelid Trachomatous Cicatricial Entropion. Clin Ophthalmol 2023; 17:2323-2332. [PMID: 37583577 PMCID: PMC10424687 DOI: 10.2147/opth.s420992] [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: 05/12/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023] Open
Abstract
Purpose This study aims to assess the combination of anterior lamellar recession (ALR) with blepharoplasty, suprasternal fixation, and internal eyelash bulb extirpation of aberrant lashes posteriorly located in patients with any grade of upper eyelid trachomatous cicatricial entropion. Patients and Methods We reviewed the clinical data of eighty-six patients (143 eyelids) including age, gender, systemic medical illnesses, and comprehensive ophthalmological assessment. Eyelid evaluation was recorded, including laterality, previous surgical technique used, possible trichiasis etiology, abnormality of the lid margin, tarsal plate consistency (shrinkage or loosening), skin fold overhanging, laxity of the pretarsal skin, margin reflex distance 1 (MRD1), lagophthalmos, and lid retraction. The success rate was assessed at 3, 6, 9, and 12 months postoperative. Results The success rate was 97.2% in the third month, which decreased significantly to 92.3% in the 6th month and 90.2% in the 9th month (P = 0.01, and 0.001 respectively). In the 9th month, we had fourteen failed cases. All of them were submitted for a second intervention. Three underwent electrolysis, four cases underwent re-internal bulb extirpation, four cases underwent the same procedure, and three cases underwent epilation. The success of the failed cases after the second intervention was significantly associated with the type of reintervention (P = 0.03), in which all of them succeed except two cases that underwent epilation. Kaplan-Meier analysis showed that the mean recurrence time in our study was 6.8 months (95% CI = 5.8-7.7 months). Conclusion This study showed the combination of ALR with blepharoplasty, suprasternal fixation, and cauterization or internal bulb extirpation of posteriorly located lashes procedure resulted in a high success rate in patients with any form of UCE with no increase in incidence or degree of lagophthalmos associated with UCE.
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Affiliation(s)
| | - Ehab Tharwat
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | | | - Ahmed Rabie Mohammed
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mostafa F Mohammed
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | | | | | - Yasser H Al-Faky
- Department of Ophthalmology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudia Arabia
| | - Mohamed Hassanein
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed N Elsayed
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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8
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Derrick T, Habtamu E, Tadesse Z, Callahan EK, Worku A, Gashaw B, Macleod D, Mabey DC, Holland MJ, Burton MJ. The conjunctival transcriptome in Ethiopians after trichiasis surgery: associations with the development of eyelid contour abnormalities and the effect of oral doxycycline treatment. Wellcome Open Res 2022; 4:130. [PMID: 37426632 PMCID: PMC10323279 DOI: 10.12688/wellcomeopenres.15419.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 07/31/2023] Open
Abstract
Background: Surgery to correct trichiasis is a key component of the World Health Organisation trachoma control strategy, however unfavourable outcomes such as eyelid contour abnormalities (ECA) following surgery are relatively common. This study aimed to understand the transcriptional changes associated with the early development of ECA and the impact of doxycycline, which has anti-inflammatory and anti-fibrotic properties, upon these transcription patterns. Methods: One thousand Ethiopians undergoing trichiasis surgery were enrolled in a randomised controlled trial following informed consent. Equal groups of randomly assigned individuals were orally administered with 100mg/day of doxycycline (n=499) or placebo (n=501) for 28 days. Conjunctival swabs were collected immediately prior to surgery and at one- and six-months post-surgery. 3' mRNA sequencing was performed on paired baseline and one-month samples from 48 individuals; 12 in each treatment/outcome group (Placebo-Good outcome, Placebo-Poor outcome, Doxycycline-Good outcome, Doxycycline-Poor outcome). qPCR validation was then performed for 46 genes of interest in 145 individuals who developed ECA at one month and 145 matched controls, using samples from baseline, one and six months. Results: All treatment/outcome groups upregulated genes associated with wound healing pathways at one month relative to baseline, however no individual differences were detected between groups. The summed expression of a highly coexpressed cluster of pro-fibrotic genes was higher in patients that developed ECA in the placebo group relative to controls. qPCR validation revealed that all genes in this cluster and a number of other pro-inflammatory genes were strongly associated with ECA, however these associations were not modulated by trial arm. Conclusions: The development of post-operative ECA is associated with overexpression of pro-inflammatory and pro-fibrotic genes including growth factors, matrix metalloproteinases, collagens and extracellular matrix proteins. There was no evidence that doxycycline modulated the association between gene expression and ECA.
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Affiliation(s)
- Tamsyn Derrick
- London School of Hygiene and Tropical Medicine, London, UK
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Esmael Habtamu
- London School of Hygiene and Tropical Medicine, London, UK
- The Carter Center, Addis Ababa, Ethiopia
| | | | | | - Abebaw Worku
- Amhara Regional Health Bureau, Bahirdar, Ethiopia
| | | | - David Macleod
- London School of Hygiene and Tropical Medicine, London, 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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10
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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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11
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Bayissasse B, Sullivan KM, Merbs SL, Munoz B, Keil A, Sisay A, Singer A, Gower EW. Maximising trichiasis surgery success (MTSS) trial: rationale and design of a randomised controlled trial to improve trachomatous trichiasis surgical outcomes. BMJ Open 2020; 10:e036327. [PMID: 32193277 PMCID: PMC7202705 DOI: 10.1136/bmjopen-2019-036327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Trachomatous trichiasis (TT) is a condition in which the eyelid turns inward and eyelashes abrade the front part of the eye. To prevent eventual blindness, surgery is recommended. Two surgical procedures are commonly used, bilamellar tarsal rotation (BLTR) and posterior lamellar tarsal rotation (PLTR). Evidence suggests that incision height and surgery type may affect the risk of postoperative TT (PTT) and other surgical outcomes. However, these studies have not prospectively compared the impact of incision height on surgical outcomes. METHODS AND ANALYSIS Maximising trichiasis surgery Success (MTSS) is a three-arm, randomised clinical trial being conducted in Ethiopia. Participants will be randomly assigned on a 1:1:1 basis to BLTR with a 3 mm incision height, BLTR with a 5 mm incision height, or PLTR 3 mm incision height. Patients are eligible for the trial if they have previously unoperated upper eyelid TT. Follow-up visits will be conducted by trained eye examiners at 1 day, 2 weeks, 6 weeks and 12 months after surgery. The primary outcome is incident PTT within 1 year following surgery. Logistic regression will be used in an intention-to-treat analysis to assess outcome incidence by surgical approach. ETHICS AND DISSEMINATION The University of North Carolina and Johns Hopkins School of Medicine institution review boards, Ethiopian National Research Ethics Review Committee and Ethiopian Food, Medicine, Healthcare and Administration and Control Authority provided ethics approval for the trial. On completion, trial results will be disseminated at local and international meetings and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03100747.
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Affiliation(s)
| | - Kristin M Sullivan
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shannath L Merbs
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Beatriz Munoz
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Alexander Keil
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, North Carolina, USA
| | | | - Alison Singer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emily W Gower
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Ophthalmology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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12
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Elbaklish KH, Saleh SM, Gomaa WA. Lamellar Tarsectomy Procedure In Major Trichiasis Of The Upper Lid. Clin Ophthalmol 2019; 13:2251-2259. [PMID: 31819349 PMCID: PMC6877448 DOI: 10.2147/opth.s210038] [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: 03/26/2019] [Accepted: 10/15/2019] [Indexed: 11/30/2022] Open
Abstract
Aims Evaluation of failure rate and outcomes between skin and muscle surgery and lamellar tarsectomy procedure in major trichiasis of the upper lid. Design Quasi-randomized clinical study. Methods and subjects One hundred individuals with major trichiasis of the upper lid were enrolled and assigned to either skin and muscle surgery (group A) or a lamellar tarsectomy procedure (group B). Participants were examined at 6 and 12 months. The primary outcome measure (failure rate) was the percentage of participants having five or more eyelashes touching the globe or having surgery performed at any follow-up time in both groups. The secondary outcomes included failure time and changes in both visual acuity and corneal opacity. Results Risk failure over 6 months was 40% in group A and 10% in group B. Absolute risk reduction was 30% (95% CI=14.08–45.92%). Cumulative risk failure over 12 months was 20% in group A and 0.00% in group B after the second intervention. Absolute risk reduction was 20% (95% CI=8.58–31.42%). The number needed to treat (NNT) was 3.3 patients (95% CI=2.2–7.1). The mean number of rubbing lashes was greater in the skin and muscle group than in the lamellar tarsectomy group for 6 and 12 month examinations (0.002, 0.005). The change in visual acuity between the two groups was not significant. Recurrent trichiasis was noticed earlier, 6 weeks after surgery, in the skin and muscle group participants, and later, 3 months after surgery, in the lamellar tarsectomy group participants. Conclusion The lamellar tarsectomy procedure is a good choice for management of major trichiasis of the upper lid. The subjective symptoms and lid margin conjunctivalization were improved in lamellar tarsectomy participants. Absence of new corneal opacity or a change in existing corneal opacification was noticed at the 12 months follow-up study.
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Affiliation(s)
| | - Safaa M Saleh
- Ophthalmology Department, Ain Shams University, Cairo, Egypt
| | - Wael Adel Gomaa
- Ophthalmology Department, Ain Shams University, Cairo, Egypt
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13
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Gower EW, Munoz B, Rajak S, Habtamu E, West SK, Merbs SL, Harding JC, Alemayehu W, Callahan EK, Emerson PM, Gebre T, Burton MJ. Pre-operative trichiatic eyelash pattern predicts post-operative trachomatous trichiasis. PLoS Negl Trop Dis 2019; 13:e0007637. [PMID: 31589610 PMCID: PMC6797216 DOI: 10.1371/journal.pntd.0007637] [Citation(s) in RCA: 8] [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: 05/14/2019] [Revised: 10/17/2019] [Accepted: 07/17/2019] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Trichiasis surgery programs globally have faced high rates of poor surgical outcomes. Identifying correctable risk factors for improving long-term outcomes is essential for countries targeting elimination of trachoma as a public health problem. OBJECTIVE To determine whether the location of trichiatic eyelashes prior to surgery influences development of post-operative trichiasis (PTT) within two years after surgery. DESIGN Secondary data analysis of four randomized clinical trials evaluating methods to improve trichiasis surgery outcomes. These include the Surgery for Trichiasis, Antibiotics for Recurrence (STAR) trial, Partnership for Rapid Elimination of Trachoma (PRET-Surgery), absorbable versus silk sutures trial, and epilation versus surgery for minor trichiasis trial. SETTING Primary trials were conducted in rural areas of Ethiopia and Tanzania. INTERVENTIONS OR EXPOSURES Trichiasis surgery performed with either the bilamellar tarsal rotation procedure or posterior lamellar rotation procedure. MAIN OUTCOMES Prevalence of PTT within two years after surgery, location of trichiatic eyelashes pre-operatively and post-operatively. RESULTS 6,747 eyelids that underwent first-time trichiasis surgery were included. PTT rates varied by study, ranging from 10-40%. PTT was less severe (based on number of trichiatic eyelashes) than initial trichiasis for 72% of those developing PTT, and only 2% of eyelids were worse at follow up than pre-operatively. Eyelids with central only-trichiasis pre-operatively had lower rates of PTT than eyelids with peripheral only trichiasis in each of the three trials that included severe TT cases. 10% of eyelids with peripheral trichiasis pre-operatively that develop PTT have central TT post-operatively. CONCLUSIONS AND RELEVANCE Pre-operative central trichiasis is less likely than peripheral trichiasis to be associated with subsequent PTT. Regardless of type of surgery, surgeon skill levels, or pre-operative trichiasis severity, the presence of peripheral trichiasis pre-operatively is associated with higher rates of PTT. Making an incision that extends the length of the eyelid and adequately rotating the nasal and temporal aspects of the eyelid when suturing may help to minimize the chance of developing peripheral PTT. TRIAL REGISTRATION ClinicalTrials.gov PRET: NCT00886015; Suture: NCT005228560; Epilation: NCT00522912.
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Affiliation(s)
- Emily W. Gower
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Beatriz Munoz
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Saul Rajak
- The Sussex Eye Hospital, Brighton, United Kingdom
| | - Esmael Habtamu
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheila K. West
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Shannath L. Merbs
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | | | - Wondu Alemayehu
- Berhan Public Health and Eye Care Consultancy, Addis Ababa, Ethiopia
| | | | - Paul M. Emerson
- International Trachoma Initiative, Atlanta, Georgia, United States of America
| | - Teshome Gebre
- International Trachoma Initiative, Addis Ababa, Ethiopia
| | - Matthew J. Burton
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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14
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Talero SL, Muñoz B, West SK. Potential Effect of Epilation on the Outcome of Surgery for Trachomatous Trichiasis. Transl Vis Sci Technol 2019; 8:30. [PMID: 31489257 PMCID: PMC6707224 DOI: 10.1167/tvst.8.4.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 04/29/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose To evaluate the association of epilation before surgery on the surgical outcome in trachomatous trichiasis (TT) patients. Methods As a secondary data analysis, 1452 patients enrolled in the STAR trial were categorized according to preoperative epilation status. The main outcome was recurrent trichiasis after surgery. We used multivariable analysis, time-to-event analysis, and Cox proportional hazards model. Results Those who epilated prior to surgery tended to be older and female, with worse entropion at baseline. The proportion with postoperative trichiasis was 7.7%, 8.8% in those who epilated versus 5.3% in those who did not (P = 0.03). Adjusting for age and sex, the risk of postoperative TT with epilation was 1.71 (P value = 0.02). Although entropion may be in the biological pathway from epilation to postoperative TT, we adjusted for entropion, and the risk of postoperative TT with epilation was 1.41 (P = 0.14). Conclusions The study suggests that preoperative epilation may increase the risk of postoperative trichiasis. Further research is needed to confirm the finding. Translational Relevance Patients with TT often self-treat, epilating their inturned eyelashes. The World Health Organization recommends surgery to treat TT, but when patients refuse the procedure or mild trichiasis is present, epilation is often recommended. There is some evidence that repetitive or improper epilation can be harmful to the lid and hair follicles. If there is damage to the lid margin, any subsequent surgery could have deleterious outcomes.
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Affiliation(s)
| | - Beatriz Muñoz
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sheila K West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, MD, USA
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15
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Derrick T, Habtamu E, Tadesse Z, Callahan EK, Worku A, Gashaw B, Macleod D, Mabey DC, Holland MJ, Burton MJ. The conjunctival transcriptome in Ethiopians after trichiasis surgery: associations with the development of eyelid contour abnormalities and the effect of oral doxycycline treatment. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15419.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Surgery to correct trichiasis is a key component of the World Health Organisation trachoma control strategy, however unfavourable outcomes such as eyelid contour abnormalities (ECA) following surgery are relatively common. This study aimed to understand the transcriptional changes associated with the early development of ECA and the impact of doxycycline, which has anti-inflammatory and anti-fibrotic properties, upon these transcription patterns. Methods: One thousand Ethiopians undergoing trichiasis surgery were enrolled in a randomised controlled trial following informed consent. Equal groups of randomly assigned individuals were orally administered with 100mg/day of doxycycline (n=499) or placebo (n=501) for 28 days. Conjunctival swabs were collected immediately prior to surgery and at one- and six-months post-surgery. 3’ mRNA sequencing was performed on paired baseline and one-month samples from 48 individuals; 12 in each treatment/ECA outcome group. qPCR validation was then performed for 46 genes of interest in 145 individuals who developed ECA at one month and 145 matched controls, using samples from baseline, one and six months. Results: All treatment/outcome groups upregulated genes associated with wound healing pathways at one month relative to baseline, however no individual differences were detected between groups. The summed expression of a highly coexpressed cluster of pro-fibrotic genes was higher in patients that developed ECA in the placebo group relative to controls. qPCR validation revealed that all genes in this cluster and a number of other pro-inflammatory genes were strongly associated with ECA, however these associations were not modulated by trial arm. Conclusions: The development of post-operative ECA is associated with overexpression of pro-inflammatory and pro-fibrotic genes including growth factors, matrix metalloproteinases, collagens and extracellular matrix proteins. There was no evidence that doxycycline modulated the association between gene expression and ECA.
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16
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Barmas-Alamdari D, D’Souza HS, Kapoor KG, Wagner AL. Intravitreal Ziv-Aflibercept: A Comprehensive Review. Semin Ophthalmol 2019; 34:420-435. [DOI: 10.1080/08820538.2019.1641526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Haley S. D’Souza
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Ophthalmology Research, Wagner Macula and Retina Center, Virginia Beach, Virginia, USA
| | - Kapil G. Kapoor
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Ophthalmology Research, Wagner Macula and Retina Center, Virginia Beach, Virginia, USA
| | - Alan L. Wagner
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Ophthalmology Research, Wagner Macula and Retina Center, Virginia Beach, Virginia, USA
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17
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Fluorometholone 0.1% as Ancillary Therapy for Trachomatous Trichiasis Surgery: Randomized Clinical Trial. Am J Ophthalmol 2019; 197:145-155. [PMID: 30267699 DOI: 10.1016/j.ajo.2018.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/12/2018] [Accepted: 09/17/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE To assess the hypothesis that fluorometholone 0.1% eye drops are safe and effective as adjunctive therapy for trachomatous trichiasis (TT) surgery; determining the most promising dose. DESIGN Randomized, placebo-controlled, double-masked parallel dose-ranging clinical trial. METHODS Patients undergoing upper lid TT surgery at a rural Ethiopian hospital were randomized to fluorometholone 0.1% twice daily for 4 weeks, 4 times daily for 4 weeks, 4 times daily for 8 weeks, or matching frequency placebo in a 3:1:3:1:3:1 ratio for 1 eye. Randomization was stratified by TT severity (1-4 vs ≥5 lashes touching the globe). Safety outcomes (intraocular pressure [IOP] elevation, cataract, and other dose-limiting toxicities) and postoperative TT incidence were assessed over 1 year. RESULTS Subjects randomized were 39:13:39:13:38:13 in the respective groups, and 1 subject in the 8-weeks fluorometholone group was withdrawn. Of 154 subjects, 148 (96.1%) completed 1 year's follow-up. Among 76 eyes receiving fluorometholone 4 times daily, 1 developed IOP elevation ≥ 30 mm Hg (to 37 mm Hg) and 1 had an allergic reaction attributed to the study drug; each resolved upon drug cessation without sequelae. No cataract or other dose-limiting toxicity events occurred. Postoperative TT within 1 year occurred in 29.3% of placebo eyes vs 17.7%, 19.6%, and 23.2% among the respective fluorometholone groups (P = .29 comparing placebo vs all active treatments combined). CONCLUSIONS The results suggest fluorometholone 0.1% is likely to be safe and efficacious to reduce postoperative TT following TT surgery, and 1 drop twice daily for 4 weeks is the most promising dose. Confirmation in a full-scale clinical trial is needed before programmatic implementation.
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18
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Habtamu E, Wondie T, Aweke S, Tadesse Z, Zerihun M, Gashaw B, Roberts CH, Kello AB, Mabey DCW, Rajak SN, Callahan EK, Macleod D, Weiss HA, Burton MJ. Oral doxycycline for the prevention of postoperative trachomatous trichiasis in Ethiopia: a randomised, double-blind, placebo-controlled trial. Lancet Glob Health 2018; 6:e579-e592. [PMID: 29653629 PMCID: PMC5912946 DOI: 10.1016/s2214-109x(18)30111-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/11/2018] [Accepted: 02/22/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Trachomatous trichiasis is treated surgically to prevent sight loss. Unfavourable surgical outcomes remain a major challenge. We investigated the hypothesis that doxycycline might reduce the risk of postoperative trichiasis following surgery in patients with trachomatous trichiasis through anti-matrix metalloproteinase and anti-inflammatory activity. METHODS In this randomised, double-blind, placebo-controlled trial, adults (aged >18 years) with upper lid trachomatous trichiasis in association with tarsal conjunctive scarring were recruited through community-based screening and surgical outreach campaigns in Ethiopia. Individuals who had previously had eyelid surgery were excluded. Participants were randomly assigned (1:1), with random block sizes of four or six, to receive oral doxycycline (100 mg once a day) or placebo for 28 days immediately after trichiasis surgery. Randomisation was stratified by surgeon. Patients, investigators, surgeons, and all other study team members were masked to study group allocation and treatment. Participants were examined at 10 days, and 1, 6, and 12 months after surgery. The primary outcome was the cumulative proportion of individuals who developed postoperative trichiasis by 12 months. Primary analyses were done in all participants who attended at least one of the four follow-up assessments. Safety analyses were done in all participants who attended either the 10 day or 1 month follow-up assessments. This trial is registered with the Pan African Clinical Trials Registry, number PACTR201512001370307. FINDINGS Between Dec 21, 2015, and April 6, 2016, 1000 patients with trichiasis were enrolled and randomly assigned to treatment (499 patients to doxycycline, 501 patients to placebo). All but one participant attended at least one follow-up assessment. Thus, 999 participants were assessed for the primary outcome: 498 in the doxycycline group and 501 in the placebo group. By month 12, 58 (12%) of 498 patients in the doxycycline group and 62 (12%) of 501 patients in the placebo group had developed postoperative trichiasis (adjusted odds ratio 0·91, 95% CI 0·61 to 1·34, p=0·63), with a risk difference of -0·5% (-4·5% to 3·5%). Significantly more patients in the doxycycline group had an adverse event than in the placebo group (18 [4%] of 498 vs six [1%] of 501; odds ratio 3·09, 95% CI 1·21-7·84; p=0·02). The most frequent adverse events in the doxycycline group were gastritis symptoms (n=9), constipation (n=4), and diarrhoea (n=4). INTERPRETATION Doxycycline did not reduce the risk of postoperative trichiasis and is therefore not indicated for the improvement of outcomes following trachomatous trichiasis surgery. Surgical programmes should continue to make efforts to strengthen surgical training and supervision to improve outcomes. FUNDING The Wellcome Trust.
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Affiliation(s)
- Esmael Habtamu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.
| | | | | | | | | | | | - Chrissy H Roberts
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | - David C W Mabey
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Saul N Rajak
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - David Macleod
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen A Weiss
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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19
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Predictors of Trachomatous Trichiasis Surgery Outcome. Ophthalmology 2017; 124:1143-1155. [PMID: 28438414 PMCID: PMC5540045 DOI: 10.1016/j.ophtha.2017.03.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Unfavorable outcomes after trachomatous trichiasis (TT) surgery are undermining the global trachoma elimination effort. This analysis investigates predictors of postoperative TT (PTT), eyelid contour abnormalities (ECAs), and granuloma in the 2 most common TT surgery procedures: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR). Design Secondary data analysis from a randomized, controlled, single-masked clinical trial. Participants A total of 1000 patients with TT, with lashes touching the eye or evidence of epilation, in association with tarsal conjunctival scarring. Methods Participants were randomly allocated and received BLTR (n = 501) or PLTR (n = 499) surgery. Disease severity at baseline, surgical incisions, sutures, and corrections were graded during and immediately after surgery. Participants were examined at 6 and 12 months by assessors masked to allocation. Main Outcome Measures Predictors of PTT, ECA, and granuloma. Results Data were available for 992 (99.2%) trial participants (496 in each arm). There was strong evidence that performing more peripheral dissection with scissors in PLTR (odd ratio [OR], 0.70; 95% confidence interval [CI], 0.54–0.91; P = 0.008) and BLTR (OR, 0.83; 95% CI, 0.72–0.96; P = 0.01) independently protected against PTT. Baseline major trichiasis and mixed location lashes and immediate postoperative central undercorrection independently predicted PTT in both surgical procedures. Peripheral lashes in PLTR (OR, 5.91; 95% CI, 1.48–23.5; P = 0.01) and external central incision height ≥4 mm in BLTR (OR, 2.89; 95% CI, 1.55–5.41; P = 0.001) were independently associated with PTT. Suture interval asymmetry of >2 mm (OR, 3.18; 95% CI, 1.31–7.70; P = 0.01) in PLTR and baseline conjunctival scarring in BLTR (OR, 1.72; 95% CI, 1.06–2.81; P = 0.03) were independently associated with ECA. Older age was independently associated with ECA in both PLTR (P value for trend < 0.0001) and BLTR (P value for trend = 0.03). There was substantial intersurgeon variability in ECA rates for both PLTR (range, 19.0%–36.2%) and BLTR (range, 6.1%–28.7%) procedures. In PLTR surgery, irregular posterior lamellar incision at the center of the eyelid (OR, 6.72; 95% CI, 1.55–29.04; P = 0.01) and ECA (OR, 3.08; 95% CI, 1.37–6.94; P = 0.007) resulted in granuloma formation. Conclusions Poor postoperative outcomes in TT surgery were associated with inadequate peripheral dissection, irregular incision, asymmetric suture position and tension, inadequate correction, and lash location. Addressing these will improve TT surgical outcomes.
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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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Anterior lamellar recession, blepharoplasty, and supratarsal fixation for cicatricial upper eyelid entropion without lagophthalmos. Eye (Lond) 2016; 30:627-31. [PMID: 26869158 DOI: 10.1038/eye.2016.12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/21/2015] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To assess the results of anterior lamellar recession, blepharoplasty, and supratarsal fixation procedure in patients with upper eyelid cicatricial entropion without lagophthalmos. METHODS In a prospective interventional case series, 52 eyelids (32 patients) were included (April 2009-December 2010). Excluded were patients with previous eyelid surgeries, lagophthalmos, and <12 months of follow-up. Using a microscope, after recessing anterior lamella 3-4 mm above the eyelid margin, it was fixed with 4-5 interrupted 6-0 vicryl sutures. Excess anterior lamella was then excised (blepharoplasty), supratarsal fixation sutures (6-0 vicryl) were put and the skin was closed with 6-0 nylon sutures. Success and failure defined based upon eyelash-globe touch on the last follow-up visit (at least 12 months), respectively. RESULTS There were 21 females (65.6%) and 11 males (34.4%) with a mean age of 69.7 years (SD=6.9) and mean follow-up of 21.06 months (SD=8.26). Success was observed in 39 (75%) and failure in 13 (25%). Mean time of failure was 4.5 months (SD=3). Although re-treatment with radio-frequency electrolysis (eight eyelids) and re-anterior lamellar recession (two eyelids) resulted in success in 12 eyelids with failure, two patients (three eyelids) declined further procedure. Except for thickened eyelid margin, no complications were observed. CONCLUSION Anterior lamellar recession, blepharoplasty, and supratarsal fixation procedure is an effective and safe technique for the treatment of the upper eyelid cicatricial entropion without lagophthalmos.
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Merbs SL, Oktavec KC, Munoz BE, Perlini EF, West SK, Othman MS, Gower EW. Lower Postoperative Scar Height is Associated with Increased Postoperative Trichiasis 1 Year after Bilamellar Tarsal Rotation Surgery. Ophthalmic Epidemiol 2015; 22:200-7. [DOI: 10.3109/09286586.2015.1036299] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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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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Pearson K, Habte D, Zerihun M, King JD, Gebre T, Emerson PM, Reacher MH, Ngondi JM. Evaluation of community-based trichiasis surgery in Northwest Ethiopia. Ethiop J Health Sci 2013; 23:131-40. [PMID: 23950629 PMCID: PMC3742890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Surgery to correct trachomatous trichiasis (TT) is recommended to prevent blindness caused by trachoma. This study evaluated the outcomes of community-based trichiasis surgery with absorbable sutures, conducted in Amhara Regional State, Ethiopia. METHODS A simple random sample of 431 patients was selected from surgical campaign records of which 363 (84.2%) were traced and enrolled into the study. Participants were interviewed and examined for trichiasis recurrence, complications of TT surgery and corneal opacity. Multilevel logistic regression models were used to explore the associations between trichiasis recurrence, corneal opacity and explanatory variables at the eye level. RESULTS The prevalence of trichiasis recurrence was 9.4% (95% Confidence Interval [CI] 6.6-12.8) and corneal opacity was found in 14.3% (95% CI 10.9-18.3) of the study participants. The proportion of participants with complications of TT surgery was: granuloma 0.6% (95% CI 0.1-2.0); lid closure defects 5.5% (95% CI 3.4-8.4) and lid notching 16.8% (95% CI 13.1-21.1). No factors were identified for trichiasis recurrence. Corneal opacity was associated with increased age (Ptrend=0.001), more than 12 months post surgery (OR=2.7; 95%CI 1.3-5.6), trichiasis surgery complications (OR=2.9; 95%CI 1.4-5.9) and trichiasis recurrence (OR=2.5; 95%CI 1.0-6.3). CONCLUSION Prevalence of recurrent trichiasis and granuloma were lower than expected but higher for lid closure defects and lid notching. The majority of the participants reported satisfaction with the trichiasis surgery they had undergone. The findings suggest that recurrence of trichiasis impacts on the patients' risk of developing corneal opacity but longitudinal studies are required to confirm this.
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Affiliation(s)
- Katherine Pearson
- Department of Public Health and Pharmacy Care, University of Cambridge, Cambridge, UK
| | - Dereje Habte
- Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | | | - Jonathan D King
- The Carter Centre, 1 Copenhill Avenue, Atlanta, Georgia, USA
| | - Teshome Gebre
- International Trachoma Initiative: The Task Force for Global Health, Addis Ababa, Ethiopia
| | - Paul M Emerson
- Health Protection Agency, Cambridge Institute of Public Health, Cambridge, UK
| | - Mark H Reacher
- The Carter Centre, 1 Copenhill Avenue, Atlanta, Georgia, USA
| | - Jeremiah M Ngondi
- Department of Public Health and Pharmacy Care, University of Cambridge, Cambridge, UK
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Lavett DK, Lansingh VC, Carter MJ, Eckert KA, Silva JC. Will the SAFE strategy be sufficient to eliminate trachoma by 2020? Puzzlements and possible solutions. ScientificWorldJournal 2013; 2013:648106. [PMID: 23766701 PMCID: PMC3671555 DOI: 10.1155/2013/648106] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/13/2013] [Indexed: 11/18/2022] Open
Abstract
Since the inception of (the Global Elimination of Blinding Trachoma) GET 2020 in 1997 and the implementation of the SAFE strategy a year later, much progress has been made toward lowering the prevalence of trachoma worldwide with elimination of the disease in some countries. However, high recurrence of trichiasis after surgery, difficulty in controlling the reemergence of infection after mass distribution of azithromycin in some communities, the incomplete understanding of environment in relation to the disease, and the difficulty in establishing the prevalence of the disease in low endemic areas are some of the issues still facing completion of the GET 2020 goals. In this narrative review, literature was searched from 1998 to January 2013 in PubMed for original studies and reviews. Reasons for these ongoing problems are discussed, and several suggestions are made as avenues for exploration in relation to improving the SAFE strategy with emphasis on improving surgical quality and management of the mass treatment with antibiotics. In addition, more research needs to be done to better understand the approach to improve sanitation, hygiene, and environment. The main conclusion of this review is that scale-up is needed for all SAFE components, and more research should be generated from communities outside of Africa and Asia.
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Affiliation(s)
- Diane K. Lavett
- Strategic Solutions, Inc., 1143 Salsbury Avenue, Cody, WY 82414, USA
| | - Van C. Lansingh
- International Agency for the Prevention of Blindness/VISION 2020 Latin America, 3720 San Simeon Circle, Weston, FL 33331, USA
- Hamilton Eye Institute, University of Memphis, Memphis, TN 38152, USA
| | - Marissa J. Carter
- Strategic Solutions, Inc., 1143 Salsbury Avenue, Cody, WY 82414, USA
| | - Kristen A. Eckert
- Strategic Solutions, Inc., 1143 Salsbury Avenue, Cody, WY 82414, USA
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Burton MJ, Rajak SN, Ramadhani A, Weiss HA, Habtamu E, Abera B, Emerson PM, Khaw PT, Mabey DCW, Holland MJ, Bailey RL. Post-operative recurrent trachomatous trichiasis is associated with increased conjunctival expression of S100A7 (psoriasin). PLoS Negl Trop Dis 2012; 6:e1985. [PMID: 23285311 PMCID: PMC3527350 DOI: 10.1371/journal.pntd.0001985] [Citation(s) in RCA: 18] [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: 09/14/2012] [Accepted: 11/12/2012] [Indexed: 01/17/2023] Open
Abstract
Background Surgery for trachomatous trichiasis (TT) is a key component of the SAFE Strategy for trachoma control. Unfortunately, recurrent TT following surgery is common, probably due to various surgical and disease factors. To develop strategies to reduce recurrence rates it is necessary to understand its pathological basis. In this study we investigated the relationship between recurrent trichiasis and the expression of various cytokines and fibrogenic genes during a two-year follow-up period. Methodology/Principal Findings Individuals undergoing surgery for TT were examined at baseline (pre-operative), 6, 12, 18 and 24 months. Conjunctival swab samples were collected from the tarsal conjunctiva for RNA isolation on each occasion. Individuals who developed recurrent TT with at least 3 lashes touching the eye on one or more occasion were designated “cases” and an equal number of “controls” were randomly selected from those without recurrent TT, frequency matched for age and baseline TT severity. The expression of the following genes was measured by quantitative RT-PCR: S100A7, IL1B, CXCL5, TNFA, NOS2A, CTGF, MMP7, MMP9 and MMP12. Thirteen hundred individuals were enrolled and underwent surgery. By two years 122 had developed recurrent TT with at least 3 lashes touching the eye. Recurrent TT was consistently associated across multiple time points with about a 2-fold increase in S100A7 expression (p = 0.008). Clinically visible conjunctival inflammation was associated with increased S100A7, IL1B, CXCL5, MMP9 and MMP12 expression. Conclusions/Significance Increased S100A7 expression was associated with trachomatous conjunctival scarring and may be linked to the pathophysiology of recurrent TT. S100A7 expression could be a potential biomarker for this disease process. As part of the epithelial innate immune response S100A7 has multiple actions, potentially contributing to a chronic pro-inflammatory response, which may lead to ongoing tissue damage and increased scarring. Trachoma causes blindness through corneal damage from in-turned eyelashes (trachomatous trichiasis [TT]). Trichiasis is treated surgically to correct the anatomical abnormality. Unfortunately, TT frequently returns following surgery, which again puts the person at risk of sight loss. Recurrent trichiasis is multifactorial. We investigated the possible role of various immuno-fibrogenic factors. To do this we operated on 1300 people with TT and followed them up every six months for a two-year period. On each occasion a conjunctival swab was collected for human gene expression analysis. We measured various factors that are thought to be important in inflammation and scarring diseases. The gene expression profile of people who developed recurrent TT was compared to a sample of those that did not have a recurrence. Recurrent TT was associated with increased expression of psoriasin (S100A7) before surgery and on multiple occasions during a two-year follow-up period. S100A7 is able to promote inflammation and may contribute to the development of the scarring process in trachoma.
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Affiliation(s)
- Matthew J Burton
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Gower EW, West SK, Cassard SD, Munoz BE, Harding JC, Merbs SL. Definitions and standardization of a new grading scheme for eyelid contour abnormalities after trichiasis surgery. PLoS Negl Trop Dis 2012; 6:e1713. [PMID: 22745845 PMCID: PMC3383763 DOI: 10.1371/journal.pntd.0001713] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 05/15/2012] [Indexed: 11/28/2022] Open
Abstract
Background Clear definitions of outcomes following trichiasis surgery are critical for planning program evaluations and for identifying ways to improve trichiasis surgery. Eyelid contour abnormality is an important adverse outcome of surgery; however, no standard method has been described to categorize eyelid contour abnormalities. Methodology/Principal Findings A classification system for eyelid contour abnormalities following surgery for trachomatous trichiasis was developed. To determine whether the grading was reproducible using the classification system, six-week postoperative photographs were reviewed by two senior graders to characterize severity of contour abnormalities. Sample photographs defining each contour abnormality category were compiled and used to train four new graders. All six graders independently graded a Standardization Set of 75 eyelids, which included a roughly equal distribution across the severity scale, and weighted kappa scores were calculated. Two hundred forty six-week postoperative photographs from an ongoing clinical trial were randomly selected for evaluating agreement across graders. Two months after initial grading, one grader regraded a subset of the 240 photographs to measure longer-term intra-observer agreement. The weighted kappa for agreement between the two senior graders was 0.80 (95% CI: 0.71–0.89). Among the Standardization Set, agreement between the senior graders and the 4 new graders showed weighted kappa scores ranging from 0.60–0.80. Among 240 eyes comprising the clinical trial dataset, agreement ranged from weighted kappa 0.70–0.71. Longer-term intra-observer agreement was weighted kappa 0.86 (95% CI: 0.80–0.92). Conclusions/Significance The standard eyelid contour grading system we developed reproducibly delineates differing levels of contour abnormality. This grading system could be useful both for helping to evaluate trichiasis surgery outcomes in clinical trials and for evaluating trichiasis surgery programs. Approximately 8 million individuals worldwide suffer from trichiasis, a condition characterized by in-turned lashes that rub against the eye. Trichiasis is caused by repeated or prolonged ocular infection with Chlamydia trachomatis. Surgery is available to correct in-turned lashes. In most programmatic and research settings, the primary determinant of surgical success is whether or not lashes are touching the globe post-operatively. However, other surgical outcomes such as the contour of the eyelid are also important. Yet, no standard method for evaluating and reporting this outcome has been defined. In this study, we developed and tested a grading system for evaluating the severity of eyelid contour abnormalities after surgery using photographs of eyelids six weeks post-operatively. We found good agreement across photograph graders and also between field and photograph grades. This system should be useful in helping to standardize reporting of this outcome.
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Affiliation(s)
- Emily W Gower
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America.
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Current world literature. Curr Opin Ophthalmol 2012; 23:330-5. [PMID: 22673820 DOI: 10.1097/icu.0b013e32835584e4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ziemssen F, Sobolewska B. Therapeutic efficacy of bevacizumab for age-related macular degeneration: what are the implications of CATT for routine management? Drugs Aging 2012; 28:853-65. [PMID: 21970950 DOI: 10.2165/11594720-000000000-00000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CATT (Comparison of Age-related macular degeneration [AMD] Treatment Trials) examined the efficacy of ranibizumab and bevacizumab for the treatment of neovascular AMD. This prospective, randomized, but unblinded trial revealed a significant improvement in vision with both treatments in terms of visual acuity; importantly, patients with juxtafoveal choroidal neovascularization (CNV) and retinal pigment epithelial detachments were not excluded from the study. Monthly treatment with the drugs resulted in similar increases in visual acuity, although angiograms indicated that ranibizumab was superior in terms of reducing retinal fluid and leakage. As the study also differentiated between a fixed regimen and an as-needed (pro re nata [PRN]) dosing regimen, a larger sample size and Bonferroni statistical correction were necessary. The equivalence of the PRN dosing of bevacizumab to the monthly treatment could not be confirmed. Almost all of the frequent deviations from the protocol (referring to retreatment criteria: 25.7-28.5%) resulted in under-treatment. Since this applied to both drugs equally, under-treatment alone could not explain the larger loss of visual acuity observed in the bevacizumab PRN arm. The PRN regimen was generally associated with a larger lesion size after 12 months compared with the fixed treatment regimens. The investigators accepted the drawbacks of an incomplete masking to allow co-payment by Medicare. As assessments of drug trials are often politically motivated, the higher demands of a non-inferiority trial compared with a superiority design must be emphasized. A comparison of the per-protocol and last-observation-carried-forward analysis has not yet been published; ongoing subgroup analysis might highlight the impact of different lesion characteristics. While CATT provided further evidence for the efficacy of bevacizumab treatment, differences in adverse events between the two treatments (e.g. a higher rate of serious adverse events with bevacizumab compared with ranibizumab) were reported; however, these still have to be analysed, with the larger sample sizes of previous ranibizumab studies needing to be taken into account. Preclinical studies imply some differences between the drugs in terms of their adverse event profiles. A possible increased risk of adverse events could not be ruled out by previous clinical case series and CATT because the sample sizes and the follow-up intervals were not adequate. The large discrepancy in the price of bevacizumab versus ranibizumab in the US means a cost-benefit analysis is warranted. A lack of quality-of-life data has prevented calculation of an appropriate bevacizumab price in the context of its performance in the ophthalmological setting. Thus, CATT suggests that a favourable visual acuity might be achieved by very frequent administration of bevacizumab in patients with neovascular AMD. Although there are certain safety caveats, increased focus on subgroup analyses and obtaining longer follow-up data are expected to yield additional information of clinical relevance.
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Affiliation(s)
- Focke Ziemssen
- Centre for Ophthalmology, University Eye Hospital, Eberhard-Karls University of Tuebingen, Tuebingen, Germany.
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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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Rajak SN, Habtamu E, Weiss HA, Bedri A, Gebre T, Genet A, Khaw PT, Bailey RL, Mabey DCW, Gilbert CE, Emerson PM, Burton MJ. Epilation for trachomatous trichiasis and the risk of corneal opacification. Ophthalmology 2011; 119:84-9. [PMID: 21975041 PMCID: PMC3694301 DOI: 10.1016/j.ophtha.2011.06.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 06/29/2011] [Accepted: 06/29/2011] [Indexed: 11/14/2022] Open
Abstract
Purpose Eight million people have trachomatous trichiasis (TT). The World Health Organization (WHO) recommends entropion surgery for TT regardless of severity. However, epilation is widely practiced for treating minor TT (1–5 lashes touching the globe). We report the frequency and effectiveness of patient-initiated epilation and its relationship to corneal opacity. Design Cross-sectional baseline data of individuals recruited to 2 randomized, clinical trials. Participants We included 2556 individuals (4310 eyes) with previously unoperated TT in ≥1 eye. Methods A single ophthalmologist examined all participants for signs of trachoma using WHO grading systems with additional assessment of entropion grading, location and number of trichiatic lashes, and evidence of epilation. A questionnaire enquired about epilation practices. Main Outcome Measures The association between epilation and degree of corneal opacity. Epilation practices of TT patients. Results Central corneal scarring was present in 1436 (33%) eyes. Entropion was absent/mild in 2328 (54%) eyes, moderate in 1259 (29.2%), and severe in 723 (16.8%). The median number of lashes touching the eye was 2 (interquartile range, 1–5; range, 0–133). There was clinical evidence of epilation in 3018 (70%) eyes, of which 738 (24%) were successfully epilated (no lashes touching globe). Epilation was performed frequently (at least monthly in 3311 [76.8%] eyes), by someone other than the patient (92.8%), and using locally made forceps (88.9%). Controlling for age and degree of entropion, successful epilation was associated with less corneal opacity (odds ratio [OR], 0.61; 95% confidence interval [CI]. 0.43–0.88; P = 0.007). The association was only significant in patients with severe entropion (OR, 0.07; 95% CI, 0.02–0.25; P<0.005). Conclusions We found an association between successful epilation and less central corneal opacity. This indicates the importance of preventing eyelashes from touching the cornea, particularly in individuals with severe entropion. This is a cross-sectional study; therefore, a causative relationship cannot be concluded. However, the results suggest that among patients who decline or are unable to access surgery, and perhaps in minor TT where the management remains controversial, the provision of high-quality forceps and epilation training may be beneficial. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.
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Affiliation(s)
- Saul N Rajak
- The London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Rabiu MM, Muhammed N, Isiyaku S. Challenges of trachoma control: an assessment of the situation in northern Nigeria. Middle East Afr J Ophthalmol 2011; 18:115-22. [PMID: 21731321 PMCID: PMC3119279 DOI: 10.4103/0974-9233.80699] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Over the last three decades, a lot has been achieved in the control of trachoma worldwide. New assessment techniques, effective evidence-based control strategy with new methods and drugs, and an aggressive global partnership for the control of the disease have evolved. As such the number of people with the disease and blindness due to the disease had drastically reduced. Trachoma is now only responsible for about 4% of blindness worldwide down from 12% some few decades ago. Some countries are on the verge of eliminating the disease as a public health problem. Despite these achievements numerous challenges remain for achieving trachoma control in endemic communities. This article highlights the challenges faced in one of the known trachoma endemic areas – northern Nigeria. Aspects on the dearth of complete situational data on trachoma, fragmented implementation of the SAFE strategy, community apathy, difficulties faced in ensuring safe, and quality lid surgery in the most difficult terrain where the disease thrives are discussed here. Other unique challenges like managing children with severe trichiasis, curbing the high rate of early-onset recurrence of trichiasis after lid rotation surgery and challenges to maintain supply of antibiotics and implementation of facial cleanliness and environmental improvement components of the control strategy are presented along with the learnt experiences and recommendations. These challenges and their remedies are likely to be shared by other trachoma endemic areas in Africa.
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Affiliation(s)
- Mansur M Rabiu
- Director of Programmes, Prevention of Blindness Union, Riyadh, Saudi Arabia
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