Epilation for minor trachomatous trichiasis: four-year results of a randomised controlled trial

The prevention and management of postoperative trachomatous trichiasis: A systematic review

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.

Trachoma

Trachoma is a neglected tropical disease caused by infection with conjunctival strains of Chlamydia trachomatis. It can result in blindness. Pathophysiologically, trachoma is a disease complex composed of two linked chronic processes: a recurrent, generally subclinical infectious-inflammatory disease that mostly affects children, and a non-communicable, cicatricial and, owing to trichiasis, eventually blinding disease that supervenes in some individuals later in life. At least 150 infection episodes over an individual's lifetime are needed to precipitate trichiasis; thus, opportunity exists for a just global health system to intervene to prevent trachomatous blindness. Trachoma is found at highest prevalence in the poorest communities of low-income countries, particularly in sub-Saharan Africa; in June 2021, 1.8 million people worldwide were going blind from the disease. Blindness attributable to trachoma can appear in communities many years after conjunctival C. trachomatis transmission has waned or ceased; therefore, the two linked disease processes require distinct clinical and public health responses. Surgery is offered to individuals with trichiasis and antibiotic mass drug administration and interventions to stimulate facial cleanliness and environmental improvement are designed to reduce infection prevalence and transmission. Together, these interventions comprise the SAFE strategy, which is achieving considerable success. Although much work remains, a continuing public health problem from trachoma in the year 2030 will be difficult for the world to excuse.

Characteristics and perspectives of patients with postoperative trichiasis in Hadiya Zone, Ethiopia

Background

Postoperative trachomatous trichiasis (PTT) is a challenge for trichiasis surgery programs. Little is known about PTT patients’ perceptions regarding outcomes and future disease management. This study aimed to understand the characteristics of PTT patients, how they managed trichiasis and their perceptions of prior surgeries and future surgery uptake.

Methods

Patients with PTT were identified during an existing trichiasis screening program in Hadiya Zone, Ethiopia. A vision assessment and evaluation of the eyelids were conducted to determine distance vision, presence and severity of trichiasis and eyelid contour abnormalities. A questionnaire was administered to obtain information regarding patients’ perceptions of surgery and PTT management approaches. Descriptive statistics were used to characterize PTT and determine associations between PTT severity and patient perceptions.

Results

Among 404 participants, most were female (79.7%) and aged 40–60 y (62.6%). In total, 514 eyelids had PTT, and nearly half had severe PTT (46.9%). Although >50% of participants were currently epilating to manage their PTT, the majority (82.8%) indicated that they wanted repeat surgery. Most participants indicated that pain persisted despite epilation. The majority (75.1%) indicated satisfaction with their prior surgery and 59.6% indicated that they would recommend surgery to others.

Conclusions

This study, which included a large proportion of severe PTT cases, indicated that individuals were generally satisfied with prior surgery and would prefer to have surgery again for PTT management.

Recurrent upper eyelid trachomatous entropion repair: long-term efficacy of a five-step approach

PURPOSE

To describe the lid characteristics of recurrent upper eyelid trachomatous entropion and to report the long-term outcomes of a five-step surgical approach based on the principles of upper eyelid crease lamellar splitting and retractor release with redirection.

SUBJECTS AND METHODS

Retrospective case review of adult patients with recurrent upper eyelid trachomatous entropion who had undergone surgical correction using the five-step surgical technique between March 2014 and March 2018. Cases with primary entropion and/or <2 years of follow-up were excluded from this series.

MAIN OUTCOME MEASURES

Eyelid deformities (type of trichiasis, anterior lamellar laxity, lid margin abnormality, lid retraction and lagophthalmos), recurrence of entropion and trichiasis, cosmetic satisfaction, and surgical complications.

RESULTS

Forty-two upper eyelids in 33 patients met inclusion criteria. Preoperative anterior lamellar laxity was present in 36 eyelids (85.7%), lid retraction in 31 eyelids (73.8%) with a mean preoperative MRD1 of 6.48 ± 1.1 mm, atrophic tarsus in 28 eyelids (66.7%), lid margin notching in 22 eyelids (52.4%), and lagophthalmos in 15 eyelids (35.7%). The surgical success rate was 92.9% (95% CI 0.805-0.985). There was no documented recurrence of entropion over a mean follow-up period of 31.79 months. Postoperative trichiasis without entropion occurred in three eyelids, which required repeat epilation.

CONCLUSIONS

The five step-approach based on the principles of lamellar splitting is effective in correction of recurrent trachomatous entropion with long-term stability. The procedure addresses the fundamental changes frequently seen in recurrent cases, in particular anterior lamellar laxity, scarred shortened posterior lamella, and trichiasis.

Uptake of Trachoma Trichiasis Surgery and Associated Factors Among Trichiasis-Diagnosed Clients in Southern Tigray, Ethiopia

BACKGROUND

Trachoma is the most common infectious cause of blindness in the globe. Trichiasis surgery is the best treatment option for this disease. Despite efforts done to eliminate blinding trachoma, there is limited evidence on the surgical uptake of trachoma trichiasis in Ethiopia. This study was aimed to assess the uptake of trachoma trichiasis surgery in Southern Tigray, Ethiopia.

METHODS

Mixed cross-sectional study was employed among 409 participants. Study participants were selected using a consecutive sampling technique. Pretested and interviewer-administered data were collected using a structured questionnaire. Binary and multivariable logistic regression was done to identify associated factors. Adjusted odds ratios 95% CI was estimated to show the strength and direction. Variables with p-values <0.05 were considered statistically significant. For qualitative data, 4 focus group discussions were conducted with 40 participants and described by thematic analysis then triangulated with quantitative findings.

RESULTS

About 234 (57.9%, 95% CI: (53.2, 62.9)) participants utilized trachoma trichiasis surgery (TT). History of trachoma trichiasis (TT) for >2 years [AOR: 0.4, 95% CI: (0.22, 0.72)], informed about surgery program by health workers [AOR: 0.3, 95% CI: (0.13, 0.71)], history of TT surgery [AOR: 0.18, 95% CI: (0.05, 0.6)], absence of someone to care the family [AOR: 14, 95% CI: (6.9, 28.6)], companion [AOR: 8.9, 95% CI: (4.3, 18.3)], nearby health facility [AOR: 2.4, 95% CI: (1.1, 5.4)], work load [AOR: 8.8, 95% CI: (4.6, 17)], fear [AOR: 4.3, 95% CI: (1.8, 10)], and believing eye drop can treat TT [AOR: 3.9, 95% CI: (1.4, 11)] were significantly associated factors.

CONCLUSION

More than half of the participants accepted the TT surgical uptake. Strengthening community awareness on proper eye care, and effective treatment options, and addressing the negative attitude towards surgical treatment in the community are important measures to achieve the elimination target of trachoma.

Effect of repeated epilation for minor trachomatous trichiasis on lash burden, phenotype and surgical management willingness: A cohort study

Background

WHO endorsed the use of epilation as an alternative treatment to surgery for the management of both minor unoperated TT (UTT) and postoperative TT (PTT). However, some trachoma control programmes hesitated to implement epilation citing concerns that it would hamper TT surgical acceptance and result in larger numbers of and stiffer trichiatic eyelashes than the original TT lashes. We investigated the burden and phenotypes of post-epilation trichiatic eyelashes, and willingness to accept surgical management separately in unoperated and postoperative TT cases.

Methodology/Principal findings

We recruited cases with minor (≤5 eyelashes from the upper eyelid touching the eye or evidence of epilation in <1/3^rd of the upper eyelid) UTT (170) and PTT (169) from community-based screenings in Amhara Region, Ethiopia. Participants eyes were examined and data on present and future willingness to accept surgical management collected at baseline and every month for 6-months. Eyelashes touching the eye were counted and their phenotypes documented. Participants were trained on how to epilate. Epilation was done by the participants at home and by the examiner during follow-ups when requested by the participant. Follow-up rates were ≥97%. There was evidence of a significant reduction in the burden of trichiatic eyelashes in unoperated (mean difference = -0.90 [-1.11– -0.69]; RR = 0.50 [95% CI, 0.40–0.62]; p<0.0001), and postoperative (mean difference = -1.16 [-1.36– -0.95]; RR = 0.38 [95% CI, 0.31–0.48]; p<0.0001) cases 6-month after frequent epilation. Post-epilation trichiatic eyelashes at 6-months had higher odds of being thin (40.2% vs 55.8%, OR = 1.88 [95% CI, 1.21–2.93]; p = 0.0048), weak (39.8% vs 70.8%, OR = 3.68 [95%CI,2.30–5.88]; p<0.0001), and half-length (30.9% vs 43.3%, OR = 1.71 [1.09–2.68]; p = 0.020) than the pre-epilation trichiatic eyelashes in unoperated cases. There was a significant increase in the proportion of weak trichiatic eyelashes (OR = 1.99 [95% CI, 1.03–3.83; p = 0.039) in postoperative cases. In all 6 follow-up time points, 120/164 (73.2%) of unoperated and 134/163 (82.2%) of postoperative cases indicated that they would accept surgery if their trichiasis progressed.

Conclusions/Significance

In this study setting, frequent epilation neither hampers surgical acceptance nor results in more damaging trichiatic eyelashes than the pre-epilation lashes; and can be used as an alternative to the programmatic management of minor unoperated and postoperative TT cases.

Trachomatous Trichiasis (TT), the blinding stage of trachoma, ranges from few peripheral eyelashes touching the eye to all eyelashes scratching the cornea. TT is mainly treated with corrective eyelid surgery. However, not all TT cases require surgical correction, and some, particularly, those with few eyelashes decline surgery. Epilation, the repeated removal of eyelashes, is a very common clinical and traditional practice in many trachoma endemic settings. The World Health Organisation recommends that epilation can be offered as an alternative management strategy to surgery for patients with few eyelashes touching the eye or refusing surgery. However, some trachoma control programmes hesitated to implement epilation with the concern that it would hamper surgical acceptance and results in larger numbers of and stiffer eyelashes touching the eye than the original TT eyelashes. In this study, we explored if these concerns are true in epilating minor (≤5 eyelashes from the upper eyelid touching the eye or evidence of epilation in <1/3^rd of the upper eyelid) unoperated (170) and postoperative TT (169) cases. We found, in the contrary to these concerns, the post-epilation eyelashes touching the eye were less damaging being fewer in number, thinner, weaker and shorter than the pre-epilation eyelashes. In addition, the majority of both unoperated and postoperative cases indicated that they are willing to accept surgery if their trichiasis progressed.

Systematic review of the incidence of post-operative trichiasis in Africa

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.

Progress toward Elimination of Trachoma as a Public Health Problem in Seven Localities in the Republic of Sudan: Results from Population-Based Surveys

Trachoma is the leading cause of infectious blindness in the world. After baseline surveys demonstrated that Sudan was endemic for trachoma, the Sudan Federal Ministry of Health (FMOH) Trachoma Control Program conducted trachoma prevention and treatment interventions in endemic localities. The Sudan FMOH conducted population-based trachoma prevalence surveys between September 2016 and April 2017 in seven localities across five states of Sudan to document current trachoma prevalence estimates and measure water, sanitation, and hygiene (WASH) indicators. Children aged 1–9 years were examined for five clinical signs of trachoma, and participants of all ages were examined for trachomatous trichiasis (TT). A household questionnaire was administered to gather demographic and WASH-related information. The prevalence of trachomatous inflammation-follicular (TF) in children aged 1–9 years ranged from 0.4% (95% CI: 0.1–1.1%) to 6.4% (95% CI: 3.3–11.9%). Trachomatous trichiasis in those aged 15 years and older ranged from 0.1% (95% CI: 0.0–0.6%) to a high of 4.4% (95% CI: 2.1–9.1%). Of seven localities surveyed, four localities had achieved the elimination threshold of less than 5% TF in children aged 1–9 years. Six localities still required interventions to achieve less than 0.2% TT in those aged 15 years and older. The presence of latrine ranged from a low of 10.8% (95% CI: 5.2–21.1%) to 88.4% (CI: 81.5–93.0%) and clean face among children ranged between 69.5% (95% CI: 63.5–75.0%) and 87.5% (95% CI: 81.2–91.9%). These results demonstrate that Sudan is within reach of eliminating trachoma as a public health problem.

Maximising trichiasis surgery success (MTSS) trial: rationale and design of a randomised controlled trial to improve trachomatous trichiasis surgical outcomes

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.

Potential Effect of Epilation on the Outcome of Surgery for Trachomatous Trichiasis

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.

Determinants for not utilizing trachomatous trichiasis surgery among trachomatous trichiasis patients in Mehalsayint District, North-East Ethiopia

Background

Globally, trachoma is the leading cause of infectious blindness. In Ethiopia, the overall Trachomatous Trichiasis (TT) surgical coverage is 41%. Identifying determinants for not utilizing TT surgery among TT patients is important to design and monitor effective intervention programs. Therefore, this study aimed to identify determinants for not utilizing TT surgery among TT patients in Mehalsayint District, North East Ethiopia.

Methodology/Principal findings

A community based unmatched case control study was employed from March 30, 2017 to April 13, 2017. A total of 482 study participants (241 cases and 241 controls) with age of ≥15 years were included in the study. The data were entered with Epi info version 7.2 software and exported to SPSS version 20 for analysis. Bivariate analysis was fitted to screen candidate variables with p<0.2 for the final model. Finally, multivariable logistic regression analysis was employed to identify significant factors (p<0.05) for not utilizing TT surgery. Respondents’ age of 16–30 years (AOR: 10.11; 95% CI: 2.72, 37.59) and widowed respondents (AOR: 0.40; 95% CI: 0.21, 0.77), time to reach the service (AOR: 0.46; 95% CI: 0.24, 0.87), unavailability of TT surgeon (AOR: 5.00; 95% CI: 1.16, 21.38), symptoms of trichiasis (AOR: 7.49; 95% CI: 2.41, 23.26), duration of the problem (AOR: 2.56; 95% CI: 1.44, 4.54), the affected eye (AOR: 2.16; 95% CI: 1.23, 3.80), epilation practice (AOR: 3.22; 95% CI: 1.84, 5.64), and place of TT surgery given (AOR: 4.21; 95% CI: 2.48, 7.14) were significant determinants for not utilizing TT surgical services.

Conclusions/Significance

In this study, TT surgery against trachoma is very low and TT remains public health problem in the district. Being younger age and widowed, time taken to reach the service, absence of TT surgeon, symptoms of trichiasis, duration of problem, the affected eye, epilation practice, and service place were determinants for the inability of TT surgical services. The findings of this study would help in designing effective interventions to reduce trachoma in that district.

Trachoma is the common ophthalmic infection and cause of blindness worldwide. It is caused by ocular infections with causative agent of Chlamydia trachomatis that might effect in chronic inflammation of the eyelids, which produces scarring of the conjunctiva that can consequently cause entropion trichiasis, resulting in interned eyelashes. The interned eyelashes as well as other changes of the eye, harm the cornea causing severe pain, corneal opacity and resulting vision loss. Over a million people in Ethiopia are estimated to have Trachomatous trichiasis (TT). Trachomatous trichiasis surgery is the backbone treatment option. Though the provision of free surgical services in the country exists, utilization rates are very low. Identifying the determinants for not utilizing the service is mandatory to take measures towards surgical uptake. A total of 482 study participants (241 cases and 241 controls) with age of ≥15 years were included in the study. The determinants for not use of surgical services were respondents in the younger age group (16–30 years) and widowed participants, lengthy distance from the service, unavailability of TT surgeon, no trichiasis symptoms, long time knowing the problem, right/left eye affected, no experience of epilation practice, and participants who knew place of service was given at health center.

Burden of trachoma in five counties of Eastern Equatoria state, South Sudan: Results from population-based surveys

BACKGROUND

In order to decrease the prevalence of trachoma within the country, the Republic of South Sudan has implemented components of the SAFE strategy in various counties since 2001. Five counties in Eastern Equatoria state were surveyed in order to monitor progress of programmatic interventions and determine if additional rounds of Mass Drug Administration with azithromycin were needed.

METHODOLOGY/ PRINCIPAL FINDINGS

Five counties (Budi, Lafon, Kapoeta East, Kapoeta South and Kapoeta North) were surveyed from April to October 2015. A cross-sectional, multi-stage, cluster-random sampling was used. All present, consenting residents of selected households were examined for all clinical signs of trachoma using the World Health Organization (WHO) simplified grading system. 14,462 individuals from 3,446 households were surveyed. The prevalence of trachomatous inflammation-follicular (TF) in children ages one to nine years ranged from 17.4% (95% Confidence Interval (CI): 11.4%, 25.6%) in Budi county to 47.6%, (95% CI: 42.3%, 53.0%) in Kapoeta East county. Trachomatous trichiasis (TT) was also highly prevalent in those 15 years and older, ranging between 2.6% (95% CI: 1.6%, 4.0%) in Kapoeta South to 3.9% (95% CI: 2.4%, 6.1%) in Lafon. The presence of water and sanitation were low in all five counties, including two counties which had a complete absence of latrines in all surveyed clusters.

CONCLUSIONS/ SIGNIFICANCE

To our knowledge, these were the first trachoma surveys conducted in the Republic of South Sudan since their independence in 2011. The results show that despite years of interventions, four of the five surveyed counties require a minimum of five additional years of SAFE strategy implementation, with the fifth requiring at minimum three more years.

Blinding Trachoma: Systematic Review of Rates and Risk Factors for Progressive Disease

BACKGROUND

Sight loss from trachoma is the end result of a scarring disease process starting in early childhood and characterised by repeated episodes of conjunctival inflammation (active trachoma). Subsequently, the conjunctiva becomes scarred, causing the eyelashes to turn inwards and scratch the cornea (trichiasis), damaging the corneal surface and leading to corneal opacification and visual impairment. It is thought that this process is initiated and driven by repeated infection with Chlamydia trachomatis. We review published longitudinal studies to re-examine the disease process, its progression rates and risk factors.

METHODOLOGY/PRINCIPAL FINDINGS

We searched PubMed for studies presenting incidence and progression data for the different stages of trachoma natural history. We only included studies reporting longitudinal data and identified 11 publications meeting this criterion. The studies were very heterogeneous in design, disease stage, duration, size and location, precluding meta-analysis. Severe conjunctival inflammation was consistently associated with incident and progressive scarring in five studies in which this was examined. One study reported an association between C. trachomatis infection and incident scarring. No studies have yet demonstrated an association between C. trachomatis infection and progressive scarring. Several studies conducted in regions with low prevalence active disease and C. trachomatis infection found evidence of on-going scarring progression.

CONCLUSIONS/SIGNIFICANCE

Overall, there are few longitudinal studies that provide estimates of progression rates and risk factors, reflecting the challenges of conducting such studies. Our understanding of this disease process and the long-term impact of control measures is partial. Intense conjunctival inflammation was consistently associated with scarring, however, direct evidence demonstrating an association between C. trachomatis and progression is limited. This suggests that on-going chlamydial reinfection may not be mandatory for progression of established scarring, indicating that sight threatening trichiasis may continue to evolve in older people in formerly endemic populations, that will require service provision for years after active disease is controlled.