The Impact of Trachomatous Trichiasis on Quality of Life: A Case Control Study

[Viral and chlamydial conjunctivitis]

Viral conjunctivitis is the most common type of conjunctivitis. It is contagious and is predominantly seen as adenovirus-related conjunctivitis and keratoconjunctivitis (ADV). These infections are the most frequent ocular surface infections and can lead to conjunctival scarring and corneal opacities. Other types of viral conjunctivitis are often secondary to systemic infection and typically resolve spontaneously. Chlamydial conjunctivitis, on the other hand, is dominated by trachoma, which remains endemic in 42 countries and is still the leading cause of infectious blindness worldwide. In industrialized countries, chlamydia can also cause neonatal conjunctivitis and sometimes chronic conjunctivitis, occasionally associated with sexually transmitted diseases. This comprehensive review provides clinicians with essential microbiological, epidemiological, clinical, and therapeutic data on these two major groups of infectious conjunctivitis.

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.

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.

Topical chlorhexidine 0.2% versus topical natamycin 5% for fungal keratitis in Nepal: rationale and design of a randomised controlled non-inferiority trial

INTRODUCTION

Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease.Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively.

METHODS AND ANALYSIS

We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2-6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF).

ETHICS AND DISSEMINATION

The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

ISRCTN14332621; pre-results.

Neglected tropical diseases and disability-what is the link?

Neglected tropical diseases (NTDs) are a diverse group of infectious conditions that vary in their epidemiology, impact and control. They are among the most common conditions globally, affecting approximately one billion people. Many NTDs have long-term consequences, such as visual and physical impairments. As a result, people with NTDs may have difficulties in carrying out activities or participating in society—in other words, NTDs can cause disabilities. Additionally, NTDs are often strongly linked to stigma and can have mental health consequences. It is therefore important to incorporate rehabilitation within NTD programmes. Rehabilitation can be conceptualized narrowly in terms of the provision of clinical services (e.g. physiotherapy and assistive devices) or, more broadly, including efforts to improve employment, overcome stigma and enhance social participation of people with disabilities. Approximately 15% of the global population has a disability, and this large group must be considered when designing NTD programmes. Improving the inclusion of people with disabilities may require adaptations to NTD programmes, such as making them physically accessible or training staff about disability awareness. Without incorporating disability within NTD programmes, the quality of life of people with NTDs will suffer and global targets for elimination and management of NTDs will not be met.

The impact of microbial keratitis on quality of life in Uganda

Background

Microbial keratitis (MK) is a frequent cause of sight loss in sub-Saharan Africa. However, no studies have formally measured its impact on quality of life (QoL) in this context.

Methods

As part of a nested case–control design for risk factors of MK, we recruited patients presenting with MK at two eye units in Southern Uganda between December 2016 and March 2018 and unaffected individuals, individually matched for sex, age and location. QoL was measured using WHO Health-Related and Vision-Related QoL tools (at presentation and 3 months after start of treatment in cases). Mean QoL scores for both groups were compared. Factors associated with QoL among the cases were analysed in a linear regression model.

Results

215 case-controls pairs were enrolled. The presentation QoL scores for the cases ranged from 20 to 65 points. The lowest QoL was visual symptom domain; mean 20.7 (95% CI 18.8 to 22.7) and the highest was psychosocial domain; mean 65.6 (95% CI 62.5 to 68.8). At 3 months, QoL scores for the patients ranged from 80 to 90 points while scores for the controls ranged from 90 to 100. The mean QoL scores of the cases were lower than controls across all domains. Determinants of QoL among the cases at 3 months included visual acuity at 3 months and history of eye loss.

Conclusion

MK severely reduces QoL in the acute phase. With treatment and healing, QoL subsequently improves. Despite this improvement, QoL of someone affected by MK (even with normal vision) remains lower than unaffected controls.

People are neglected, not diseases: the relationship between disability and neglected tropical diseases

People with disabilities and the neglected tropical diseases (NTDs) are separately receiving increased focus. In light of this positive development, and the similarities and intersections between the negative impacts experienced by both people with disabilities and people with NTDs, we believe now is the right time to focus attention on the overlap between the two. Both people with NTDs and people with disabilities experience a myriad of overlapping negative health, financial and socio-cultural consequences. Despite this, we believe that disability is not yet properly prioritised on the development agenda, and that there are multiple opportunities to make NTD programming more inclusive, to the benefit of those at this neglected intersection and beyond. There are both opportunities and need to scale up, integrate, and invest in inclusive, health system-focused NTD programming. Realisation of the Sustainable Development Goals, Universal Health Coverage, and the control and elimination of NTDs all rely on ensuring people with disabilities are not left behind.

Risk Factors of Microbial Keratitis in Uganda: A Case Control Study

Purpose: Microbial keratitis (MK), is a frequent cause of sight loss worldwide, particularly in low and middle-income countries. This study aimed to investigate the risk factors of MK in Uganda.Methods: Using a nested case control, we recruited healthy community controls for patients presenting with MK at the two main eye units in Southern Uganda between December 2016 and March 2018. Controls were individually matched for age, gender and village of the cases on a 1:1 ratio. We collected information on demographics, occupation, HIV and Diabetes Mellitus status. In STATA version 14.1, multivariable conditional logistic regression was used to generate odds ratios for risk factors of MK and a likelihood ratio test used to assess statistical significance of associations.Results: Two hundred and fifteen case-control pairs were enrolled. The HIV positive patients among the cases was 9% versus 1% among the controls, p = .0003. Diabetes 7% among the cases versus 1.4% among the controls, p = .012. Eye trauma was 29% versus 0% among the cases and controls. In the multivariable model adjusted for age, sex and village, HIV (OR 83.5, 95%CI 2.01-3456, p = .020), Diabetes (OR 9.38, 95% CI 1.48-59.3, p = .017) and a farming occupation (OR 2.60, 95%CI 1.21-5.57, p = .014) were associated with MK. Compared to a low socio-economic status, a middle status was less likely to be associated with MK (OR 0.29, 95%CI 0.09-0.89, p < .0001).Conclusion: MK was associated with HIV, Diabetes, being poor and farming as the main occupation. More studies are needed to explore how these factors predispose to MK.

Development and Validation of a Smartphone-based Contrast Sensitivity Test

Purpose

Contrast sensitivity (CS) testing is an important measure of visual function reflecting variations in everyday visual experience in different conditions and helps to identify more subtle vision loss. However, it is only infrequently used. To make this more accessible, we have developed and validated a smartphone-based CS test.

Methods

A new tumbling-E smartphone-based CS test was developed, Peek Contrast Sensitivity (PeekCS). This was field tested and refined through several iterations. Reference standard was a tumbling-E Pelli-Robson CS test (PRCS). The validation study was conducted in community clinics in Ethiopia. Test-retest variability was measured for both PRCS and PeekCS. PRCS and PeekCS were then compared. Correlation coefficients and 95% confidence intervals (CIs) were calculated; 95% limits of agreement were calculated and displayed on Bland-Altman plots.

Results

PeekCS showed strong repeatability (correlation coefficient: 0.93; 95% CI: 0.91–0.95), which was comparable with PRCS (correlation coefficient: 0.96; 95% CI: 0.95–0.97). The 95% limit of agreement for test-retest variability of PRCS and PeekCS were −0.20 to 0.21 and −0.31 to 0.29, respectively. PRCS and PeekCS were highly correlated: 0.94 (95% CI: 0.93–0.95); 95% limits of agreement −0.27 to 0.29; and mean difference 0.010 (95% CI: −0.001 to 0.022). PeekCS had a faster testing time (44.6 seconds) than PRCS (48.6 seconds): mean difference −3.98 (95% CI: −5.38 to −2.58); P < 0.001.

Conclusions

The smartphone-based PeekCS is a repeatable and rapid test, providing results that are highly comparable with the commonly used PRCS test.

Translational Relevance

PeekCS provides an accessible and easy to perform alternative for CS testing, particularly in the community setting.

Neglected Tropical Diseases and Mental Health: Progress, Partnerships, and Integration

Neglected tropical diseases (NTDs) are increasingly recognised as major drivers of psychosocial morbidity in affected individuals and their caregivers. Nevertheless, there has remained a lack of prioritisation at the policy level of some of the most stigmatising and chronic NTDs, with subsequent under-representation within NTD programmes. In response, the Neglected Tropical Disease/Non-Governmental Organization/Network (NNN) has established a Mental Wellbeing and Stigma Task Group (MWS) to address these issues through a comprehensive research agenda. In our article, we highlight the progress in understanding the scope of the mental health impact of NTDs and the innovative practice emerging in this area. Finally, we examine opportunities for integration of mental and physical health for individuals with NTDs.

Sanitation and water supply coverage thresholds associated with active trachoma: Modeling cross-sectional data from 13 countries

BACKGROUND

Facial cleanliness and sanitation are postulated to reduce trachoma transmission, but there are no previous data on community-level herd protection thresholds. We characterize associations between active trachoma, access to improved sanitation facilities, and access to improved water sources for the purpose of face washing, with the aim of estimating community-level or herd protection thresholds.

METHODS AND FINDINGS

We used cluster-sampled Global Trachoma Mapping Project data on 884,850 children aged 1-9 years from 354,990 households in 13 countries. We employed multivariable mixed-effects modified Poisson regression models to assess the relationships between water and sanitation coverage and trachomatous inflammation-follicular (TF). We observed lower TF prevalence among those with household-level access to improved sanitation (prevalence ratio, PR = 0.87; 95%CI: 0.83-0.91), and household-level access to an improved washing water source in the residence/yard (PR = 0.81; 95%CI: 0.75-0.88). Controlling for household-level water and latrine access, we found evidence of community-level protection against TF for children living in communities with high sanitation coverage (PR80-90% = 0.87; 95%CI: 0.73-1.02; PR90-100% = 0.76; 95%CI: 0.67-0.85). Community sanitation coverage levels greater than 80% were associated with herd protection against TF (PR = 0.77; 95%CI: 0.62-0.97)-that is, lower TF in individuals whose households lacked individual sanitation but who lived in communities with high sanitation coverage. For community-level water coverage, there was no apparent threshold, although we observed lower TF among several of the higher deciles of community-level water coverage.

CONCLUSIONS

Our study provides insights into the community water and sanitation coverage levels that might be required to best control trachoma. Our results suggest access to adequate water and sanitation can be important components in working towards the 2020 target of eliminating trachoma as a public health problem.

Impact of trichiasis surgery on daily living: A longitudinal study in Ethiopia

Background: Trachomatous trichiasis (TT) may lead to disability, impeding productive activities, resulting in loss of income. This study was conducted to determine if trichiasis surgery improves participation in productive and leisure activities, and ability to perform activities without difficulty or assistance. Methods: We recruited 1000 adults with trichiasis (cases) and 200 comparison participants, matched to every fifth trichiasis case on age (+/- two years), sex and location. The ‘Stylised Activity List’ tool, developed for the World Bank Living Standard Measurement Survey, was adapted to collect data on activity in the last week (participation in activity, difficulty with activity, requirement of assistance for activity), at baseline and 12 months later. All trichiasis cases received trichiasis surgery at baseline. Random effect logistic regression was used to compare cases and comparison participants. Results: There was strong evidence that trichiasis surgery substantially improves the ability of trichiasis cases to perform all the productive and leisure activities investigated without difficulty, with large increases in processing agricultural products, 21.1% to 87.0% (p<0.0001), farming, 19.1% to 82.4% (p<0.0001), and fetching wood, 25.3% to 86.0% (p<0.0001). Similarly, there was a significant increase in the proportion of cases who could perform activities without assistance, with the largest increases in animal rearing 54.2% to 92.0% (p<0.0001) and farming 73.2% to 96.4% (p<0.0001). There was no change in the proportion of comparison participants performing activities without difficulty or assistance. The change in most of the activities in cases was independent of visual acuity improvement and recurrent TT at 12 months. One year after trichiasis surgery, the proportion of cases reporting ocular pain reduced from 98.9% to 33.7% (p<0.0001). Conclusions: Eyelid surgery for TT improves functional capabilities regardless of vision gains. These data lend strong support to the view that TT surgery improves function and contributes to improved household income and wealth.

Impact of trichiasis surgery on daily living: A longitudinal study in Ethiopia

Background: Trachomatous trichiasis (TT) may lead to disability, impeding productive activities, resulting in loss of income. This study was conducted to determine if trichiasis surgery improves participation in productive and leisure activities, and ability to perform activities without difficulty or assistance. Methods: We recruited 1000 adults with trichiasis (cases) and 200 comparison participants, matched to every fifth trichiasis case on age (+/- two years), sex and location. The 'Stylised Activity List' tool, developed for the World Bank Living Standard Measurement Survey, was adapted to collect data on activity in the last week (participation in activity, difficulty with activity, requirement of assistance for activity), at baseline and 12 months later. All trichiasis cases received trichiasis surgery at baseline. Random effect logistic regression was used to compare cases and comparison participants. Results: There was strong evidence that trichiasis surgery substantially improves the ability of trichiasis cases to perform all the productive and leisure activities investigated without difficulty, with large increases in processing agricultural products, 21.1% to 87.0% (p<0.0001), farming, 19.1% to 82.4% (p<0.0001), and fetching wood, 25.3% to 86.0% (p<0.0001). Similarly, there was a significant increase in the proportion of cases who could perform activities without assistance, with the largest increases in animal rearing 54.2% to 92.0% (p<0.0001) and farming 73.2% to 96.4% (p<0.0001). There was no change in the proportion of comparison participants performing activities without difficulty or assistance. The change in most of the activities in cases was independent of visual acuity improvement and recurrent TT at 12 months. One year after trichiasis surgery, the proportion of cases reporting ocular pain reduced from 98.9% to 33.7% (p<0.0001). Conclusions: Eyelid surgery for TT improves functional capabilities regardless of vision gains. These data lend strong support to the view that TT surgery improves function and contributes to improved household income and wealth.

Eyelash Epilation in the Absence of Trichiasis: Results of a Population-Based Prevalence Survey in the Western Division of Fiji

BACKGROUND

The WHO definition of trachomatous trichiasis (TT) is "at least one eyelash touching the globe, or evidence of recent epilation of in-turned eyelashes", reflecting the fact that epilation is used as a self-management tool for TT. In Fiji's Western Division, a high TT prevalence (8.7% in those aged ≥15 years) was reported in a 2012 survey, yet a 2013 survey found no TT and Fijian ophthalmologists rarely see TT cases. Local anecdote suggests that eyelash epilation is a common behaviour, even in the absence of trichiasis. Epilators may have been identified as TT cases in previous surveys.

METHODS

We used a preliminary focus group to design an interview questionnaire, and subsequently conducted a population-based prevalence survey to estimate the prevalence of epilation in the absence of trichiasis, and factors associated with this behaviour, in the Western Division of Fiji.

RESULTS

We sampled 695 individuals aged ≥15 years from a total of 457 households in 23 villages. 125 participants (18%) reported epilating their eyelashes at least once within the past year. Photographs were obtained of the eyes of 121/125 (97%) individuals who epilated, and subsequent analysis by an experienced trachoma grader found no cases of trachomatous conjunctival scarring or trichiasis. The age- and sex- adjusted prevalence of epilation in those aged ≥15 years was 8.6% (95% CI 5.7-11.3%). iTaukei ethnicity, female gender, and a higher frequency of drinking kava root were independently associated with epilation.

CONCLUSION

Epilation occurs in this population in the absence of trichiasis, with sufficient frequency to have markedly inflated previous estimates of local TT prevalence. Individuals with epilated eyelashes should be confirmed as having epilated in-turned eyelashes in an eye with scarring of the conjunctiva before being counted as cases of TT.

Impact of Trichiasis Surgery on Quality of Life: A Longitudinal Study in Ethiopia

BACKGROUND

Trachomatous trichiasis significantly reduces vision and health related quality of life (QoL). Although trichiasis surgery is widely performed to treat trichiasis, there is little data on the effect of surgery on QoL. We measured the impact of trichiasis surgery on vision and health related QoL in a longitudinal study from Amhara Region, Ethiopia.

METHODOLOGY/PRINCIPAL FINDINGS

We recruited 1000 adult participants with trichiasis (cases) and 200 comparison participants, matched to every fifth trichiasis case on age (+/- two years), sex and location. Vision-related quality of life (VRQoL) and health-related quality of life (HRQoL) were measured using the WHO/PBD-VF20 and WHOQOL-BREF questionnaires respectively, at enrolment and 12 months after enrolment. All trichiasis cases received free standard trichiasis surgery immediately after enrolment. The mean difference in QoL scores between enrolment and follow-up for cases and comparison participants, and the difference-in-differences by baseline trichiasis status was analysed using random effects linear regression, the later adjusted for age, sex and socioeconomic status. At 12-months follow-up, data was collected from 980 (98%) and 198 (98%) trichiasis cases and comparison participants respectively. At this follow-up visit, VRQoL and HRQoL scores of trichiasis cases improved substantially in all subscales and domains by 19.1-42.0 points (p<0.0001) and 4.7-17.2 points (p<0.0001), respectively. In contrast, among the comparison participants, there was no evidence of improvement in VRQoL and HRQoL domain scores during follow-up. The improvement in VRQoL and HRQoL in cases was independent of the presence of visual acuity improvement at 12 months.

CONCLUSIONS/SIGNIFICANCE

Trichiasis surgery substantially improves both VRQoL and HRQoL regardless of visual acuity change. Unprecedented effort is needed to scale-up trichiasis surgical programmes not only to prevent the risk of sight loss but also to improve overall wellbeing and health perception of affected individuals.