Trichiasis Recurrence—Why the Surgery Part of Trachoma Control is Still Uncontrolled

Abstract

Trachoma is the leading infectious cause of blindness worldwide. 2 The burden of trichiasis is likely even greater than would be measured by visual loss alone; one study found persons with trichiasis but no visual loss reported disruption of daily activities equivalent to that reported by persons with visual loss from other causes.3 Trichiasis SurgeryAs part of a multifaceted approach to trachoma control, the WHO recommends surgery to correct trichiasis. Many techniques have been used to correct trichiasis, including epilation, cryoablation, tarsal advance and rotation, the Trabut method, Cuenod Nataf, and the bilamellar tarsal rotation procedure (BTRP). BTRP has been shown in a clinical trial to provide good long-term results compared with other techniques. 4 In addition to improvement in ocular symptoms, trichiasis surgery appears to improve visual acuity, likely due to decrease in photophobia and resolution of corneal swelling. 5 A handbook illustrating the correct techniques for BTRP has been published by the WHO. 6 As trachoma is most endemic in resource-poor areas, it became immediately clear that there were insufficient ophthalmologists to reduce the backlog of trichiasis surgery, or handle new cases. Trichiasis surgeons were trained from the ranks of eye care nurses, medical assistants, and integrated eye care workers. A study of outcomes of trichiasis surgery, comparing ophthalmologists with these trained non-physicians, showed equivalent results, thus paving the way for surgery to be carried out at health posts, district centers, and even in the villages using this new cadre of manpower. 7,8 The WHO has now published a manual for certification of trichiasis surgeons, which can be used by country programs to be certain that standards for undertaking trichiasis surgery are met.9 Adverse Outcomes of SurgeryHowever, some reports from trachoma programs based on outcomes after follow-up of trichiasis surgery patients paint a dismal picture. One study of trichiasis surgery cases with follow-up of at least two years, carried out in several districts of Tanzania, found a recurrence rate of trichiasis of 28%, varying by district from 16 to 38%. 10 In The Gambia, trichiasis recurrence rates at one year were 41%, and varied among surgeons from 0% to >80%. AbstractTrichiasis surgery is a pillar of the World Health Organization (WHO) strategy for trachoma control. Visual acuity improvement and symptomatic relief follow surgery for trichiasis, and non-ophthalmologists have been trained to carry out the surgery in trachoma-endemic communities. However, recurrence of trichiasis following surgery is unfortunately common, which can undermine public confidence in national trachoma programs.Recurrence of trichiasis following surgery is more likely in high-risk patients (those with previous surgery or who have severe entropion). The most common cause appears to be surgeon skill, with large variations in recurrence reported by surgeon. Proper training, standardization, certification, and supervision would reduce adverse out...

Global surgery and the neglected tropical diseases

“…Proper standardization and supervision of procedures could reduce adverse outcomes and improve surgeon skill. Additionally, 1 dose of azithromycin given postoperatively has been shown to yield a 30% reduction in recurrence in Ethiopia [ 17 ].…”