Kilimanjaro Centre for Community Ophthalmology

Moshi, Tanzania

Trichiasis Update

• Epidemiology & magnitude

• Ultimate intervention goals & annual targets

• Surgical procedures

• Training of surgeons

• Strategies to improve uptake

• Outcome of surgery

• Scaling up surgery

Magnitude of the problem

Reference (year)

Cases of active trachoma

Trachoma blind

Trachoma low vision

WHO (1995) 146 m 6 m 17 m

Ransom & Evans (1996)

0.6 m 2.9 m

Frick (2000) 3.7 m

WHO (2003) 81 m 3 m

Surgery No surgery

Conjunctival scarring

Trichiasis No trichiasis

Success Failure

Corneal opacity

No corneal opacity

Vision loss No vision loss

Progression to vision loss in trachoma

6%

2%

Ultimate intervention goals for surgery (UIG-S)

• Indicates the total number of surgeries that must be done to eliminate blinding trachoma

• Dynamic figures (based on current estimates)

• Total UIG-S can be put into annual targets (AIG-S)

Ultimate intervention goals for surgery (UIG-S)

Example from a national perspective:• Tanzania (2005) = 54,000 (167,000) people

with TT (UIG)– 2005 AIG = 6,000– Estimated # of people receiving surgery = 2,700– Coverage = 45%

• Ghana (2005) = 9,900– 2005 AIG = 1,500– Estimated # of people receiving surgery = 780– Coverage = 55%

Ultimate intervention goals for surgery (UIG-S)

Gambia 0 (surveillance only)

Uganda 90,000

Nigeria 101,000

Pakistan (2 areas) 27,000

Malawi ?

Kenya ?

Zambia ?

Including UIG-S into “district” implementation plans

Region UIG AIG

Kilimanjaro

Arusha

Manyara

Shinyanga

Mwanza

Mara

Annual intervention goals part of VISION 2020 implementation plan

Surgical procedures

• Full-thickness incision of the tarsal plate and rotation of terminal tarsal strip 180º– Bilamellar tarsal rotation procedure (BTRP)– Unilamellar tarsal rotation procedure (Trabut)

• Other procedures– Cuenod Nataf procedure– Epilation (non-surgical, immediate management)

Training of trichiasis surgeons

• Trainers ophthalmologists/well-trained

ophthalmic nurse

• Trainees ophthalmic nurse

• Training guidelines national guidelines

• Certification check list

• Instruments surgical instruments list

Training of trichiasis surgeons

• Selection criteria – Prior surgical experience– Knowledge of sterile techniques– Experience giving injections– Experience in eye examinations

• Expectations of surgical productivity– According to national guidelines (30/month

in Tanzania)

Factors associated with high productivity of trichiasis

surgeons• Good supervision • “Pro-active” system for ensuring

access to surgery• Adequate instruments and

consumables• [based at “district” hospital &

dedicated to eye care services]

How many surgeons do we need to meet our UIGs?

Surgical failure & recurrence following surgery

• Surgical failure (within 3-6 months)– Technical skills of surgeon– Sutures used (type=silk; and number=4+)– Range 10-15%

• Recurrence (>6 months following surgery)– Conjunctival scarring– Age of the patient– Duration since surgery– Range 15-45%

No difference in outcome of surgery by ophthalmologists or trained nurses

Quality of surgery

• Defined as:– Few surgical failures (adequate eversion)– Good cosmesis

• Good quality of surgery can be achieved through:– Training supported by certification– Routine supervision of surgeons– Use of appropriate (and well-maintained)

instruments and consumables

Implications of surgical failure & recurrence following surgery

• Monitoring short-term outcome critical to correct surgical failure

• Certification and supervision of surgeons important to maintain quality

• Patient education to focus on the possibility of recurrence

Who needs surgery?

• Anyone with one or more lash touching the eye?

• Epilation until more severe trichiasis develops?

• Where contact with eye care services infrequent?

• Surgery for mild disease technically easier and has better outcome

Observations

• In many (not all) settings, females have higher prevalence of active disease

• Women account for 60-85% of trichiasis cases (2-3 times higher than men)

• Blindness due to trachoma about 3 times higher in women compared to men.

Is access to Surgery equal for men and women?

• Burden of need primarily for women

• Measurable?– Need baseline data to know burden by sex– Need to monitor separately for men and women

• Current evidence: – Yes….if….

….there are community-based efforts to encourage/enable use of trichiasis surgical services

Barriers to use of eye care services are different for men &

women• Cost of using service (access to

financial resources)• distance to services (ability to travel and

need for assistance)• knowledge of service (awareness and

literacy) • perceived “value” (social support)• fear of a poor outcome (cosmesis)

Global surgical totals reported to WHO

103,574

149,000

213,000

21,798

99,680 102,804

0

40000

80000

120000

160000

200000

240000

2004 2005 2006

AIO - SSurgery

Scaling up trichiasis surgery

• At VISION 2020 implementation “district” (1+ million)– Determine UIG and set annual targets– Integrate with other eye care (surgical) services

• Ensuring certification, good supervision and support to surgeons (set targets for surgeons)

• Active screening necessary; “bridging strategy” needed (dependency on specific/dedicated TT funding).

• Monitoring of surgical failure & patient counseling implemented