Strategies to improve follow-up of children after surgery for cataract: findings from Child Eye Health Tertiary Facilities in sub-Saharan Africa and South Asia.

PurposeWe sought to conduct a systematic literature review on follow-up of children with ocular surgical management (primarily childhood cataract) in developing countries. Second, we sought to determine the current practices regarding follow-up for clinical, optical, low vision, rehabilitation, and educational placement among children receiving surgical services at Child Eye Health Tertiary Facilities (CEHTF) in sub-Saharan Africa (SSA) and South Asia.MethodsA systematic literature review was conducted. Separately, we conducted a cross-sectional study among CEHTF in SSA and South Asia (India, Nepal, and Bangladesh) to assess current capacities and practices related to follow-up and educational placement.ResultsThe articles that met the systematic review eligibility criteria could be grouped into two areas: factors and strategies to improve post-operative follow-up and educational placement of children after surgery. Among the 106 CEHTF in SSA and South Asia, responses were provided by 75 CEHTF. Only 59% of CEHTF reported having a Childhood Blindness and Low Vision Coordinator; having a coordinator was associated with having appropriate follow-up mechanisms in place. Educational referral practices were associated with having a low-vision technician, having low-vision devices, and having donor support for these services.ConclusionsThe systematic literature review revealed evidence of poor follow-up after surgical interventions for cataract and other conditions, but also showed that follow-up could be improved significantly if specific strategies were adopted. Approaches to follow-up are generally inadequate at most facilities and there is little external support for follow-up. Findings suggest that funding and supporting a coordinator would assist in ensuring that good practices for follow-up (cell phone reminders, patient tracking, and reimbursement of transport) were followed.

Primary eye care skills scores for health workers in routine and enhanced supervision settings.

INTRODUCTION: Primary health care in Tanzania is provided at two types of health units, the dispensary and the health centre. Theoretically, primary health workers (with knowledge of primary eye care [PEC]) are ideally placed to identify people in need of eye care services. In Tanzania, they are expected to be able to identify, treat, or correctly refer a number of eye conditions including cataract, trauma, presbyopia, and the 'red eye'. They are also expected to be able to measure visual acuity correctly and to educate the community about prevention. OBJECTIVES: The objective was to determine the effect of enhanced supervision of health workers on PEC knowledge and skills in Kilimanjaro Region, Tanzania. STUDY DESIGN: This was a quasi-experimental, cluster randomized intervention study of an enhanced supervisory method compared to a routine supervisory method; 36 dispensaries were randomly allocated into the two groups. PARTICIPANTS: Health workers based at government dispensaries in Mwanga District. DATA COLLECTION: Participants were interviewed pre and post intervention and the information was recorded using a standardized pretested questionnaire. RESULTS: Mean scores of knowledge in healthcare workers was higher in the intervention group (score = 6.43, 80.4% improvement) compared to the non-intervention group (score = 4.71, 58.9% improvement). The ability to describe and demonstrate vision testing was better (score = 1.8) in the enhanced supervision group compared to the routine supervision group (score = 0.88, P = 0.03). There was a high level of attrition (24%) within one year from the time of baseline survey, especially amongst clinical officers (44%). CONCLUSION: During the pilot study, enhanced supervision improved PEC knowledge and skills of health workers compared to health workers with routine supervision. RECOMMENDATIONS: Training in PEC needs revision to become more practicum-based. There is need to revise supervision guidelines (to be skills-based) and the supervision skills of district eye coordinators (DECs) need to be enhanced. There is a huge need to improve governance (accountability and rule of law) of health staff.

The potential impact of a cataract surgery programme on the care of orphans and vulnerable children in Swaziland.

We aimed to evaluate the potential impact of a cataract surgery programme at the Good Shepherd Hospital, Siteki, Swaziland, on the care of orphans and vulnerable children in Swaziland. We studied consecutive patients aged 50 years and older undergoing surgery for age-related cataract who reported having children living in their household. Of 131 subjects recruited, 65 (49.6%) were the primary caregivers for the child(ren) in their household. Visual acuities measured 2 weeks after surgery significantly improved. Four weeks after surgery, there was a sizable increase in the proportions of subjects who were able to undertake self-care activities, attend to activities of daily living, undertake income-generating activities and care for children. Cataract surgery on elderly visually impaired patients has the potential to impact positively on the care of orphans and vulnerable children.

Primary eye care in sub-Saharan African: do we have the evidence needed to scale up training and service delivery?

The models for addressing the delivery of an eye-care service in sub-Saharan Africa have seen considerable revision in the last 30 years, and the on-going challenges, as well as the future needs, will probably require many more changes and new systems. There is a need to assess the different models that are currently employed, in order to ensure that all potential contributions to the elimination of avoidable blindness are used; the evolving concept of primary eye care (PEC) requires such assessment. For the current review, the published literature on eye care provided by general front-line healthworkers was screened for articles that provided evidence of the impact of such PEC on the general delivery of eye care in sub-Saharan Africa. Of the 103 relevant articles detected, only three provided evidence of the effectiveness of PEC and the authors of all three of these articles suggested that such eye care was not meeting the needs or expectations of the target populations, the trainers, or programmes of eye care. Among the main problems identified were a lack of a clear definition of the scope of practice for PEC, the need for clarifying the specific skills that a front-line healthworker could perform correctly, and the changing needs and expectations for the delivery of an eye-care service in Africa. If PEC is to become adequately grounded in Africa, the generation of further evidence of the effectiveness and limitations of such care would be a prudent move.

Ocular hypotension and hypotony in multibacillary leprosy patients; at diagnosis, during and after completion of multidrug therapy.

The prevalence and incidence of ocular hypotony (IOP < 7 mm Hg) and factors associated with them were determined in a Leprosy Referral Centre at Tamilnadu, India. Applanation intraocular pressures were measured every six months in a cohort of newly diagnosed multibacillary (MB) leprosy patients who were followed-up during the two year period of multidrug therapy (MDT) and for five years thereafter. Transient hypotony was present in two patients at the time of diagnosis, in 3 patients during MDT and in 9 patients after MDT with a cumulative prevalence of 4.65%. Transient ocular hypotension was present in 24 patients (8%) at disease diagnosis. 25 patients developed hypotension during MDT that was associated with trichiasis (HR 8.83 95% CI 2.06, 37.78 p = 0.003) and flare or/and cells (HR 4.60 95% CI 1.08, 19.64 p = 0.039). 29 patients developed ocular hypotension after MDT that was associated with punctate keratitis and uveal involvement. In general, MB leprosy patients with hypotension had a mean IOP of 12.60 mm Hg which differed significantly (p < 0.0001) from the mean IOP of 14.9 mm Hg in those who did not have hypotension. Transient hypotension and hypotony in MB leprosy patients are associated with signs of intraocular inflammation.

Estimating numbers of blind children for planning services: findings in Kilimanjaro, Tanzania.

AIM: Childhood blindness is included in the VISION 2020 initiative. However, childhood blindness is rare, so there is limited population-based evidence to assist with the planning of services. We carried out a survey of childhood blindness in Kilimanjaro Region, Tanzania, to generate information needed for planning eye care services. METHODS: The study was carried out in parallel with a Rapid Assessment of Avoidable Blindness (RAAB) survey. Villages within Kilimanjaro Region were selected on a probability-proportional-to-size basis. Key informants in each village were trained to identify children with any vision problems; a visiting team assessed the children to determine visual status and arranged for further assessment as needed at hospital. The files of children at schools for the blind in the Region were reviewed to identify children in schools from the selected study villages. RESULTS: Among the 95 040 children in the 72 villages sampled, 13 children were identified as blind; an additional three children were found in the schools for the blind. The prevalence of blindness was 0.17 per 1000 children; the causes of blindness varied but there was no vitamin A- or measles-related corneal blindness and only one case of unoperated cataract. DISCUSSION: The low prevalence of blindness in children suggests that efforts at reducing childhood blindness in Kilimanjaro Region have been effective. Planners there should focus on community-based approaches to ensure that blind children have appropriate rehabilitation services and educational placements. While it remains impractical to carry out large childhood blindness surveys, this approach attached to a RAAB survey may be useful for generating information for planning services.

Inappropriate enrollment of children in schools for the visually impaired in east Africa.

BACKGROUND: Many visually impaired children can learn to read print with appropriate training and simple visual aids. This may allow them to attend normal schools and to be integrated into society, which has lifelong benefits. Yet, in Africa, many visually impaired children are enrolled in special schools and taught only Braille. The purpose of this analysis was to document the extent of inappropriate enrollment of visually impaired children in special schools and annexes for the blind in four African countries. METHODS: Schools were selected through a population-proportional-to-size method so that they would represent all children attending special schools in Kenya, Malawi, Tanzania and Uganda. Children were examined by ophthalmologists trained in standardised methods to determine visual acuity and the cause of decreased acuity. RESULTS: Of 1062 children examined in special schools and annexes for the blind, 361 (34%, 95% CI 31.2, 36.8) had visual acuity >or=6/60; the most common cause of visual impairment was retinal disease. Of the 120 children with normal vision (>or=6/18), 69 (57.5%) had two normal eyes, 21 (17.5%) had an obvious ocular disfigurement in the fellow eye and 10 (8.4%) had had successful cataract surgery. CONCLUSIONS: In these countries, many children are placed inappropriately in special schools and annexes for the blind. The reasons are multiple and to rectify the situation will require advocacy and cooperation between ministries of health and education.

Productivity of key informants for identifying blind children: evidence from a pilot study in Malawi.

OBJECTIVES: To determine the productivity of village-based 'key informants' (KIs) in identifying blind children. MATERIALS AND METHODS: Ngabu subdistrict (population 101,000) of Chikwawa district was divided into KI catchment areas. KIs, selected by local village leaders, were trained to register children reported to be blind or with severe visual impairment. These children were clinically assessed at designated centres. RESULTS: In total, 44 KIs were selected and trained to cover 196 villages in Ngabu. They identified and referred 151 children, 37 of whom were blind (presenting vision <3/60 best eye). Overall, village leaders tended to choose female KIs (80%) compared to male KIs (20%); however, male KIs tended to be more productive, identifying 4.22 children each (compared to 3.23 for female KIs). Male KIs were 2.7 times more likely to identify blind children compared to female KIs. Only 25% of all identified blind children of school going age were in school. CONCLUSIONS: KIs may be effective in identifying blind children in the community; however, additional work is needed to determine who will be the most effective KI in a community and whether gender roles will limit interpretation of findings from KIs activities.

Cataract surgical coverage remains lower in women.

BACKGROUND: Cataract remains the leading cause of global blindness. Evidence from population-based surveys, carried out up to 2000, and the launch of the VISION 2020 initiative to address avoidable blindness showed that women in low- and middle-income countries had a lower cataract surgical coverage (CSC) than men. METHODS: A systematic review identified population-based surveys reporting CSC in low- and middle-income countries published since 2000. Researchers extracted data on sex-specific CSC rates and estimated the overall CSC differences using meta-analyses. RESULTS: Among the 23 surveys selected for this review, 21 showed higher CSC among men. The Peto odds ratio revealed that men were 1.71 times (95% CI 1.48 to 1.97) more likely to have cataract surgery than women. The risk difference in the rates of surgery varied from -0.025 to 0.276, and the combined average was 0.116 (95% CI 0.082 to 0.149). DISCUSSION: Gender inequity in use of cataract surgical services persists in the low- and middle-income countries. It is estimated in this study that blindness and severe visual impairment from cataract could be reduced by around 11% in the low- and middle-income countries if women were to receive cataract surgery at the same rate as men. Additional effort globally is needed to ensure that women receive the benefits of cataract surgery at the same rate as men.

Measuring cataract surgical services in children: an example from Tanzania.

BACKGROUND: Childhood cataract is becoming increasingly recognised as a priority for reducing childhood blindness in developing countries. However, there have been no standard methods to monitor progress in providing this service, besides sporadic reports of surgeries performed. METHODS: Information on all children receiving surgery for congenital/developmental cataract in the two Child Eye Health Tertiary Facilities (CEHTF) in Tanzania was collected for 2004-6. An annual childhood cataract surgical rate (CCSR) was calculated per region. Male-to-female ratios were also generated by region of residence. RESULTS: Overall, the CCSR (2006) in Tanzania was 9.9 per million population, ranging from 32.3 for regions where CEHTF are located to 5.4 for regions not adjacent to CEHTF regions. There were, on average, 148 boys for every 100 girls receiving surgery. CONCLUSION: Practical application of a measure of service delivery for childhood cataract has been useful in identifying gaps in utilisation of existing services by region as well as by gender. Testing in other settings would be helpful. An apparent inequity in use of services by girls requires attention.

Acceptance of cataract surgery in a cohort of Tanzanians with operable cataract.

BACKGROUND: In spite of recent increases in the number of surgeries carried out within some hospitals and programmes in sub-Saharan Africa, there are indications that the acceptance of cataract surgery remains quite low. METHODS: We conducted a population-based prospective (cohort) study of cataract patients from 12 villages in Hai district of Kilimanjaro region, Tanzania. Those identified with operable cataract were informed of the regular community programmes (within 5 km) in place providing transportation and high-quality surgery. At years 1 and 2 after the survey, we traced the patients to determine uptake of cataract surgery. RESULTS: Among patients eligible for surgery (128), 31 could not be followed up after 1 year due to deaths, moving, and refusal. Among the remaining patients, 18 accepted surgery in the first year and four accepted in the second year. Among these 22 patients, only five were blind or with severe visual impairment. The most elderly were those least likely to accept surgery. DISCUSSION: Even with bridging strategies in place to make cataract surgery accessible and affordable, the uptake of cataract surgery remains low. Strategies aimed to identifying and referring all patients recognizing vision loss as a personal disability rather than using predefined vision cutoffs will likely be most successful in reducing the burden of vision loss due to cataract.

Incidence of ocular complications in patients with multibacillary leprosy after completion of a 2 year course of multidrug therapy.

AIM: To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients following completion of 2 year, fixed duration, multidrug therapy (MDT). METHODS: Biannual eye examinations were conducted prospectively on a cohort of MB patients who had completed MDT and followed up for 5 years. The incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding before completion of MDT. RESULTS: 278 patients had one or more follow up visits after completion of MDT. The incidence of lagophthalmos was 0.24%/patient year (95% CI 0.10% to 0.37%); corneal opacity, 5.35%/patient year (95% CI 4.27% to 6.70%); uveal involvement, 3.78%/patient year (95% CI 2.96% to 4.83%); and cataract that reduced vision to 6/18 or less, 2.4%/patient year (95% CI 1.77% to 3.26%). Overall, 5.65%/patient year (95% CI 4.51% to 7.09%) developed leprosy related ocular disease and 3.86%/patient year (95% CI 3.00% to 4.95%) developed leprosy related, potentially blinding ocular pathology during the period following MDT. Age and other disability also predicted incident eye disease. CONCLUSIONS: Every year, approximately 5.6% of patients with MB who have completed MDT can be expected to develop new ocular complications of leprosy, which often (3.9%) are potentially vision threatening. Because many of these complications cannot be detected without slit lamp examination, periodic monitoring, particularly of older patients and those with other disability, is recommended, in order to detect and treat ocular complications satisfactorily.

Incidence of ocular morbidity among multibacillary leprosy patients during a 2 year course of multidrug therapy.

AIM: To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients during their 2 year, fixed duration, multidrug therapy (MDT). METHODS: Periodic eye examinations were conducted prospectively on a cohort of 301 consecutive newly diagnosed MB patients every 6 months during their 2 year course of MDT. Incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding at baseline. RESULTS: 292 (97%) patients had one or more follow up visits. The incidence of lagophthalmos was 1.2%/patient year (95% CI 0.5% to 2.8%); corneal opacity was 7.4%/patient year (95% CI 5.1% to 10.6%); uveal involvement was 5.1%/patient year (95% CI 3.3% to 7.8%), and cataract that reduced vision to 6/18 or less was seen in 4.3%/patient year (95% CI 2.7% to 6.9%) of patients. Overall, 23 individuals (5.8%/patient year, 95% CI 3.9 to 8.8) developed leprosy related potentially blinding pathology during the 2 years of MDT. CONCLUSIONS: Approximately 20% of patients with MB leprosy can be expected to develop ocular complications of leprosy during a 2 year course of MDT, many (11%) of which are potentially vision threatening. Ophthalmological monitoring to detect and treat ocular complications at defined intervals during MDT is indicated.

Distance to water source and altitude in relation to active trachoma in Rombo district, Tanzania.

OBJECTIVES: To investigate the relationship between distance to water source, altitude and active trachoma in children in Rombo district, Tanzania. METHODS: In each of Rombo's 64 villages, 10 balozis (groups of 8-40 households) were selected at random and all resident children aged 1-9 years were examined for clinical signs of active trachoma. The households of these children and village water sources were mapped using differentially corrected global positioning system data to determine each household's altitude and distance to the nearest water supply. RESULTS: We examined 12 415 children and diagnosed 1171 cases of active trachoma (weighted prevalence=9.1%, 95% CI: 8.0, 10.2%). Active trachoma prevalence ranged from 0% to 33.7% across villages. Increasing distance to the nearest water source was significantly associated with rising trachoma prevalence (age-adjusted odds ratio for infection (OR) for highest quartile compared to lowest=3.56, 95% CI 2.47, 5.14, P for trend <0.0001). Altitude was significantly inversely associated with trachoma prevalence (age-adjusted OR for highest quartile compared to lowest=0.55, 95% CI 0.41, 0.75, P for trend <0.0001). These associations remained significant after adjustment in multivariate analysis. CONCLUSIONS: Trachoma is endemic in Rombo district, although the prevalence varies considerably between villages. Spatial mapping is a useful method for analysing risk factors for active trachoma.

The social and family dynamics behind the uptake of cataract surgery: findings from Kilimanjaro region, Tanzania.

AIMS: To describe and understand better the barriers that elderly cataract patients in Kilimanjaro region (Tanzania) experience at the family level in order to access surgery. METHODS: A phenomenological study carried out in the catchment area of a teaching hospital in Kilimanjaro Region. 60 semi-structured interviews were conducted with patients and ex-cataract patients. RESULTS: The perceived need for sight and for surgery appears partly socially constructed at the family level. It was found that women were less likely to express a need for sight for fear of being seen as a burden. Furthermore, young heads of family are more inclined to support old men than old women. The consensus is that asking children for help can be difficult. Going for cataract surgery must be seen as a social process where elderly patients might have to wait or negotiate support for weeks, months, or even years. CONCLUSIONS: Eye programmes must promote the benefits of cataract surgery to all family members, not just to the patient. A changing social climate, changing expectations of vision, and evolving cost sharing systems will have significant, sometimes contradictory, impacts on use of eye care services. Strategies for reaching those without access to financial resources need to be strengthened.

Delay in presentation to hospital for surgery for congenital and developmental cataract in Tanzania.

BACKGROUND: Childhood cataract is a leading cause of blindness in children in eastern Africa. High quality surgical services have been established at a few tertiary facilities in the region; however, there appears to be delay in presentation to hospital. METHODS: Parents or guardians of all children presenting to KCMC Hospital or CCBRT Hospital with congenital (recognised since birth or within the first year) or developmental (cataract leading to reduction in vision after 1 year of age) cataract were interviewed regarding the actions taken (and timing of these) before coming to hospital. Demographic information was also collected. For analysis children were grouped as either late presenters (more than 12 months after recognition) or not late presenters (within 12 months of recognition) and predictors of late presentation were assessed. RESULTS: Among 178 children (74 congenital cataract and 104 developmental cataract) analysed, the mean delay between recognition by the caregiver and presentation to hospital was 34 months, almost 3 years. The median delay was 18 months-9 months for congenital cataract and 24 months for developmental cataract. Long delay in presentation was associated with having developmental cataract, living far from the hospital, and low socio-educational status of the mother. Among children with congenital cataract, having another sibling increased the likelihood of early presentation. CONCLUSION: Delay in presentation remains a significant problem for children needing surgery for congenital or developmental cataract. Parents who have multiple children may be more likely to seek early treatment, possibly because their expectations of achievable sight at a young age are based on previous experience of their older children. Educational efforts should aim to reach the most "unreachable" (those living the furthest from the hospital and having the lowest socio-educational status of the mother).

Increasing cataract surgery to meet Vision 2020 targets; experience from two rural programmes in east Africa.

BACKGROUND: The numbers of cataract surgeries done in sub-Saharan Africa fall short of Vision 2020 targets. Over a few years, two programmes in rural east Africa both achieved significant increases in the number of cataract surgeries they provide, resulting in cataract surgical rates of 1583 for Kwale District in Kenya and 1165 for Kilimanjaro Region in Tanzania. Key components of success in these two programmes are described. METHODS: Data were collected on standard indicators and key personnel interviewed to describe the results and compare the methods employed to increase cataract surgical rates by the Kwale District Eye Centre programme and the Kilimanjaro regional Vision 2020 programme. RESULTS: Key components of success shared by the programmes included: (1) programmes in the community and at the hospital are closely linked so that they increase capacity together; (2) community programmes are "patient friendly," providing service in one stop; (3) the examination team includes eye workers with enough skill to provide treatment and decide who is operable so that patients are not transported needlessly or sent through a lengthy referral chain; (4) sites for visits in the community are selected according to population distribution and they are visited according to a regular schedule. CONCLUSION: The development of "bridging strategies" that create a strong link between hospitals providing clinical service and communities needing these services is a key component to realising Vision 2020 goals in sub-Saharan Africa.

Cataract surgical coverage and outcome in the Tibet Autonomous Region of China.

BACKGROUND: A recently published, population based survey of the Tibet Autonomous Region (TAR) of China reported on low vision, blindness, and blinding conditions. This paper presents detailed findings from that survey regarding cataract, including prevalence, cataract surgical coverage, surgical outcome, and barriers to use of services. METHODS: The Tibet Eye Care Assessment (TECA) was a prevalence survey of people from randomly selected households from three of the seven provinces of the TAR (Lhoka, Nakchu, and Lingzhr), representing its three main environmental regions. The survey, conducted in 1999 and 2000, assessed visual acuity, cause of vision loss, and eye care services. RESULTS: Among the 15,900 people enumerated, 12,644 were examined (79.6%). Cataract prevalence was 5.2% and 13.8%, for the total population, and those over age 50, respectively. Cataract surgical coverage (vision <6/60) for people age 50 and older (85-90% of cataract blind) was 56% overall, 70% for men and 47% for women. The most common barriers to use of cataract surgical services were distance and cost. In the 216 eyes with cataract surgery, 60% were aphakic and 40% were pseudophakic. Pseudophakic surgery left 19% of eyes blind (<6/60) and an additional 20% of eyes with poor vision (6/24-6/60). Aphakic surgery left 24% of eyes blind and an additional 21% of eyes with poor vision. Even though more women remained blind than men, 28% versus 18% respectively, the different was not statistically significant (p = 0.25). CONCLUSIONS: Cataract surgical coverage was remarkably high despite the difficulty of providing services to such an isolated and sparse population. Cataract surgical outcome was poor for both aphakic and pseudophakic surgery. Two main priorities are improving cataract surgical quality and cataract surgical coverage, particularly for women.

Determinants of patient satisfaction with cataract surgery and length of time on the waiting list.

AIMS: To assess determinants of patient satisfaction with their waiting time (WT) and cataract surgery outcome. METHODS: A prospective cohort of consecutive patients waiting for cataract surgery were assessed by their ophthalmologist. Satisfaction, maximum acceptable waiting time (MAWT), urgency, visual function, visual acuity (VA), and health related quality of life (EQ-5D) were assessed using mailed questionnaires before surgery and 8-10 weeks after surgery. Ordinal logistic regression was used to build explanatory models. RESULTS: 166 patients (61.9% female, mean age 73.4 years) had a mean WT of 16 weeks. Patients whose actual WT was shorter than their MAWT had greater odds of being satisfied with their WT than those whose WT was longer (adjusted OR 3.86, 95% CI 1.38 to 10.74). Improvement in visual function (OR 3.19, 95% CI 1.78 to 5.73), and VA (OR 4.27, 95% CI 1.70 to 10.68) significantly predicted satisfaction with surgery. Models were adjusted for age and sex. CONCLUSION: Patient perspectives on MAWT and satisfaction with WT are important inputs to the process of determining WT standards for levels of patient priority. Patient expectation of WT may mediate satisfaction with actual WT.

One year recurrence of trachomatous trichiasis in routinely operated Cuenod Nataf procedure cases in Vietnam.

BACKGROUND: Recurrence of trichiasis following surgery remains unacceptably high, regardless of the surgical procedure. Few prospective studies of sufficient size are available to assess the rate of recurrence and the factors contributing to recurrence. A prospective study of the modified Cuenod Nataf surgical procedure was conducted in Vietnam to determine recurrence and co-factors. METHODS: The prospective study of Cuenod Nataf surgery for trachomatous trichiasis took place in four districts of Vietnam. All patients from identified villages who had surgery were followed for a period of 1 year. 10 Surgeons using standard techniques and recording procedures carried out the surgery. The presence of an eyelash touching the eyeball in the operated eye was considered as recurrence. Information on all subjects was recorded preoperatively, intraoperatively, and postoperatively. An independent examiner recorded postoperative information. Relative risks were calculated to assess the contribution of various risk factors to recurrence (by eye and by person). Cox proportional hazards modelling was used to assess the independent contribution of relevant factors to the outcome. RESULTS: 471 individuals had trichiasis surgery; 463 were followed for a period of 1 year. Overall, the recurrence rate was 10.8% (95% CI 8.0 to 13.6). Among people having surgery recurrence (one or both eyes) was most common in the most elderly (relative risk (RR) 2.49) and among those with a history of previous surgery (RR = 2.49). Cox proportional hazards analysis (by eye) revealed that visual acuity, conjunctival scarring, and suture adjustment were associated with recurrence at 1 year. CONCLUSION: The Cuenod Nataf procedure, which is well accepted in the community and by eye care providers in Vietnam, has an acceptable 1 year success rate. Individuals with severe conjunctival scarring have the highest rate of recurrence suggesting that other surgical approaches are needed to manage these patients or that these patients need to be educated regarding the risk of recurrence. Active follow up of these patients would be warranted. The association with suture adjustment requires further investigation.