Longitudinal study of trachomatous trichiasis in The Gambia: barriers to acceptance of surgery.

PURPOSE: Investigation of compliance with surgery for trachomatous trichiasis has become a priority of the World Health Organization. This study was conducted to investigate attitudes toward trichiasis and its treatment and to determine the rate of surgical uptake in The Gambia. METHODS: A 1-year longitudinal study was performed in 190 subjects with trichiasis. Persons with major trichiasis (involving five lashes or more) were referred for surgery, and those with minor trichiasis were advised to epilate. Outcome measures included attitudes toward trichiasis and its treatment, reported barriers to surgical uptake, acceptance rates for surgery, and factors affecting acceptance. RESULTS: Twenty-three percent (95% confidence interval [CI] 16.5%-30.6%) of subjects with major trichiasis attended for surgery during the year. Degree of ignorance about surgery, symptoms impeding work, and a multiple income source for the head of household predicted attendance. Reported lack of time predicted nonattendance. Sixty-eight percent of patients who had undergone surgery were trichiasis free at last follow-up. CONCLUSIONS: Poor attendance for surgery remains a problem in The Gambia. Barriers include ignorance and lack of time and money. Health education and surgical delivery strategies are needed to overcome these barriers. Regular audit of surgical results is necessary, with retraining where indicated.

Recurrence of trichiasis: a long-term follow-up study in the Sultanate of Oman.

BACKGROUND: The prevalence of long-term trichiasis recurrence following tarsal rotation and electro-epilation procedures has not been determined. A non-concurrent prospective study of surgical cases of trichiasis was therefore undertaken in Oman. METHODS: A sample of 603 surgical cases of trichiasis (approximately half tarsal rotation and half electro-epilation) was followed for an average of 3.1 years to determine recurrence. Recurrence was defined as either mild (<5 lashes touching the globe) or severe (5 or more lashes touching the globe). RESULTS: Overall, 56% (95% confidence interval of 50.6%-61.0%) of all surgical cases recurred; ranging from 61.8% of tarsal rotation patients to 50.6% of electro-epilation patients. Severe recurrence was detected among 27% of tarsal rotation patients and 10% of electro-epilation patients. Recurrence was associated with female sex, residence in a high-risk region, and time since surgery. DISCUSSION: The risk of recurrence after electro-epilation and bilamellar tarsal rotation surgery is high; strategies that account for recurrence need to be introduced.

Magnitude of trachoma and barriers to uptake of lid surgery in a rural community of northern Nigeria.

AIMS: A population-based cross-sectional survey for trachoma prevalence was conducted in a subdistrict of northern Nigeria. The objectives of the survey were to determine the magnitude and pattern of trachoma and the barriers to uptake of lid surgery in the area. METHODS: A total of 2903 people of all ages were examined out of 3715 registered eligible persons. The study population was chosen by a two-stage cluster random sampling technique. Each person was examined for signs of trachoma. The World Health Organization (WHO) simplified trachoma grading was used. Persons with trichiasis that had not attended hospital were asked why they had not sought hospital treatment. RESULTS: A blindness prevalence of 1.5% (95% CI 0.4%-2.7%) was found in the study population. About 20% of the blindness were due to trachoma. The prevalence of trichiasis among women 15 years and above was found to be 8.6% (95% CI 6.8%-10.7%). The prevalence of active trachoma among children was 11.8% (95% CI 10.1%-13.3%). Over 90% of people with trichiasis have not sought medical attention. The major identified factor that prevents people from accessing hospital treatment for trichiasis was cost (57%). CONCLUSION: This study suggests that trachoma is of public health significance in this area; as such, an effective trachoma control program with emphasis on lid surgery should be established.

Epidemiological, demographic, and economic analyses: measurement of the value of trichiasis surgery in The Gambia.

AIM: Untreated trichiasis can lead to corneal opacity. Surgery to prevent the eyelashes from rubbing against the cornea is available, but many individuals with trichiasis never undergo the operation. This study estimates the cost of illness of untreated trichiasis and the willingness to pay for surgery and compares them with the actual cost of providing surgery. MATERIALS AND METHODS: The cost of illness estimate is based on trichiasis patient demographics. Data on the implicit price of obtaining surgery and surgical utilization in a matched pair randomized trial are used to infer individual willingness to pay for trichiasis surgery. Patients in the study paid nothing out-of-pocket for surgery; the price of obtaining surgery is the value of the individual's time needed for travel and surgery plus the price of public transportation. The cost of producing surgery was calculated from project records. RESULTS: All monetary figures are reported in 1998 US dollars. The average cost of untreated trichiasis, or the net present value of life-time lost economic productivity, was $89. Individuals facing a lower cost were more likely to undergo an operation; the inferred average willingness to pay was $1.43 (SD 0.244). Surgery cost $6.13 to provide, including $0.86 for transportation to the village. DISCUSSION: Whether the value of trichiasis surgery exceeds the cost in The Gambia depends on how the value is measured. Individuals are willing to use only limited resources to obtain surgery even though lifetime economic productivity may increase substantially. All three economic measures can be used to inform policy.

The SAFE strategy for trachoma control: planning a cost-effectiveness analysis of the antibiotic component and beyond.

AIM: A limited literature addresses the cost-effectiveness of the prevention and treatment of trachoma and its sequelae. The literature focuses on government costs. This paper motivates the inclusion of and details methods for measuring the costs for the target population. METHODS: Costs to the targeted population can be measured while studying efficacy or effectiveness. These costs can be added to the more frequently measured costs to the government to calculate costs for the entire society. This section indicates the types of costs to consider, refines the concept of costs, describes the necessary data, outlines how the methods of data collection fit with the methods that would be employed for a general effectiveness study, and describes the appropriate calculation of a cost-effectiveness ratio. RESULTS: The costs to the targeted population can be measured with few additional resources. Placing a value on villagers' time or translating clinical results into summary, preference-based health-related quality of life measures would increase the resources required more substantially. DISCUSSION: For theoretical and practical reasons, future cost-effectiveness analyses of the full SAFE strategy and the antibiotic component of the strategy should be done from a perspective that includes both the government and the targeted population. This can be useful in policy making and increase our understanding of reasons for less than universal participation.

Prospective evaluation of the argon laser treatment of trachomatous trichiasis.

PURPOSE: To evaluate the effectiveness of argon laser photocoagulation for the treatment of trachomatous trichiasis. METHODS: This report presents a prospective, non-masked study of 22 patients (36 eyelids) with trachomatous trichiasis treated with the argon laser. Each abnormal lash was treated with a beam of 50- to 200-micron spot size, for 0.2 seconds, and 1 to 1.2 watts power. In 30 lids (83.3%) infiltration anesthesia was used and in 6 lids (16.7%) no anesthesia was used. RESULTS: Successful treatment with no evidence of recurrence was achieved in 55.5% of lids after one laser session. The remaining 44.5% of the lids required two or three sessions. The final success rate of the method was 88.9%. No complications were observed. The mean follow-up time was 10.6 months. CONCLUSION: Argon laser photocoagulation is an effective and safe method for the treatment of trachomatous trichiasis.

Should trichiasis surgery be offered in the village? A community randomised trial of village vs. health centre-based surgery.

INTRODUCTION: Surgery for trachomatous trichiasis prevents blindness and is advocated by the WHO as part of the SAFE strategy for the global elimination of trachoma. We conducted a randomised community trial to investigate the effect of providing surgery in villages on surgical uptake in The Gambia. METHODS: 56 villages from two divisions were assigned to eight pairs of clusters matched by geographical division and proximity. One cluster from each pair was randomly assigned to receive village-based surgery and the other cluster health centre-based surgery. Outcome measures were uptake rates and surgical results after 1 week and 3 months. The paired t-test was used to analyse the results. RESULTS: Overall uptake was 66% in the village-based clusters and 44% in the health centre-based clusters. Subjects in the village-based surgery arm had significantly shorter journey times (P = 0.01) and lower costs (P = 0.002). The mean difference in absolute acceptance rates of surgery was 20% better in village-based clusters (95% CI -9 to + 49%, P = 0.15), which would equate to an improvement of 45% (95% CI -20% to 120%) on the average acceptance rates of 44% in the health centre-based group. CONCLUSION: These results strongly suggest better surgical uptake when surgery is provided in patients' villages due to lower cost to the patient, time saved and less fear of the operation.

[The quality of trichiasis surgery in the kingdom of Morocco]. / Qualité de la chirurgie du trichiasis au royaume du Maroc.

In December 1998, a survey was carried out on the quality of trichiasis surgery, based on a random sample of 750 people chosen from the surgical records of 13 health centres of the provinces of Zagora and Errachidia (Kingdom of Morocco). Among those, 740 people were examined (participation ratio: 98.6%). The study population was mainly composed of women (63.8%) and people > 40 years (83.5%). The average age was 51.8 (48.5 for women and 57.4 for men). The most common surgical technique was the bilamellar tarsal rotation procedure. In 98.7% of cases, the operation concerned one of the upper eyelids, and in 58.5% of cases the right eye. At the time of the interviewers' visit, 11.1% of the people examined were blind (vision < 1/20 for the best eye) and 28.9% were visually impaired (vision > 1/20 but < 3/10). In addition, 17.6% of the eyes whose eyelids had been operated on rated as blind and 29% of them as visually impaired. The definition of recurrence was the presence of at least one or more eyelashes in contact with the eyeball. The recurrence rate is estimated to be 15.8%, divided into 2 categories: (1) Severe or total recurrence (2.4%) - At least one eyelash from the median part of the lid margin is in contact with the cornea - and, (2) Partial recurrence "One or more eyelashes affect the corners of the eyelids but never rub against the cornea" (13.4%). 14. 3% of the patients operated on were removing their eyelashes regularly which is a clear indicator of the failure of the operation. The following constitute risk factors for recurrence: being aged over 40, having been operated on in Errachidia province, having been operated on by a general practitioner or by an ophthalmologist. However, "time elapsed since the operation" does not appear to influence the recurrence rate in each of the three cohorts which were subsequently formed using the date of the operation (retrospectively). Most recurrences seem to develop during the first twelve months after the operation. The post-operational complications/sequelae detected were rarely sight-threatening, except in four cases, i.e., three ptoses and one case of tegumental necrosis with permanent exposure of the cornea. The most common complications were excessive rotation of the lid margin (over-correction) (2.3%) and cutaneous necroses with no exposure of the cornea (3.6%). In this series, 15.7% of the eyes examined presented central corneal opacity and 2.1% xerosis. In 1.6% of cases the eyeball was either destroyed (phthisis bulbi) or absent. A majority of patients (51.8%) was affected by persistent lacrimation or secretions.

Direct internal eyelash bulb extirpation for trichiasis.

PURPOSE: To evaluate the success of internal eyelash bulb extirpation in the management of trichiasis. METHODS: The procedure was performed on 26 consecutive eyelids. RESULTS: Our technique was successful in all cases, with no recurrence of signs or symptoms. CONCLUSIONS: Internal eyelash bulb extirpation is a safe and effective technique to remove trichiatic lashes, while avoiding injury to the conjunctiva.

[Treatment of trichiasis with a diode laser]. / Behandlung der Trichiasis mit einem Diodenlaser.

BACKGROUND: Various methods have been used in the treatment of trichiasis: epilation, excision, cryosurgery, thermocaustic needle, and argon laser. None of these is satisfactory. Based on the principle of selective photothermolysis for destroying specifically the hair follicle, we used a diode laser and evaluated its efficacy. MATERIAL AND METHODS: Nineteen eyes with 301 itching lashes were treated in three sessions at intervals of 1 week. In each session the single hair follicle received laser energy of 20 J/cm2 at a frequency of 806 nm for 15 ms. We used a bare fiber of 0.8 mm at a distance of 2 mm from the follicle. RESULTS: After 4 months two-thirds of the hairs were destroyed. The regrown lashes, however, are lighter and softer than the original ones. This treatment is less painful than all others. The laser is small, easy to use, and inexpensive. CONCLUSIONS: The diode laser is a useful tool for the treatment of trichiasis. The laser parameters, however, should be ameliorated.

Treatment of trichiasis with argon laser.

PURPOSE: In this prospective study, argon laser photocoagulation was used to eliminate misdirected cilia. The cases were followed up to see the results and recurrences with this treatment. METHODS: 60 eyelids of 45 patients with trichiasis were treated with the argon laser. After topical anesthesia a blue-green argon laser was used with 1 watt power, for 0.20 seconds, with 100 micrometer beam diameter. The beam was directed coaxially to the lash follicle to create a 2-3 mm crater and vaporization was observed. After crater formation, the laser parameters were changed to 1.2 watt power, for 0.20 seconds, with 200 micrometer beam diameter, to destroy residual follicular tissue. Up to five lashes were treated in one session. At the end of each session an antibiotic ointment was used t.i.d. for a week. RESULTS: Patients have been followed for 4-12 months (mean 6 months). Recurrences have been seen in 15 of 60 eyelids (25%). Laser treatment has been used with the same protocol for the cases with recurrence and results have been successful in eight of them. Postoperatively severe pain, hemorrhage, scar formation, neovascularization of lid margin, or infection were not seen in any patient. In three cases mild hypopigmentation and in three other cases mild lid notching were observed. CONCLUSIONS: Argon laser lash ablation can be done as an effective office procedure with topical anesthesia. The advantages include low recurrence and complication rates in carefully selected patients and minimal postoperative discomfort.

Thermoablation treatment for trichiasis in trachoma using the semiconductor diode pumped laser.

PURPOSE: The aim of this prospective study was to verify the efficacy of laser therapy for trichiasis in trachoma. Trichiasis is one of the most important complications of trachoma which is endemic in Sanliurfa, a city in the southeast of Turkey. METHODS: Twenty-eight eyelids of 22 patients - 15 males and 7 females - with trichiasis related to trachoma involving the upper, lower, or both lids, were included in the study and treated with a semiconductor diode-pumped, frequency-doubled, solid-state laser operating true CW at 532 nm. RESULTS: 19 (67.9%) of the lids were successfully treated in two sessions or less. Six lids (21.4%) required a third laser session and three (10.7%) a fourth session. Mild notching or dimpling occurred in two eyelids (5.6%). Postoperative swelling was minimal or absent. CONCLUSIONS: The results show that laser treatment may be successful for trichiasis caused by trachoma. Laser thermoablation is an effective and safe method, with many advantages over other modalities.

Reconstruction of the eyelids of a dog using grafts of oral mucosa.

A five-month-old English cocker spaniel with distichiasis had been treated four times surgically by a tarsomeibomian resection technique. As a result, three-quarters of the margins of its upper eyelids had been eliminated and the lower eyelids had become considerably thinner. The dog had developed upper entropion and upper eyelid trichiasis, and keratoconjunctivitis sicca. It was treated medically and grafts of oral mucosa were used to reconstruct its upper eyelids. A year after surgery, the new palpebral margin was completely functional and cosmetically acceptable. The dog's eyes appear normal and only require treatment with artificial tears.

Scorched eyelashes--do we treat them right?

Scorched eyelashes and burned eyelids are a common finding in facial burns, though the eye itself is often spared. Affected patients often complain of foreign body sensation and ocular discomfort in the absence of objective physical findings, other than scorched eyelashes and burned eyelash particles in the conjunctival sacs. This study was designed to evaluate the efficacy of prophylactic trimming of scorched eyelashes as a treatment for these findings and complaints. Eleven consecutive facial burn patients with bilateral eyelash scorching and no accompanying ocular damage were included. The eyelashes of one eye were trimmed, and those of the fellow eye served as untreated controls. Ophthalmic examinations were performed and eye-related complaints noted every other day for 10 days. We found that symptoms of foreign body sensation and discomfort occurred at a lower rate in the treated eyes (P<0.002) and no scorched eyelash particles were found in their conjunctival sacs (P<0.004) as compared to the untrimmed side. Conjunctival hyperemia was reduced. We suggest that shedding of scorched eyelash particles is a major cause of the ocular complaints in facial burn patients. Trimming the eyelash affords a simple and effective method of prophylactic treatment.

Anatomy and physiology of eyelash follicles: relevance to lash ablation procedures.

BACKGROUND: This study aimed to define the anatomy of the eyelash follicles in order to improve methods of selective lash ablation. MATERIALS AND METHODS: Dimensions of eyelash follicles were determined from histological specimens of the upper and lower lids of 10 patients. For one of these patients, the eyelash follicles were categorized as quiescent or actively growing, according to standard hair-cycle morphology. RESULTS: Follicle dimensions were (mean +/- SD): upper lid follicle depth, 1.8 +/- 0.3 mm; bulb width, 188 +/- 44 microns; shaft width, 205 +/- 28 microns; lower lid follicle depth, 0.9 +/- 0.2 mm; bulb width 132 +/- 19 microns; and shaft width, 158 +/- 26 microns. The upper lid comprised 41% active follicles compared to 15% in the lower lid. CONCLUSIONS: There are significant differences in the anatomy of the follicles between the two lids. For an electrolysis needle to completely contact 95% of all follicles, it must be inserted 2.4 mm into the upper lid and 1.4 mm into the lower lid (mean depth +2 SD). Argon laser ablation requires a beam width of < 200 and < 250 microns for the lower and upper lids, respectively, to treated similar depths as electrolysis. The higher proportion of actively growing upper lid follicles explains why upper lid lashes are longer.