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