Surgeon operating
Trichiasis surgery during an outreach campaign

Post-operative trichiasis

Post operative trichiasis is when trichiasis is found again in patients after surgery. It can develop at any time after surgery. Early post-operative trichiasis is probably related to how well the operation was performed and to wound healing responses. Trichiasis redeveloping may also be related to the trachomatous scarring disease.

Is post-operative trichiasis a problem?

Completely successful trichiasis surgery is defined as:

  • No eyelashes rubbing on the eyeball (in the absence of epilation or further surgery), and
  • No complications (infection) or no severe eyelid contour abnormalities such as granuloma or even necrosis of lid margin

Post-operative trichiasis is a significant problem in the control of trachoma because it puts the eye at risk again of sight loss.

The proportion of eyes that develop post-operative trichiasis is variable. The level reported in clinical trials is typically around 20% by one year. And this number rises as the years pass. However, very little data has been published from settings in which trachoma elimination programmes are active. It is possible that in these conditions, recurrence rates of trichiasis are even higher.

The four S’s: Key factors associated with post-operative trichiasis

  1. The severity of a patient’s trichiasis before surgery is a major factor affecting whether trichiasis will redevelop. The more severe the trichiasis before surgery the more likely it is to be found following surgery.
  2. The surgical method used is important. Some procedures are associated with higher post-operative trichiasis rate than others.
  3. The skill of the surgeon is very important – research has found that recurrence rates vary significantly between different surgeons. This suggests that there are subtle variations in how the procedure is performed that can influence the outcome.
  4. Excessive scarring contraction of the healing tissue frommore aggressive post operative wound healing may be related to some recurrent trichiasis. Post-operative trichiasis developing later may be due to progressive scarring of the conjunctiva from trachoma.

Impact of post-operative trichiasis

Failure to provide a good quality service with acceptable outcomes for patience will undermine progress towards eliminating trachoma. If people with trichiasis see others receiving poor quality surgery they will be much less inclined to accept the treatment themselves. Good follow up of patients and feedback to the community will also strengthen health promotion and community mobilisation for the other trachoma elimination activities - mass drug administration and interventions for facial cleanliness and environmental improvement.

Managing post-operative trichiasis

Individual patients should be advised by the surgical team that trichiasis can return after surgery, especially in patients who had severe trichiasis before the operation. Patients should be told to seek medical help if they develop symptoms of trichiasis again. When a patient does seek help, someone familiar with treating trichiasis should assess them.

Trichiasis surgeons should carefully assess all patients found to have post-operative trichiasis and determine whether or not they need additional treatment.

  • If the trichiasis is mild with only a few lashes touching the peripheral parts of the eye – epilation can be considered
  • If the lashes are central and regularly coming into contact with the cornea, then repeat surgery may be needed. Ideally the patient should be assessed by an ophthalmologist or by the most experienced trichiasis surgeon available

The type of procedure surgeons use to correct the post-operative trichiasis will depend on the anatomical abnormality. It may not be appropriate to simply repeat the same operation. The eyelid may have been shortened slightly by the original surgery. In these cases, a procedure which lengthens the eyelid may be needed to ensure good eyelid closure and protection of the eye.

Trachoma programme managers should monitor data on post-operative trichiasis for each outreach campaign and for individual surgeons. They should use the data to help them actively manage trichiasis surgical outcomes.

Every manager needs to have a system for detecting and managing post-operative trichiasis:

  • Patients should be followed up and assessed for post-operative trichiasis at least 6 months after surgery
  • Surgical outcome must be recorded and also the follow-up data on any post- operative trichiasis. For quality assurance purposes this data should ideally be collected by surgeon.

If a surgeon is found to have an unusually high post-operative trichiasis rate (e.g 30% and above) then enhanced supportive supervision by a more experienced surgeon or re-training may be needed.

The role of national trachoma programmes in managing post-operative trichiasis is to:

  • Monitor surgical outcomes and data on the appearance of eyelids and recurrence of trichiasis after surgery across districts
  • Assess whether rates of post-operative trichiasis are affecting acceptance of surgery in the community To do this, programmes need to put quality assurance systems in place to track data. Trends on post-operative trichiasis rates at the 6 month follow-up can be used as a measure of quality.

Data collection for monitoring trichiasis surgery

Data collection activities by the surgical team at each outreach campaign or static unit

At each outreach campaign or static unit the following information on trichiasis surgery should be collected by the team:

  • Number of patients operated per outreach
  • Surgeon and type of surgery done
  • Number of patients with post-operative trichiasis at 6 weeks
  • Number of patients with post-operative trichiasis at 6 months

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Eliminating Trachoma

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