Providing good quality trichiasis surgery at high volume

Around 2.5 million people worldwide have trachomatous trichiasis (TT) and need trichiasis surgery to prevent further visual impairment and blindness. To eliminate trachoma we need to address this backlog of trichiasis cases while ensuring good quality results.

The trichiasis component of “elimination of trachoma as a public health problem” requires there to be a prevalence of <0.2% in people aged 15 years and above in an endemic district. The Global Trachoma Mapping Project provided evidence of where trichiasis surgery is likely to be most needed and an estimate of how many surgeries are needed. To increase the volume and coverage of surgery we need to strengthen demand for surgery and improve delivery of surgical services.

Activities to achieve these two goals include:

• Strengthen demand for surgery: raising awareness, supporting decisions for acceptance and ensuring that distance to a surgical point is not a barrier
• Improve delivery of surgical services: ensuring the surgery teams are well equipped, making services accessible, affordable and of good quality.

A well-equipped trichiasis surgeon can perform 15 surgeries per surgical day. If we assume 50 operating days a year, this equals 750 surgeries per surgeon per year. These surgeries will often need to be done on outreach in remote locations.

Improving quality

Poor quality surgery has a detrimental effect on both the patient and the reputation of the surgical programme. Poor outcomes deter other patients from accepting surgery.

It is important to minimise complications in trichiasis surgery by providing standardised training and on-going supportive supervision, as well as sufficient supplies of high quality equipment and consumables.

There are four important elements to delivering an efficient high quality service:

1. Selecting the right people to perform the surgery,
2. Training them well,
3. Providing supportive supervision, and
4. Monitoring surgical outcomes.

1. Selecting trichiasis surgeons

In most trachoma endemic countries, there are not enough ophthalmologists to treat people with TT. Therefore many programmes train mid-level health workers as TT surgeons. Results from a clinical trial and subsequent programmatic experience suggest that TT surgeons can perform TT surgery to a similar standard to ophthalmologists.

Candidates for TT surgery training need to be selected carefully. Key individual requirements are:

• Have a potential to learn (aptitude for) surgery
• Be willing to serve in rural health facilities, close to populations most in need. Ideally, candidates should be from the area and speak local language(s).
• Past experience in giving injections, knowledge of sterile surgical techniques.
• Good manual dexterity and eyesight.

In some programmes, attrition (reduction in surgical workforce) has been a key challenge. It can be difficult to maintain services because trained trichiasis surgeons may be moved or promoted. Programmes therefore need to adopt approaches to ensure stability of services. For example, in the Amhara region of Ethiopia, trainees agree to work in the programme for at least 1 year following training. A supportive employment environment is likely to motivate staff to remain in the programme.

2. Surgical training

Training of trichiasis surgeons follows the WHO manual, Trichiasis surgery for trachoma.

Training programmes need to be led by an ophthalmologist or trichiasis surgeon who is highly experienced in both trichiasis surgery and surgical training.

Rigorous standardisation is essential to ensure that surgery is taught correctly. It is highly recommended that training programmes incorporate use of the mannequin-based simulator known as HEAD START. This provides trainees with the opportunity to learn and practice all the major steps of the trichiasis surgical procedure prior to operating on patients.

Training has to cover all elements of the surgical process:

• Correct patient selection
• Counselling
• Surgical technique
• Managing a surgical environment and instruments
• Correctly recording the data
• Post-operative counselling and follow up

It is good practice to provide certification of trichiasis surgeons. Guidelines for establishing this process are provided in the WHO manual, Trichiasis surgery for trachoma.

3. Supportive supervision

Trichiasis surgeons must have ongoing and supportive supervision. This is crucial for improving the outcome of surgery but unfortunately programmes often overlook its importance. Lack of supportive supervision has been cited to be a major reason for poor surgical productivity.

Supportive supervisors:

• Provide continuing guidance
• Address any problems that are identified
• Encourage (motivate) surgeons as performance improves
• Act as a conduit for any developments in best practice to be transferred to the front line

Instead of fault finding, supervision is a two-way communication between supervisor and surgeon so that together they can identify poor practices, take action to increase volume and take steps to prevent complications and improve quality.

Supervisors

To provide comprehensive support, supervisors themselves need training.

Supervisors need to have the necessary clinical knowledge and to have performed successful high quality trichiasis surgery themselves. They must be capable of transferring skills and providing hands-on training in all aspects of trichiasis surgery.

To deliver a good quality and efficient service careful planning is needed. So supervisors also need strong programme management skills to manage people, logistics and supplies. For example, it is necessary for surgeons to have access to good quality instruments and a reliable supply of consumables at all times. This requires systems to monitor supply and ensure restocking in a timely manner.

4. Monitoring outcomes

Most importantly, it is necessary to actively monitor the outcome of trichiasis surgery. This requires the active follow-up of patients several months after their surgery to look at the results. If there is recurrence of trichiasis or poor post-operative eyelid contour then the surgical technique being used should be carefully examined and any technical errors addressed.