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Clinically assessing trichiasis patients

Obtaining a good surgical outcome is central to provising trichiasis services. Watch this video on how to evaluate and select patients for surgery.
By the end of this presentation you should be able to: Understand how to evaluate and select patients for trichiasis surgery in the community. Discuss the key steps in preparing patients for trichiasis surgery. It’s important that each patient is correctly assessed because in some cases the presence of trachomatous trichiasis may not be an indication for surgery.
The definite indications for trichiasis surgery in the community are: One or more eyelashes from the upper eyelid which turn in and touch the cornea when the patient looks straight ahead Evidence of epilation from the upper eyelid Evidence of corneal damage from trichiasis Severe discomfort from trichiasis.
Contra-indications to performing trichiasis surgery in the community are: Defective eyelid closure, or repeat trichiasis after surgery Children need surgery in hospital, possibly with a general anaesthetic Poor general health Trachomatous trichiasis of the lower eyelid. These cases require referral to an ophthalmologist for management. The surgeon (or examiner) starts by taking a short clinical history of any eye problems the patient has.
Ideally using the local language they ask: Are you aware of having trichiasis? And if so how long and what are the symptoms? Do you epilate? If yes, what with? Have you had previous surgery to the eyelids? Do you have any general health problems such as high blood pressure, shortness of breath, bleeding problems? Do you take any medication and do you have any drug allergies?
To examine the eyes, the surgeon uses a bright torch and a pair of magnifying loupes. The right eye is examined first, then the left eye. Most trichiasis in trachoma endemic settings is caused by trachoma. However, trichiasis can also be caused by other conditions,
such as: blepharitis, Stevens–Johnson syndrome, burns, trauma, tumours, herpes zoster or ocular cicatricial pemphigoid. It is therefore very important to take a good medical history and make a careful clinical assessment of each trichiasis patient.
Trichiasis can be caused in three ways: Firstly, there may be entropion this is when the lid shortens and the lid margin rotates inwards and often becomes rounded, bending the lashes towards the cornea. Secondly, there may be metaplastic lashes. These are lashes which grow from abnormal places, usually behind the normal lash line. Finally, the lashes may be misdirected. This is when lashes grow from the normal lash line but instead of growing outward, they point backwards. All three types of trichiasis can occur at the same time in the same eyelid. When examining a patient for trichiasis the surgeon asks them to look directly ahead in the “primary position of gaze”.
Then they ask the patient to look up and count the number of eyelashes that touch the eye. The tarsal conjunctiva should be examined to assess the degree of scarring. To view the tarsal conjunctiva, the upper eyelid needs to be everted. To evert the upper eyelid, the surgeon asks the patient to look down. Then they gently hold the edge of the eyelid and flip it up to examine the conjunctiva for the amount of scarring. Scarring usually appears as white bands [sheets].
Corneal scarring is the blinding stage of the disease. The cornea is assessed with the torch held from the side. This helps to show up fainter opacities more clearly.
Lagophthalmos is incomplete lid closure. A small gap is seen between the eyelids when the patient is asked to gently close their eyes. Lagophthalmos occurs when there is shortening of the eyelids due to scarring of the conjunctiva. These patients may need to be referred to an ophthalmologist. It is very important that the surgeon records both the history and the clinical findings in the patient’s notes or a log book Sufficient contact information must be recorded so that the patient can be followed up. After a trichiasis patient is assessed, the surgeon can make a decision about clinical management.
This will vary significantly depending on various factors: The clinical appearance and severity of the trichiasis The available resources Surgeon’s training The views of the patient And finally, national policies on the preferred type of trichiasis surgery and indications for surgery. Not all patients accept surgical treatment. In these cases surgeons need to guide and support the patient. For minor trichiasis - five or fewer in-turned eyelashes - or cases in which the patient declines surgery, or [is] not immediately available, surgeons can advise patients to epilate, and provide further follow up. Epilation is the removal of eyelashes by the roots, usually by plucking. The surgeon must alert patients to the risks of epilation. Eyelashes can break and leave sharp stubs at the lid margin.
These can cause damage to the cornea.
It is important to: Demonstrate the correct epilation procedure. And provide high quality epilation forceps. These should have durable frames and rounded tips with non-cutting opposing edges. They should be provided in a size that patients with different sized fingers can all use comfortably. Patients need to be counselled and informed about all their options. There are two methods used for trichiasis surgery
in trachoma endemic countries: Bilamellar tarsal rotation; and Posterior lamellar tarsal rotation Bilamellar tarsal rotation involves an incision approached from the skin. This leaves a scar on the eyelid in the immediate post-operative period, but as time passes, this tends to become harder and harder for others to see. Posterior lamellar tarsal rotation involves an incision from the tarsal conjunctiva, and leaves no scar on the eyelid. It is important that all team members undertaking case-finding, counselling, surgical management, or follow-up are able to clearly explain which procedure is recommended for use in their local setting.
In summary: To prepare a patient for trichiasis surgery, surgeons must carry out a detailed examination of the eyes and a basic medical assessment They must explain to the patient in a sensitive way the procedure that will be used and obtain appropriate consent Epilation may be offered as an alternative treatment for minor trichiasis, or for cases in which the patient declines surgery or has no immediate access to surgery.
Trichiasis surgery aims to prevent vision loss by turning the eyelid margin outwards. This prevents any in-turned eyelashes from rubbing against the eye. The techniques and approaches used have evolved over the years. The ancient Greek physician Hippocrates (460-380 BC) described only four eye operations, three of which were for trachoma!

Approaches to trichiasis surgery have evolved considerably in recent years. Obtaining a good surgical outcome is central to the service we provide to patients, and recent work makes good outcomes more and more likely for each patient.

An effective trichiasis surgery service aims to:

  • Provide high quality surgical outcomes for all patients
  • Detect and manage any complications of trichiasis surgery, and any post-surgical recurrence of trichiasis
  • Achieve high surgical coverage of individuals with trichiasis

Any surgical intervention is a major consideration for both patient and surgeon. The first step is to correctly assess and prepare the patient for surgery.

As you watch this video reflect on the effect of the statement “you will need eye surgery” on an individual with trichiasis. Who is best placed to inform and counsel the patient?

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Eliminating Trachoma

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