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Selecting appropriate treatment: What’s the evidence

Watch Dr Matthew Burton and Dr Esmael Ali discuss trichiasis management in Ethiopia and about findings from recent research into TT surgery methods.
Matthew Burton: I’m here today with Esmael Habtamu from Ethiopia to discuss the management of trachomatous trichiasis. Esmael has recently led a study looking at how to manage trichiasis, and we’ll be hearing from him a bit more about this later. Esmael, thank you for joining us today.
Esmael Habtamu: Hello. It’s a pleasure to be here.
Matthew: Esmael, you work in an area of Ethiopia where trachomatous trichiasis is really common. Can you describe for us the context in which treatment is being provided for people with this problem please?
Esmael: Yup. In Ethiopia, most of the surgery is performed by integrated eye care workers. These are general nurses or ophthalmic officers, which received intensive training on management of trachomatous trichiasis– community-level management of trachomatous trichiasis. Therefore, whatever we do we need to make sure that the surgery is reliable, safe, and easy to perform. In the community it’s also not unusual to find people who practice traditional epilation. Epilation is a removal of internal eyelash using some locally available tools.
Matthew: What are the current treatment options being used in Ethiopia for trichiasis?
Esmael: Currently, patients identified with trachomatous trichiasis are being offered surgical management. In Ethiopia, the two most commonly used surgical procedures are the bilamellar tarsal rotation surgery and the posterior lamellar tarsal rotation surgery, which is also known as the Trabut method. And these are actually usually performed by nurses at the community level.
Matthew: Esmael, you recently conducted a study in Ethiopia comparing the two most commonly used operations. Can you describe this and what you found please?
Esmael: Yes. We compared these two surgical procedures, the posterior lamellar tarsal rotation surgery and the bilamellar tarsal rotation surgery in a randomized controlled trial. And we found that the posterior lamellar tarsal rotation surgery has fewer complications, such as bleeding and infection post-operatively. And also in addition to this, we found that the posterior lamellar tarsal rotation surgery has fewer recurrences after 12 months of follow up. The patients randomised to the posterior lamellar tarsal rotation surgery had 12% trachomatous trichiasis recurrence while the patients randomised to the bilamellar tarsal rotation surgery had a 20% to about 22% recurrence rate after 12 months after surgery.
Matthew: Does this mean that we should be moving to using the posterior lamellar tarsal rotation rather than by bilamellar tarsal rotation do you think?
Esmael: Yup. That depends on context. So in programs where bilamellar tarsal rotation surgery is practiced and there are a group of well-trained surgeons on the bilamellar tarsal rotation surgery probably continue using this surgical procedure might be a better choice. But for new surgical programs, for new trachoma control programmes where there is a need of training in trichiasis surgeons, I think programmes should consider training surgeons using the posterior lamellar tarsal rotation surgery.
Matthew: You mentioned earlier that epilation is commonly practiced in this part of Ethiopia by people with trachomatous trichiasis. What do you think going forward the place for epilation is in the management of this disease?
Esmael: Yeah. So surgery is the first-line treatment. And it’s very common treatment for trachomatous trichiasis. But usually in programmatics, I think, there are people who refuse or decline to undergo trichiasis surgery. So for these type of cases I think we need to consider providing them epilation as an alternative management rather than doing nothing. The other thing is I think for recurrent trachomatous trichiasis cases with some few peripheral lashes probably considering epilation might be the best option.
Matthew: Esmael, so how would you advise epilation should be done?
Esmael: Firstly, to do a proper and a good epilation I think we need good quality epilation forceps so that we can grip the lash from the base and avoid cutting them. Probably if we cut the lash that will result into short stubbing lashes, which probably may cause discomfort and more damage to the cornea. The other thing that we need to consider when doing epilation is I think that the patient needs to find a person who can do this properly, who has a good near vision and who would be readily available when they need to have that epilation who can do that frequently when they need it.
In a programmatic setting, they probably– if we are doing epilation in health facility, we might need to ask patients to come back for follow up so that they can be frequently examined for progress of trichiasis. And if the need arises they might be offered surgery again or they might have a repeated epilation after that.
Matthew: So in conclusion, for surgeons who have been previously taught in one or other of these operations we’ve heard about today they should continue practicing that procedure. But for new surgeons who are being trained afresh it is probably advisable for them to be trained in the posterior lamellar tarsal rotation. Secondly, for people who refuse surgery for their trichiasis or who have a mild degree of recurrence following the surgery epilation is probably a reasonable management approach. For this, they need to have good quality forceps, for the epilation to be done regularly as needed, and for the person doing it for them that they have good near vision in order to be able to see the fine lashes.
And finally, and very importantly, people with trichiasis who have surgery experience a marked improvement in their quality of life. Esmael, thank you very much for joining us today.
Esmael: Thank you.

In this video Dr Matthew Burton talks with Dr Esmael Ali about his experiences of trichiasis management in Ethiopia and about some interesting findings from a recent study he carried out on trichiasis surgery methods.

Patients identified with trichiasis are offered surgical treatment. Two methods of trichiasis surgery are recommended by the World Health Organization and are in routine use: bilamellar tarsal rotation (BLTR) and posterior lamellar tarsal rotation (PLTR). Surgery teams should offer epilation, removal of the eyelashes, to patients who refuse surgery.

As you watch the discussion, consider how to monitor the quality of trichiasis surgery and what to do with that information?

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