Esmael Habtamu Ali (Co-Lead Educator)
Postdoctoral Research Fellow at the International Centre for Eye Health, London School of Hygiene and Tropical Medicine, UK, focusing on research to improving the management of TT.
Location Bahirdar, Ethiopia and London, UK.
Activity
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Hi Susan, the trial was done in rural community setting. The PLTR is currently extensively used in various trachoma endemic settings as a preferred procedure to manage TT patients. Would be great for you to try out these procedures in the community and see what you think as both are also still being used in some settings.
We believe the better outcome...
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Hi Olorunsogo, MOH and partners can facilitate this process by creating a working and safe (in terms of data safety and sharing regulation) data storage system. This would to the minimum require server and dedicated personnel who can review and make a good use of the data being collected. However, some trachoma endemic settings my struggle to properly...
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Esmael Habtamu Ali (Co-Lead Educator) made a comment
Hi everyone, Esmael here. I am one of the Co-Lead Educators. I am a trachoma expert based in Ethiopia. Looking forward to engaging with you in the coming five weeks.
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Welcome Everyone! Thanks for joining the course. Looking forward for a lively discussion with you all throughout the course. Please do not hesitate to put in the chat any questions you may have or experiences that you would like to share. Thanks.
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4) Both ointments work - but its tetracycline eye ointment that is mostly used in programmes given its readily and cheaply available. Please note that Azithromycin is not contraindicated for pregnant women - but the decision is left for national programmes. Counselling would play a major role in resolving those issues and minimising the rate of refusals....
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Hi Kainat, these are great questions. Below are some thoughts from me:
1) Allergic reactions from Azithromycin are not common. As in most clinical practices, no sensitivity tests are done during MDA. The procedure is to ask the person or parents (if child) if there is any previous history of allergic reaction. Those new to MDA are often advised to report... -
Hi Gordon - Similar approaches are used for MDAs of other NTDs control/elimination efforts. MDA was first successfully demonstrated for onchocerciasis control through the African Programme for Onchocerciasis Control (APOC) which used Community-directed distributors (CDDs) to distribute ivermectin. This experience I believe gave the platform to develop the...
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Hi Hue, thats great point. You are correct that should be the case. What is indicated here is only on what the "Focus" area of of these two stakeholders are. Otherwise, the distribution itself involves lots of planning for the reasons you have pointed. MDA planning process actually starts from the community (villages) and district health offices. Most fo the...
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Hi Nigusie, its something great to have if possible or preferred. Otherwise most surgical programmes tend to practice verbal informed consent.
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Hi Bockarie, this is great question. Not always. For instance, In trachoma endemic settings, lower eyelid lid trichiasis is also common in people affected with upper-eyelid trichiasis. But lower eyelid trichiasis is also common from other (non-trachomatous) causes.
This has been discussed in the WHO 4th global scientific meeting on trachoma. Below are the...
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Yes, thats correct Bockarie.
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Hi Rita, yes thats correct. This is related to the damage to the corneal epithelium from the constant scratching caused by the in turned eyelashes. This disrupts the tear film, increases susceptibility to infection and sensitivity to light and irritation.
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@KainatZahid thats good question. Thanks Hue. This is mainly attributed to their greater lifetime exposure to Chlamydia trachomatis through childcare activities. As you have learnt in the first week, Active trachoma commonly affects children.
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Hello everyone, Welcome! Great to have you all in this course. I am Esmael, one of the co-lead educators. I will be with you throughout the course to facilitate the learning process, along with other co-lead educators and course facilitators. Please do engage in the discussions and feel free to forward any of your questions and comments in the comment section....
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@EmmaHarding-Esch(Co-LeadEducator) great thanks for sharing that.
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As you all know very well, follow-up is part of the surgical service - the service is not completed until the necessary follow-up examinations are conducted. Its allows to review the quality of the service being delivered. Its important to device locally relevant strategies to improve follow-up uptake by the operated cases.
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@AnthonyAfriyie many thanks for sharing your experience. Doing follows few months after surgery has been also raised as a challenge by many programmes.
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@MahaAdam many thanks for sharing your experience on this.
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@AnthonyAfriyie thanks for commenting more on those points.
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Yes. Thanks Samantha and Sarah. Sarah, you may have also already seen the difference between the Posterior (Trabut) and Bilamellar Tarsal Rotation procedures from the short video link provided at the bottom of session 2.9.
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@RinretEhiorobo, thats excellent question. Glad that you raised it. As you have indicated surgical successes are hugely influenced by the operating surgeons' skill differences. To nullify such influence, the analysis in that trial was conducted by controlling for surgeon as a fixed effect in all comparisons between the two surgical procedures. Therefore those...
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Would be great to hear experiences of fellow course participants in doing/facilitating follow-ups after TT surgery:
1) How frequently it is done in your programmes?
2) What proportions of cases attend the follow-ups?
3) What are the most common unwanted surgical outocmes reported at the different follow-up time points?
4) Challenges of doing... -
@SamanthaNyathi, that sounds really great approach that most of us can learn from. Thanks for sharing. Would also be good to here from other course participants.
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Boumkouth, what you have mentioned are great points. Would you please elaborate the "community/patient acceptance". Is the acceptance related with generally around accepting surgery as the first line treatment strategy for TT or is it related with the surgeon skill? Would also be great to hear the experiences of fellow course participants on this point.
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Nowadays the most challenging thing for surgical programmes is delivering the service after a patient has been identified. Not all patients would accept surgical management. Would you please share us your experiences from your respective settings around this? What strategies have been employed in your areas to improve surgical uptake?
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Thats true, Rinret. A study conducted in Ethiopia showed that a bidirectional causative relationship possibly may exist between poverty and trachoma: poor households are more affected by trachoma and trichiasis reduces productivity even prior to development of visual impairment, which may exacerbate poverty. Please follow this link to read more on this...
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Many thanks for this useful update, Rom.
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Hi everyone, Wellcome to the course. I am Esmael, one of the lead educators on this course. Looking forward to engaging with you all in the coming few weeks. We would love to hear your thoughts and suggestions and of course feel free to ask any questions that you may have. We (all of us singed-up here) will try to address them together. Enjoy.
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These are among the major challenges trachoma programmes are facing today. Attrition of TT surgeons has been a major issue. The reality is we can not hold trained TT surgeons in remote areas with no or less infrastructure for long period of time. They would want to move on to a better place or get promoted after few years. The backlog of TT cases need to be...
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I agree, Brenda. This has been tried in Ethiopia and has worked. There is some details on this in the next section (2.6).
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Oluwatoyin, like you pointed out the impact of TT is devastating and it goes beyond the risk of visual impairment. It hugely affects overall wellbeing (hampers quality of life and ability to participate in productive activities). Trachoma mostly affects the poor and the disease itself may push families to further poverty. We have have recently measured such...
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Hi Bernabas, please kindly see these two published papers with data from the Malawi baseline trachoma survey:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673584/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706967/And this one on the results of impact assessment survey:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016948/ -
Hi Oluwatoyin, thats great question. The impact asessemnt survey schedule depends on the baseline prevalence of active trachoma. You will learn this on week 5 under "How to monitor and evaluate trachoma programmes".
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Hi Birhan, I agree completely with you - no blindness is acceptable from trichiasis or any cause. Here we say "acceptable" because there will be few cases of trichiasis anyway in any setting regardless of trachoma. Cases of trichiasis from other causes have been reported in developing settings. Therefore even if we implement a very successful programme and...
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Good quality corrective eyelid surgery not only averts the risk of blindness from TT, but also significantly improves quality of life and functional capabilities of affected people.
Below are the links for studies conducted around this:
https://www.ajo.com/article/S0002-9394(10)00947-5/fulltext
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The effect fo trichiasis is not only limited irreversible visual impairment. But also the pain and the discomfort from the trichiasis, regardless of the presence of visual impairment, significantly reduces vision and health related quality of life of affected individuals. In addition it limits participation in productive, leisure and social activities. Blow...
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Hi Rebecca, you raised an important point. We do not always classify misdirected eyelashes as trachomatous. There are also other conditions which can cause trichiasis. However, in trachoma affected communities, it is believed that most trichiasis is probably due to trachoma. Therefore, just to avid complication for graders and case identifiers in the field,...
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I agree with your points Rebecca. To share you my experience in Ethiopia, most people try to avoid surgery because they think the wound healing may take few months and that they need to stop working during those months - which is not possible for most people particularly women which are burdened with lots of household responsibilities.
Other colleagues,...
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Good points by Marvellous and Rebecca. It is not uncommon to see TT cases declining surgery for lots of reasons. Making the service accessible or available is not enough in most communities. A discussion based approach where the cases can be identified by community based TT case identifiers (Eye Ambassadors), and counselled for surgery has been found to...
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Esmael Habtamu Ali (Co-Lead Educator) made a comment
Dear Millie, many thanks for sharing this. We would not be able to "close the gap" if we are not able to improve service accessibility. This is true for most trachoma affected communities globally. Like you said, one way of doing this is through outreach programmes for those far from the regular services.
Creating a community based approach is important for...
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Esmael Habtamu Ali (Co-Lead Educator) made a comment
Hi everyone, welcome to this course. I am the co-lead educator. Looking forward to engaging in discussion with you all. I hope you will enjoy the course.
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Esmael Habtamu Ali (Co-Lead Educator) made a comment
Welldone, Mubarik. Any one with different view to this, please share us.
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Proper counseling for trichiasis cases has improved productivity in Amhara Region. Can you colleagues share us what strategies have you been using to improve TT surgery productivity in your areas?
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One barrier that prevented Yuol from accessing surgery probably is his lack of knowledge about the availability of surgical management for his condition.
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Dear Tatowela, such cases are difficult to manage as the eyelid (tarsus) will be short from repeated surgical scarring. These cases may need to be manged using different type of surgical procedure such as Posterior Lamellar Lengthening which involves elongating the posterior lamella using a graft. However, this surgical procedure can only be done by a skilled...
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Esmael Habtamu Ali (Co-Lead Educator) replied to [Learner left FutureLearn]
You may also want to see this page on posoperative care after trichiais surgery: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100476/pdf/jceh_29_94_038.pdf
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Abdurahaman, that is good point. In trachoma, hyper endemic settings it is not uncommon children with trichiasis. This certainly tells the severity of the condition in that area. Severe persistent inflammation from repeated chlamydial infection would accelerate the development of scarring and fibrosis in the tarsal conjunctiva leading to the development of...
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...can also be managed with epilation.
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Habtamu, you raised two important points. Tetracycline ointment is still widely used after trichiasis surgery. The WHO Trichiasis surgery training manual indicates that we should apply tetracycline eye ointment into the conjunctival sac and onto the wound. And, to give a single does Azithromycin (1gm) “if available”, along with paracetamol tablets....
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Selecting the right people is essential - People respected and accepted by their communities. In addition, they should have good communication skill so that they can give adequate information to the people in need of the service.
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Thats true Saleh, you may want to see the following study confirming this.
http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0004228
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John, one belief I know is that people think this is given from God. Therefore would rather accept it as it is and would not go to seek medical attention as they would not know that this is easily treatable. But this is not a particular scenario for trachoma or TT. There is also a similar belief for other blinding diseases such as cataract or Galucoma. There...
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John, I do not know if this particularly exists. Is there anyone who came across with such belief? Please share us.
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Thats great idea Akinola.
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Well explained, Akinola and Dr Leonard.
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Thanks Makoy. I definitely think that providing azithromycine after surgery (if available) is a good practice for such settings. This is also the current WHO guideline. In addition to what Christine already said (thanks Christine), adequate use of postoperative antibiotics might have played a major role in reducing the rate of postoperative infection.
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Hi Charles, glad that the BLTR is working well for you. Would you please reflect to the group on the following questions? How do you manage TT cases with one or two misdirected lashes? Do you still operate on them? How do you manage recurrent cases with short eyelids from previous surgery?
You may want to see the following papers on the evidence for...
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Hi Annie, good question. The current WHO guideline on this is using both topical antibiotic (tetracycline ye ointment) and single dose (1gm) oral azithromycine (if available). However, until recently most programmes usually do not have access to azithromycine for use after surgery, so tend to give only the ointment to patients to be applied for two weeks.
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You may also want to take similar approach to address shortage of surgical materials. As you said, shortage of surgical sets is always frustrating particularly in areas where the uptake of surgery is high. Patient are usually impatient and want to get the service immediately. In such situations, we should plan how many patients we would expect, then therefore...
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Gbresselassie, I had a chance to visit your programme. You are doing already a great job. Again, the two challenges you raised are common concerns for other surgical programmes too. You may have already tried this, but I think both can be resolved with adequate planning. In some settings, it is not the number of the surgeons that is bothering, but their...
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Dear Gebreselassie
You raised a very practical question.
I am glad that the TT surgeons like the PLTR. This is in line with the evidence available. It’s true one extra silk is needed to evert the eyelid when using PLTR. Some may perceive this as its disadvantage as this may seem to add cost to the PLTR surgery. However, the PLTR surgery is probably rather... -
Nicola, yes recurrence or postoperative TT is currently a huge concern for trachoma control programmes. More is required on improving the quality of surgery. The prevalence for recurrent TT from different studies is between 10% - 20% at one year; and up to 60% at around 3 - 4 years.
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Makoy, in most cases it will completely heal within 2 - 4 weeks. However, its is strongly advised to examine operated cases on the next day after surgery, at 7 - 14 days (mainly to remove suture if unabsorbable material is used), and then at a round 3 - 6months later. However, it is also important to note that we can not keep patients for long for follow-up or...
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Rukkaiya, thats great. This is actually what has been done in the Eye Ambassadors Programme. The people selected to find and counsel the cases should be accepted by the community.
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Thats great idea Oluchi. In some communities people want to hear from their own community members about the surgery before they go to the health facility or access a health professional. They usually want to hear the perception of their community towards the service and surgery being provided; from people who themselves had the surgery. Want to ask how it...
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Thats correct Akinola. What other factors do you think would influence uptake of TT surgery?
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In the meantime you may want to read the following documents. https://www.cartercenter.org/resources/pdfs/health/trachoma/women_trachoma.pdfhttp://www.gawh.org/publications/trach-e.pdf
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Constance and Akinola, you raised a very important question. This is mainly because women in low income settings have increased time of contact with children (care giving) infected with trachoma. You will learn from week 3 that children are the reservoir of trachoma infection. Other factors may include women's poor socio-economic status (less able to access...
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All all of the video chapters can be accessed from here: https://vimeo.com/channels/trachomasurgery/videos
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Hi Kevin, there is a trichiasis surgery training video prepared by ICEH. This has been distributed for trachoma control programmes worldwide. You can access this video online via this link: https://vimeo.com/channels/trachomasurgery
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Its true Lana. Programmes consider to go to the patients for follow-up as well.
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The Amhara Regional Health Bureau - Carter Center Trachoma Control Programme is providing training for lead TT Surgeons and midlevel eye care works to be supportive supervisors, so that they will be well versed on how to successfully condct the supportive supervision. Good step to improve both quantity and quality of the surgery.
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It is important that supportive supervision should be provided by someone who can give on the spot technical support, someone which can do quality surgery himself and solve any surgical quality issues. The trend in most programmes has been people with no any or adeqaute technical and supervision skills doing the supportive supervision. This should change.
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Thats correct Fatma. What might have worked in some settings may not work in others. We need to device the best suited method for our setting. Here, the Eye Ambassadors provided like first stage of counselling to get the the cases to the health facility. Then a more detailed explanation about the surgery and counselling was done by the Integrated Eye care...
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It will also be good to read the following articles to understand how TT affects the lives of affected comunities.
http://journals.plos.org/plosntds/article/file?id=10.1371/journal.pntd.0004254&type=printable
http://journals.plos.org/plosntds/article/file?id=10.1371/journal.pntd.0004228&type=printable -
Moungui, I do not think there is specific module for complications. But it is included in the WHO TT surgery manual (Yellow book), and often the trichiasis surgery training focus on practices such as identifying them and how to manage them ... etc.
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Patricia, thats is excellent suggestion. There are lots of established programmes with hundreds of surgeons already operating using the BLTR. Therefore, disrupting this existing system and retraining these will take time and needs other resources. In addition, it is the only large trial conducted to compare these two surgical procedures in area where PLTR is...
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Very important point Moungui!
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One suggestion is due to their frequent contact with children which are known to be the reservoir of C trachomatis. They touch their children eyes and then theirs, they share towels and clothes, they sleep together...etc. Then after the infection, they are also less likely to recieve medical attention for different reasons ranging from cultural beliefs and...
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Nasir, good question. This is under process. Programme people were not sure about its role as an alternative management for trichiasis. The evidence came out very recently.
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Mukula, good point. Epilation success is likely to be influenced by the epilator, the epilation forceps used and the severity of the trichiasis. Epilators should be well trained on how to epilate, with good vision and willingness to do it when required. The epilation forceps should be good quality that will allow easy gripping of the lash roots. The epilator...
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Paul, thank you for raising this important point. Would you guys like to give some suggestions for this?
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Samantha, thats good thought. The surgery will only take about 20 minutes for one eyelid.
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Saad, sorry I only can tell you figures, (Such as The recent WHO figures shows that both countries are affected by trachoma with more than 48,000 (Pakistan) and 83,000 (Afganistan) with TT, and millions in Pakistan at risk of active infection).
I would like to learn from you guys working in those countries about your first hand field experience. This will...
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Mukula, would you please kindly suggest one so that we will use it as a point for discussion?
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Saad, thats good. Lets discuss it in the coming couple of days.
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Saad and Hina, you raised a very good point. This is also true for many communities where they can not access surgery for so many reasons. The current WHO direction on this is offering Epilation as an alternative second line management to surgery for cases who do not have immediate access to surgery, refuse surgery for some reasons or for those with few...
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Julian, very interesting and sad story. Do you guys have similar interesting stories to share?
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Igbokwe and Denis, you raised good point. In almost all trachoma programmes the surgery is provided free of charge to the patients. However, in some areas there might be some costs. The point here is, either way we need to make this clear to the patients.
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Bridget, that is excellent point. These people would be perfect "Eye Ambassadors", sharing their communities about the surgery, its benefit...etc. I personally believe that this would even work better. The Amhara Region Trachoma Programme in Ethiopia is implementing such strategies. It is also important to note that Eye Ambassadors should be those respected by...
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Rosalie, that is an interesting point. However there is no data to support that assumption. I have personally seen many patients with successful surgery for long periods( more than 10-15 years). What we know right now is rate of recurrence increases with increasing time from surgery. The recurrence rate for TT might be as high as 60% within 3 to 4 years....
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Israj, thats good question. No medical treatment so far for TT.
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Jeewa, that is possible. But they may also have other reasons such as having very few misdirected lashes that may intermittently come into contact with the eyeball? In some areas, lack of awareness, being afraid or embarrassed to tell?. Can you think other possible reasons based on local context?
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Lukombo, thats very interesting question. There is no clear answer for this. The risk of blindness increases with severity of trichiasis. Patients with severe trichiasis would have a higher chance of developing corneal opacity within short time than those with minor/mild trichiasis. In addition the location of the trichiatic lashes would also be important....
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Aba, what you pointed out is true of most African countries. I hope you would get ideas from the next sections for some of your questions.
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Denise, you raised a good point. It is important to deliver what we promised to the community. Otherwise, this might create mistrust between the community and other providers. Currently, there is a huge worldwide effort led by WHO to scale-up surgical output and outcome. This in most country is hugely assisted by NGOs. I hope the NGOs in your area are also...
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Yes, I agree with this point. Corneal opacification from TT is irreversible. TT surgery is conducted mainly to avert the risk of blindness. I just want to add that some studies, however, showed TT surgery is significantly associated with improved vision after surgery. One clinical trial found that 58% (Burton et al, 2005) of the TT cases with TT surgery had...
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Hey guys, the text/table in the vidio on the recurrence rate between the two surgeries has been typed incorrectly. The rate of recurrence for the posterior lamellar tarsal rotation in that study was 12% while the rate for the Bilamellar tarsal rotation was 22%. Sorry if this has created any confusion.
