Victor Hu (facilitator)
Assistant Clinical Professor at the LSTHTM, Consultant Ophthalmologist at Mid Cheshire Hospitals UK (Glaucoma/Cornea) & Medical Editor of the Community Eye Health Journal
Location UK
Activity
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Very interesting case, hope she is doing well now
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Some good suggestions here
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Yes, this would be excellent. The Van Herrick test can give some information, but cannot replace gonioscopy.
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Yes, counselling is very important. This issue from the Community Eye Health Journal on glaucoma has an article on this, as well as other useful articles: https://www.cehjournal.org/update-on-glaucoma/
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Where would routine eye examinations take place in your context?
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A 90 dioptre lens is helpful (especially with smaller pupils), or something like 78 dioptre lens gives very good magnification and good detail of the disc. However, these lenses can be expensive
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Do you have any ideas on how to inform patients and the population better about glaucoma?
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Agree. The cost can be on many different levels as well
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Yes, these are major challenges in glaucoma care. Regular follow up and monitoring is required to work out the rate of progression. Humphrey Field Analysers have an option to look at change over time which can be helpful. What do you think might help improve patient adherence to treatment and returning for follow up?
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Can you let us know what you setting is? Very interesting that there is no name in the local language. Maybe this is something you work on?
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Yes, surgery is preferable where possible. However, for minor trichiasis, good quality epilation can also be helpful:
https://pubmed.ncbi.nlm.nih.gov/25768796/ -
Yes, good point, thank you. Integrating trachoma control within wider public health programmes could be very helpful, especially for the F and E components of the SAFE programme. Have you seen any examples of this has happened?
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Yes, auditing outcomes of surgery is very important. Poor outcomes can deter others from coming forward for surgery. Do you have any experience of looking at surgical outcomes?
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Do you have any thoughts on who should perform TT surgery, and where it should be done?
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Auditing outcomes is extremely outcome, but barriers can exist, do you have any thoughts on what these are and how they can be overcome?
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Great news for Ghana. Do you think there will still be an issue with incident trichiasis in the future?
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Good point. Are you aware of, or had any involvement, with projects or work on improving water supply?
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Victor Hu (facilitator) made a comment
The shortage of ophthalmologists is one of the challenges facing eye care delivery. What do you think about allied health care professionals doing TT surgery, eg. well trained nurses?
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Victor Hu (facilitator) made a comment
Dear Helen,
Good questions. Human volunteer studies and non-human primate studies have shown that on re-infection with ocular C. trachomatis there were more mild symptoms, and infection was cleared more quickly than on primary innoculation. However, this was serovar-specific. Cohort studies have shown that infection gets cleared more quickly in adults than... -
Victor Hu (facilitator) made a comment
It is sad to hear this story. It sounds as if he may have developed corneal opacity? This is very challenging to treat in most areas where trachoma is endemic. If epilation is performed well it can have a protective effect in earlier disease, for example, if surgery is not possible:
Epilation for minor trachomatous trichiasis: four-year results of a randomised... -
Yes, good point. There may be trichiasis for other reasons, and so everting the upper lid to check that there is actually conjunctival scarring consistent with trachoma is important. Some surveys previously may have over-estimated trichiasis from trachoma by not doing this.
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This is a good point. Azithromycin is only recommended from age 6 months as it was felt that safety below that age was not established. However, it probably is safe even in young infants and is actually recommended by the CDC for the treatment of pertussis. We also know that much of of the Chlamydial infection is in this very young age group and failure to...
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Taking a generator can also supply electricity for the light source.
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Some really interesting thoughts, it would be good to hear how the community based health insurance works out. Thanks
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Yes, I agree that monitoring is crucial, and being open about results (although this can be challenging in any part of the world!)
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What are your thoughts on how health care should be funded in trachoma endemic countries?
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Victor Hu (facilitator) replied to [Learner left FutureLearn]
If the skin wound or suture sites have healed then normal cleaning can be done - with soap or clean water. If the wound is still healing then ideally sterile gauze and water (eg. cooled boiled) should be used.
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Victor Hu (facilitator) replied to [Learner left FutureLearn]
Interesting point this, Jill. Eyelashes can grow back at an abnormal angle. However, I am not sure if eyelashes are effective in keeping flies out of the eyes. I have seen young children, with normal eyelashes, with their eyes covered with flies. The flies can be incredibly persistent and overcome the children's resistance to brushing them away (seeing this is...
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Instruments would be sterilised in an autclave. This would probably be done at a central base hospital/medical centre, but the the surgical team could carry surgical packs including the sterilised instruments to the community where surgery can be performed.
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Corneal opacity is very difficult to treat as this will probably require a corneal transplant operation. The cornea is donated from someone that has died and requires an eye bank. The cost of the cornea is currently in the region of £1600-£2500 from eye banks in Europe or the USA. The surgery is technically challenging requiring a highly trained corneal...
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Yes, this is a very good point. If patients with trichiasis see other patients who have not done well after surgery then this naturally puts them off going for surgery themselves, especially if they have to travel, have a fear of surgery, etc. This is why it is important to have properly trained trichiasis surgeons, and robust monitoring of outcomes. A high...
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Can I ask if you work in an urban area? Trachoma tends to be found in rural areas, with associations to poor access to water and poor facial hygiene. It would be interesting to see how much trachoma there is in more rural settings.
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An informative article on the two surgical techniques:
https://www.ncbi.nlm.nih.gov/pubmed/26774708 -
It would also be important to look at the evidence in the literature and the experience other people have had. The surgical video covers this, with the choices essentially between posterior lamellar and bilamellar tarsal rotation surgery.
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Esmael Ali may like to comment on this. There is some limited evidence for the role of azithromycin after TT surgery compared to tetracycline ointment:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3898462/
However, it would seem sensible to use some antibiotic postoperatively to prevent general bacterial infection. Something like 3 times a day for 1 week... -
Victor Hu (facilitator) replied to abram tong
What are your thoughts on this, Abram?
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I believe this will be covered in subsequent weeks. Any medication or antibiotic can have side effects as you point out. However, azithromycin is extremely safe, one of the very nice features about it and does not require direct medical supervision for distribution.
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As the article "How much trachoma is there?" pointed out, Trachoma is a public health problem if there Trachomatous trichiasis (TT) in ≥0.2% in adults aged 15 years and above. If the estimated trachoma backlog for India is correct, then trachoma would appear to be a public health problem for India, but further trachoma surveys are needed to get a better idea...
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What do you think might be the some of the answers to the barriers and challenges you have raised?
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Good quality training is indeed important, and this course signposts many useful resources. As highlighted, monitoring outcomes is also really important, and should be done in a non-critical, supportive manner.
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There are indeed many barriers for patients to undergo surgery. Some of these can be overcome if the trichiasis surgery can be performed in the community. Having a mobile surgical team is certainly possible as the surgery is not very high tech. A clean room is needed, and a good light source. Surgical instruments, drapes, couch, etc, can be transported.
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The Betty Kirkwood book is definitely recommended. As a clinical ophthalmologist I went on a couple of courses which gave some basic insight into statistical analysis and data handling. However, I found it was only when I engaged full time in research that the learning became more real. I went on the courses at the London School of Hygiene and Tropical...
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Victor Hu (facilitator) made a comment
Dear All,
Fantastic to have such interest in this course, and looking forward to having some engaging and interesting discussions and debates.
Best wishes,
Victor
