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Sheila K. West - One of the best experts on this subject based on the ideXlab platform.
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Potential Effect of Epilation on the Outcome of Surgery for Trachomatous Trichiasis.
Translational vision science & technology, 2019Co-Authors: Sandra Liliana Talero, Beatriz Munoz, Sheila K. WestAbstract:Purpose To evaluate the association of epilation before surgery on the surgical outcome in trachomatous Trichiasis (TT) patients. Methods As a secondary data analysis, 1452 patients enrolled in the STAR trial were categorized according to preoperative epilation status. The main outcome was recurrent Trichiasis after surgery. We used multivariable analysis, time-to-event analysis, and Cox proportional hazards model. Results Those who epilated prior to surgery tended to be older and female, with worse entropion at baseline. The proportion with postoperative Trichiasis was 7.7%, 8.8% in those who epilated versus 5.3% in those who did not (P = 0.03). Adjusting for age and sex, the risk of postoperative TT with epilation was 1.71 (P value = 0.02). Although entropion may be in the biological pathway from epilation to postoperative TT, we adjusted for entropion, and the risk of postoperative TT with epilation was 1.41 (P = 0.14). Conclusions The study suggests that preoperative epilation may increase the risk of postoperative Trichiasis. Further research is needed to confirm the finding. Translational Relevance Patients with TT often self-treat, epilating their inturned eyelashes. The World Health Organization recommends surgery to treat TT, but when patients refuse the procedure or mild Trichiasis is present, epilation is often recommended. There is some evidence that repetitive or improper epilation can be harmful to the lid and hair follicles. If there is damage to the lid margin, any subsequent surgery could have deleterious outcomes.
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corneal sensitivity and presence of pathogenic organisms among participants who have undergone Trichiasis surgery differ by surgical outcome
Cornea, 2016Co-Authors: Yvette Schein, Sheila K. West, Jennifer C Harding, Shannath L Merbs, Sandra D Cassard, Kasubi Mabula, Majid S Othman, Emily W GowerAbstract:PURPOSE To explore the potential association between reduced corneal sensation and/or conjunctival bacterial colonization and postoperative Trichiasis and eyelid contour abnormalities after corrective eyelid surgery among participants with a history of trachomatous Trichiasis. METHODS As an ancillary study to the Partnership for Rapid Elimination of Trachoma (PRET) Surgery Trial in southern Tanzania, we collected data on 580 PRET participants who had undergone Trichiasis surgery 1 year earlier and 200 age-group-matched individuals without Trichiasis. Assessments included eyelid status evaluation (presence and severity of postoperative Trichiasis and/or eyelid contour abnormality), corneal sensitivity by Cochet-Bonnet aesthesiometer, a questionnaire on symptoms of ocular irritation, and conjunctival microbiology. We divided PRET participants based on their eyelid status and compared results across PRET groups and versus normals. RESULTS PRET participants had reduced corneal sensitivity compared with age-matched normals (mean sensitivity ranged from 2.8 to 3.8 cm in PRET participants vs. 5.9 cm in normals), and increasing severity of postoperative Trichiasis was associated in a stepwise fashion with reduced corneal sensitivity (mean = 3.5 cm for mild and 2.6 cm for severe postoperative Trichiasis). Conjunctival colonization with pathogenic bacteria was also associated with more severe postoperative Trichiasis (Cochran-Armitage trend test P = 0.001) and with reduced corneal sensitivity (trend test P < 0.0001). Symptoms of ocular irritation were not associated with previous Trichiasis surgery, postoperative Trichiasis, or eyelid contour abnormality. CONCLUSIONS These findings indicate that reduced corneal sensitivity accompanies trachomatous Trichiasis and suggest that reduced corneal sensitivity may play an important role in the harboring of pathogenic bacteria on the ocular surface.
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lower postoperative scar height is associated with increased postoperative Trichiasis 1 year after bilamellar tarsal rotation surgery
Ophthalmic Epidemiology, 2015Co-Authors: Shannath L Merbs, Beatriz Munoz, Sheila K. West, Majid S Othman, Kathleen C Oktavec, Erin F Perlini, Emily W GowerAbstract:ABSTRACTPurpose: To investigate the relationship between postoperative scar height and surgical success of the bilamellar tarsal rotation (BLTR) procedure, commonly used to correct Trichiasis secondary to trachoma.Methods: Using data from the Partnership for the Rapid Elimination of Trachoma surgical trial, comparing the new trachomatous Trichiasis (TT) clamp with standard BLTR instrumentation, 145 sequential participants (245 eyelids) at their 1-year postoperative visit were examined. We measured internal and external scar heights from the upper eyelid margin for nasal, central and temporal sections and compared these to recurrence location at 1 year. We calculated odds of location-specific postoperative Trichiasis and examined possible risk factors associated with postoperative Trichiasis.Results: A total of 77 eyelids (31%) had postoperative Trichiasis, which most commonly occurred centrally. Regardless of instrumentation used, the closer the internal scar was to the eyelid margin, the higher the propo...
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definitions and standardization of a new grading scheme for eyelid contour abnormalities after Trichiasis surgery
PLOS Neglected Tropical Diseases, 2012Co-Authors: Emily W Gower, Beatriz Munoz, Sheila K. West, Jennifer C Harding, Sandra D Cassard, Shannath L MerbsAbstract:Background Clear definitions of outcomes following Trichiasis surgery are critical for planning program evaluations and for identifying ways to improve Trichiasis surgery. Eyelid contour abnormality is an important adverse outcome of surgery; however, no standard method has been described to categorize eyelid contour abnormalities. Methodology/Principal Findings A classification system for eyelid contour abnormalities following surgery for trachomatous Trichiasis was developed. To determine whether the grading was reproducible using the classification system, six-week postoperative photographs were reviewed by two senior graders to characterize severity of contour abnormalities. Sample photographs defining each contour abnormality category were compiled and used to train four new graders. All six graders independently graded a Standardization Set of 75 eyelids, which included a roughly equal distribution across the severity scale, and weighted kappa scores were calculated. Two hundred forty six-week postoperative photographs from an ongoing clinical trial were randomly selected for evaluating agreement across graders. Two months after initial grading, one grader regraded a subset of the 240 photographs to measure longer-term intra-observer agreement. The weighted kappa for agreement between the two senior graders was 0.80 (95% CI: 0.71–0.89). Among the Standardization Set, agreement between the senior graders and the 4 new graders showed weighted kappa scores ranging from 0.60–0.80. Among 240 eyes comprising the clinical trial dataset, agreement ranged from weighted kappa 0.70–0.71. Longer-term intra-observer agreement was weighted kappa 0.86 (95% CI: 0.80–0.92). Conclusions/Significance The standard eyelid contour grading system we developed reproducibly delineates differing levels of contour abnormality. This grading system could be useful both for helping to evaluate Trichiasis surgery outcomes in clinical trials and for evaluating Trichiasis surgery programs.
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the trachomatous Trichiasis clamp a surgical instrument designed to improve bilamellar tarsal rotation procedure outcomes
Archives of Ophthalmology, 2012Co-Authors: Shannath L Merbs, Amir Bedri Kello, Sheila K. West, Hassan Gelema, Emily W GowerAbstract:The World Health Organization has endorsed the bilamellar tarsal rotation procedure to correct blinding trachomatous Trichiasis. Our field observations of bilamellar tarsal rotation have revealed some significant departures from this procedure as described in the World Health Organization manual. We designed the trachomatous Trichiasis clamp to address the shortcomings of the standard instrumentation and to help nonphysicians perform the procedure more safely, reproducibly, and successfully. The trachomatous Trichiasis clamp standardizes several aspects of the surgical technique that are not always performed consistently, providing guides for correct clamp and incision placement. A full-thickness eyelid incision can be made and sutures placed in a bloodless field. Two surgical technicians tested the trachomatous Trichiasis clamp in 10 patients and found that it was easier to use, shortened surgery time, allowed straighter and more precisely placed incisions, and offered excellent protection for the eye.
Beatriz Munoz - One of the best experts on this subject based on the ideXlab platform.
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Potential Effect of Epilation on the Outcome of Surgery for Trachomatous Trichiasis.
Translational vision science & technology, 2019Co-Authors: Sandra Liliana Talero, Beatriz Munoz, Sheila K. WestAbstract:Purpose To evaluate the association of epilation before surgery on the surgical outcome in trachomatous Trichiasis (TT) patients. Methods As a secondary data analysis, 1452 patients enrolled in the STAR trial were categorized according to preoperative epilation status. The main outcome was recurrent Trichiasis after surgery. We used multivariable analysis, time-to-event analysis, and Cox proportional hazards model. Results Those who epilated prior to surgery tended to be older and female, with worse entropion at baseline. The proportion with postoperative Trichiasis was 7.7%, 8.8% in those who epilated versus 5.3% in those who did not (P = 0.03). Adjusting for age and sex, the risk of postoperative TT with epilation was 1.71 (P value = 0.02). Although entropion may be in the biological pathway from epilation to postoperative TT, we adjusted for entropion, and the risk of postoperative TT with epilation was 1.41 (P = 0.14). Conclusions The study suggests that preoperative epilation may increase the risk of postoperative Trichiasis. Further research is needed to confirm the finding. Translational Relevance Patients with TT often self-treat, epilating their inturned eyelashes. The World Health Organization recommends surgery to treat TT, but when patients refuse the procedure or mild Trichiasis is present, epilation is often recommended. There is some evidence that repetitive or improper epilation can be harmful to the lid and hair follicles. If there is damage to the lid margin, any subsequent surgery could have deleterious outcomes.
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lower postoperative scar height is associated with increased postoperative Trichiasis 1 year after bilamellar tarsal rotation surgery
Ophthalmic Epidemiology, 2015Co-Authors: Shannath L Merbs, Beatriz Munoz, Sheila K. West, Majid S Othman, Kathleen C Oktavec, Erin F Perlini, Emily W GowerAbstract:ABSTRACTPurpose: To investigate the relationship between postoperative scar height and surgical success of the bilamellar tarsal rotation (BLTR) procedure, commonly used to correct Trichiasis secondary to trachoma.Methods: Using data from the Partnership for the Rapid Elimination of Trachoma surgical trial, comparing the new trachomatous Trichiasis (TT) clamp with standard BLTR instrumentation, 145 sequential participants (245 eyelids) at their 1-year postoperative visit were examined. We measured internal and external scar heights from the upper eyelid margin for nasal, central and temporal sections and compared these to recurrence location at 1 year. We calculated odds of location-specific postoperative Trichiasis and examined possible risk factors associated with postoperative Trichiasis.Results: A total of 77 eyelids (31%) had postoperative Trichiasis, which most commonly occurred centrally. Regardless of instrumentation used, the closer the internal scar was to the eyelid margin, the higher the propo...
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definitions and standardization of a new grading scheme for eyelid contour abnormalities after Trichiasis surgery
PLOS Neglected Tropical Diseases, 2012Co-Authors: Emily W Gower, Beatriz Munoz, Sheila K. West, Jennifer C Harding, Sandra D Cassard, Shannath L MerbsAbstract:Background Clear definitions of outcomes following Trichiasis surgery are critical for planning program evaluations and for identifying ways to improve Trichiasis surgery. Eyelid contour abnormality is an important adverse outcome of surgery; however, no standard method has been described to categorize eyelid contour abnormalities. Methodology/Principal Findings A classification system for eyelid contour abnormalities following surgery for trachomatous Trichiasis was developed. To determine whether the grading was reproducible using the classification system, six-week postoperative photographs were reviewed by two senior graders to characterize severity of contour abnormalities. Sample photographs defining each contour abnormality category were compiled and used to train four new graders. All six graders independently graded a Standardization Set of 75 eyelids, which included a roughly equal distribution across the severity scale, and weighted kappa scores were calculated. Two hundred forty six-week postoperative photographs from an ongoing clinical trial were randomly selected for evaluating agreement across graders. Two months after initial grading, one grader regraded a subset of the 240 photographs to measure longer-term intra-observer agreement. The weighted kappa for agreement between the two senior graders was 0.80 (95% CI: 0.71–0.89). Among the Standardization Set, agreement between the senior graders and the 4 new graders showed weighted kappa scores ranging from 0.60–0.80. Among 240 eyes comprising the clinical trial dataset, agreement ranged from weighted kappa 0.70–0.71. Longer-term intra-observer agreement was weighted kappa 0.86 (95% CI: 0.80–0.92). Conclusions/Significance The standard eyelid contour grading system we developed reproducibly delineates differing levels of contour abnormality. This grading system could be useful both for helping to evaluate Trichiasis surgery outcomes in clinical trials and for evaluating Trichiasis surgery programs.
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Three-year outcomes of the surgery for Trichiasis, antibiotics to prevent recurrence trial.
Archives of ophthalmology (Chicago Ill. : 1960), 2011Co-Authors: Fasika A. Woreta, Beatriz Munoz, Wondu Alemayehu, Emily W Gower, Sheila K. WestAbstract:Trachoma is the leading infectious cause of blindness, accounting for 15.5% of blindness worldwide.1 It is caused by infection with the bacterium Chlamydia trachomatis, with years of repeated infection leading to a chronic follicular conjunctivitis, which may result in scarring of the eyelid and in-turned lashes rubbing the globe. This condition, known as trachomatous Trichiasis, may result in corneal scarring and eventual blindness.1 The World Health Organization (WHO) estimates that more than 6 million people are blind from trachoma. In regions where trachoma is hyperendemic, such as in Ethiopia, the prevalence of Trichiasis in adults has been reported to be as high as 7%.2 The WHO has endorsed a multifaceted strategy for eliminating trachoma by the year 2020; this strategy consists of surgical correction of Trichiasis, antibiotic use, facial cleanliness, and environmental improvement (SAFE).3,4 Bilamellar tarsal rotation is the current standard operation recommended by the WHO for correction of Trichiasis because it has been shown to be more effective than electrolysis or cryoablation.5 However, Trichiasis recurrence rates following surgery have been reported to be as high as 28% to 56% at 1 to 3 years in various studies.6-9 One-year data from a randomized trial of patients with Trichiasis (the Surgery for Trichiasis, Antibiotics to Prevent Recurrence [STAR] trial) demonstrated that a single 1-g dose of oral azithromycin compared with the administration of topical tetracycline twice per day for 6 weeks (control group) was effective in reducing the recurrence of Trichiasis by 33% 1 year after surgery.10 The specific objectives of our study were to determine the 3-year rates of Trichiasis recurrence in this trial and to assess whether the protective effect of azithromycin was still evident 3 years after surgery.
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Rates and Risk Factors for Unfavorable Outcomes 6 Weeks after Trichiasis Surgery
Investigative ophthalmology & visual science, 2011Co-Authors: Emily W Gower, Amir Bedri Kello, Beatriz Munoz, Alemush Imeru, Wondu Alemayehu, Shannath L Merbs, Sheila K. WestAbstract:Trachoma remains the leading infectious cause of blindness worldwide, with an estimate of over 1.3 million people blind and 8 million with Trichiasis, which puts them at risk of subsequent blindness.1,2 Repeated episodes of infection with Chlamydia trachomatis typically lead to conjunctival scarring. Scarring ultimately can lead to entropion and Trichiasis, which may lead to irreversible blindness if not surgically corrected. Previous research has shown that eyes with Trichiasis self-reported as being present for more than a year were 4.5 times more likely to have corneal opacity than eyes with incident Trichiasis self-reported to have occurred within the past year,3 highlighting the importance of timely surgical management. Surgical correction of trichiatic lashes is available in many countries. However, several studies have reported Trichiasis recurrence rates after surgery ranging from 10% to 42% within 1 year,4–10 and longer-term recurrence rates are often even higher.11–16 Severe Trichiasis at baseline has consistently been reported as a risk factor for Trichiasis recurrence,6,9,17,18 and several studies have reported an association between conjunctival inflammation at follow-up and Trichiasis recurrence.6,12,20,21 Investigations into some other risk factors for recurrence remain inconclusive. In a case–control study with 53 cases and 26 controls, Zhang et al.18 found an association between chlamydial infection and Trichiasis recurrence, while in a retrospective cohort study of 394 Trichiasis patients, West et al.12 found no association. Burton et al.6,19,21 have published multiple articles suggesting an association between bacterial infection and both incident Trichiasis and Trichiasis recurrence; these studies have not yet been repeated in areas of high trachoma endemicity. Numerous studies have suggested that Trichiasis recurrence after surgery is in part related to surgical skill or performance. A study of Trichiasis surgery patients conducted in The Gambia reported that 1-year recurrence rates varied significantly between surgeons (from 0% to 83%).6 In Tanzania, recurrence rates have varied significantly by district where the surgery was performed.12 This district-level variation may represent a difference in surgeon-related factors, since in four of the five districts studied, one surgeon in each district conducted most, if not all the surgeries in that district. Furthermore, Merbs et al.22 demonstrated that left eyelids were significantly more likely to have recurrence than right eyelids (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.0–2.1) and that recurrence was more common on the left side of the eyelid for both right and left eyes. All these studies suggest that recurrence in part may be due to surgical skill and technique, although exactly which aspects of the surgery most influence outcome are unclear. In any case, differences due to surgeon or aspects of the surgery may be evident very early in follow-up, whereas with longer follow-up other host and environmental factors have more time to contribute to unfavorable outcomes. The Surgery for Trichiasis Antibiotics to prevent Recurrence (STAR) clinical trial was conducted in southern Ethiopia to examine whether the use of single-dose oral azithromycin at the time of surgery for the patient alone and for the patient plus all household members reduces the risk of Trichiasis recurrence within 1 year, compared to 6 weeks of twice daily topical tetracycline, the current standard of care. This study showed a 33% reduction in Trichiasis recurrence to 1 year among patients treated with oral azithromycin9 and followed on the heels of two smaller studies which also evaluated the use of antibiotics at the time of surgery6,8 but found no association between treatment and overall recurrence at 1 year. Zhang et al.,8 however, reported a protective effect of azithromycin at one time point, among the subgroup with major Trichiasis at baseline. As part of the STAR trial, we evaluated risk factors for early Trichiasis recurrence and other unfavorable outcomes of Trichiasis surgery 6 weeks after surgery. This time interval was selected because we wanted to evaluate surgical factors during a period when infection was unlikely, because of the antibiotic treatment given at baseline.
Saul N. Rajak - One of the best experts on this subject based on the ideXlab platform.
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oral doxycycline for the prevention of postoperative trachomatous Trichiasis in ethiopia a randomised double blind placebo controlled trial
The Lancet Global Health, 2018Co-Authors: Esmael Habtamu, Amir Bedri Kello, David Mabey, Mulat Zerihun, Tariku Wondie, Sintayehu Aweke, Zerihun Tadesse, Bizuayehu Gashaw, Chrissy H Roberts, Saul N. RajakAbstract:Summary Background Trachomatous Trichiasis is treated surgically to prevent sight loss. Unfavourable surgical outcomes remain a major challenge. We investigated the hypothesis that doxycycline might reduce the risk of postoperative Trichiasis following surgery in patients with trachomatous Trichiasis through anti-matrix metalloproteinase and anti-inflammatory activity. Methods In this randomised, double-blind, placebo-controlled trial, adults (aged >18 years) with upper lid trachomatous Trichiasis in association with tarsal conjunctive scarring were recruited through community-based screening and surgical outreach campaigns in Ethiopia. Individuals who had previously had eyelid surgery were excluded. Participants were randomly assigned (1:1), with random block sizes of four or six, to receive oral doxycycline (100 mg once a day) or placebo for 28 days immediately after Trichiasis surgery. Randomisation was stratified by surgeon. Patients, investigators, surgeons, and all other study team members were masked to study group allocation and treatment. Participants were examined at 10 days, and 1, 6, and 12 months after surgery. The primary outcome was the cumulative proportion of individuals who developed postoperative Trichiasis by 12 months. Primary analyses were done in all participants who attended at least one of the four follow-up assessments. Safety analyses were done in all participants who attended either the 10 day or 1 month follow-up assessments. This trial is registered with the Pan African Clinical Trials Registry, number PACTR201512001370307. Findings Between Dec 21, 2015, and April 6, 2016, 1000 patients with Trichiasis were enrolled and randomly assigned to treatment (499 patients to doxycycline, 501 patients to placebo). All but one participant attended at least one follow-up assessment. Thus, 999 participants were assessed for the primary outcome: 498 in the doxycycline group and 501 in the placebo group. By month 12, 58 (12%) of 498 patients in the doxycycline group and 62 (12%) of 501 patients in the placebo group had developed postoperative Trichiasis (adjusted odds ratio 0·91, 95% CI 0·61 to 1·34, p=0·63), with a risk difference of −0·5% (–4·5% to 3·5%). Significantly more patients in the doxycycline group had an adverse event than in the placebo group (18 [4%] of 498 vs six [1%] of 501; odds ratio 3·09, 95% CI 1·21–7·84; p=0·02). The most frequent adverse events in the doxycycline group were gastritis symptoms (n=9), constipation (n=4), and diarrhoea (n=4). Interpretation Doxycycline did not reduce the risk of postoperative Trichiasis and is therefore not indicated for the improvement of outcomes following trachomatous Trichiasis surgery. Surgical programmes should continue to make efforts to strengthen surgical training and supervision to improve outcomes. Funding The Wellcome Trust.
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Absorbable Versus Silk Sutures for Surgical Treatment of Trachomatous Trichiasis in Ethiopia: A Randomised Controlled Trial
2016Co-Authors: Saul N. Rajak, Esmael Habtamu, Hele A. Weiss, Amir Bedri Kello, Teshome Gebre, Asra Gene, Robi L. Ailey, David C. W. Mabey, Peng T. Khaw, Clare E. GilbeAbstract:Background: Trachoma causes blindness through an anatomical abnormality called Trichiasis (lashes touching the eye). Trichiasis can recur after corrective surgery. We tested the hypothesis that using absorbable sutures instead of silk sutures might reduce the risk of recurrent disease among patients with major Trichiasis in a randomised trial. Methods and Findings: 1,300 individuals with major Trichiasis from rural villages in the Amhara Region of Ethiopia were recruited and assigned (1:1) by computer-generated randomisation sequence to receive Trichiasis surgery using either an absorbable suture (polyglactin-910) or silk sutures (removed at 7–10 days) in an otherwise identical surgical technique. Participants were examined every 6 months for 2 years by clinicians masked to allocation. The primary outcome measure was recurrent Trichiasis ($one lash touching the eye) at 1 year. There was no difference in prevalence of recurrent Trichiasis at 1 year (114 [18.2%] in the absorbable suture group versus 120 [19.7%] in the silk suture group; odds ratio = 0.90, 95 % CI 0.68–1.20). The two groups also did not differ in terms of corneal opacification, visual acuity, conjunctival inflammation, and surgical complications. Conclusions: There was no evidence that use of absorbable polyglactin-910 sutures was associated with a lower prevalence of Trichiasis recurrence at 1 year postsurgery than silk sutures. However, from a programmatic perspective, polyglactin-910 offers the major advantage that patients do not have to be seen soon after surgery for suture removal. The postoperativ
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Trachomatous Trichiasis and its Management in Endemic Countries
Survey of ophthalmology, 2012Co-Authors: Saul N. Rajak, J. Richard O. Collin, Matthew J. BurtonAbstract:Trichiasis is the sight-threatening consequence of conjunctival scarring in trachoma, the most common infectious cause of blindness worldwide. Trachomatous Trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, Trichiasis, and ultimately blinding corneal opacification. The disease causes painful, usually irreversible sight loss. Over eight million people have trachomatous Trichiasis, mostly those living in poor rural communities in 57 endemic countries. The global cost is estimated at US$ 5.3 billion. The WHO recommends surgery as part of the SAFE strategy for controlling the disease.We examine the principles of clinical management, treatment options, and the challenging issues of providing the quantity and quality of surgery that is needed in resource-poor settings.
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Surgery versus epilation for the treatment of minor Trichiasis in ethiopia: a randomised controlled noninferiority trial.
PLoS medicine, 2011Co-Authors: Saul N. Rajak, Esmael Habtamu, Hele A. Weiss, Amir Bedri Kello, Teshome Gebre, David C. W. Mabey, Peng T. Khaw, Asrat Genet, Robin L. Bailey, Clare GilbertAbstract:Background: Trachomatous Trichiasis can cause corneal damage and visual impairment. WHO recommends surgery for all cases. However, in many regions surgical provision is inadequate and patients frequently decline. Self-epilation is common and was associated with comparable outcomes to surgery in nonrandomised studies for minor Trichiasis (,six lashes touching eye). This trial investigated whether epilation is noninferior to surgery for managing minor Trichiasis. Methods and Findings: 1,300 individuals with minor Trichiasis from Amhara Regional State, Ethiopia were recruited and randomly assigned (1:1) to receive Trichiasis surgery or epilation. The epilation group were given new forceps and epilation training. The surgical group received Trichiasis surgery. Participants were examined every 6 months for 2 years by clinicians masked to allocation, with 93.5% follow-up at 24 months. The primary outcome measure (‘‘failure’’) was $five lashes touching the eye or receiving Trichiasis surgery during 24 months of follow-up, and was assessed for noninferiority with a 10% prespecified noninferiority margin. Secondary outcomes included number of lashes touching, time to failure, and changes in visual acuity and corneal opacity. Cumulative risk of failure over 24 months was 13.2% in the epilation group and 2.2% in the surgical group (risk difference=11%). The 95% confidence interval (8.1%–13.9%) includes the 10% noninferiority margin. Mean number of lashes touching the eye was greater in the epilation group than the surgery group (at 24 months 0.95 versus 0.09, respectively; p,0.001); there was no difference in change in visual acuity or corneal opacity between the two groups. Conclusions: This trial was inconclusive regarding inferiority of epilation to surgery for the treatment of minor Trichiasis, relative to the prespecified margin. Epilation had a comparable effect to surgery on visual acuity and corneal outcomes. We suggest that surgery be performed whenever possible but epilation be used for treatment of minor Trichiasis patients without access to or declining surgery. Trial registration: http://ClinicalTrials.gov NCT00522912
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Absorbable Versus Silk Sutures for Surgical Treatment of Trachomatous Trichiasis in Ethiopia: A Randomised Controlled Trial
PLoS medicine, 2011Co-Authors: Saul N. Rajak, Esmael Habtamu, Hele A. Weiss, Amir Bedri Kello, Teshome Gebre, Peng T. Khaw, Asrat Genet, Robin L. Bailey, David Mabey, Clare GilbertAbstract:Background: Trachoma causes blindness through an anatomical abnormality called Trichiasis (lashes touching the eye). Trichiasis can recur after corrective surgery. We tested the hypothesis that using absorbable sutures instead of silk sutures might reduce the risk of recurrent disease among patients with major Trichiasis in a randomised trial. Methods and Findings: 1,300 individuals with major Trichiasis from rural villages in the Amhara Region of Ethiopia were recruited and assigned (1:1) by computer-generated randomisation sequence to receive Trichiasis surgery using either an absorbable suture (polyglactin-910) or silk sutures (removed at 7–10 days) in an otherwise identical surgical technique. Participants were examined every 6 months for 2 years by clinicians masked to allocation. The primary outcome measure was recurrent Trichiasis ($one lash touching the eye) at 1 year. There was no difference in prevalence of recurrent Trichiasis at 1 year (114 [18.2%] in the absorbable suture group versus 120 [19.7%] in the silk suture group; odds ratio=0.90, 95% CI 0.68–1.20). The two groups also did not differ in terms of corneal opacification, visual acuity, conjunctival inflammation, and surgical complications. Conclusions: There was no evidence that use of absorbable polyglactin-910 sutures was associated with a lower prevalence of Trichiasis recurrence at 1 year postsurgery than silk sutures. However, from a programmatic perspective, polyglactin-910 offers the major advantage that patients do not have to be seen soon after surgery for suture removal. The postoperative review after surgery using absorbable polyglactin-910 sutures can be delayed for 3–6 months, which might allow us to better determine whether a patient needs additional surgery. Trial registration: http://ClinicalTrials.gov NCT00522860 Please see later in the article for the Editors’ Summary.
Emily W Gower - One of the best experts on this subject based on the ideXlab platform.
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corneal sensitivity and presence of pathogenic organisms among participants who have undergone Trichiasis surgery differ by surgical outcome
Cornea, 2016Co-Authors: Yvette Schein, Sheila K. West, Jennifer C Harding, Shannath L Merbs, Sandra D Cassard, Kasubi Mabula, Majid S Othman, Emily W GowerAbstract:PURPOSE To explore the potential association between reduced corneal sensation and/or conjunctival bacterial colonization and postoperative Trichiasis and eyelid contour abnormalities after corrective eyelid surgery among participants with a history of trachomatous Trichiasis. METHODS As an ancillary study to the Partnership for Rapid Elimination of Trachoma (PRET) Surgery Trial in southern Tanzania, we collected data on 580 PRET participants who had undergone Trichiasis surgery 1 year earlier and 200 age-group-matched individuals without Trichiasis. Assessments included eyelid status evaluation (presence and severity of postoperative Trichiasis and/or eyelid contour abnormality), corneal sensitivity by Cochet-Bonnet aesthesiometer, a questionnaire on symptoms of ocular irritation, and conjunctival microbiology. We divided PRET participants based on their eyelid status and compared results across PRET groups and versus normals. RESULTS PRET participants had reduced corneal sensitivity compared with age-matched normals (mean sensitivity ranged from 2.8 to 3.8 cm in PRET participants vs. 5.9 cm in normals), and increasing severity of postoperative Trichiasis was associated in a stepwise fashion with reduced corneal sensitivity (mean = 3.5 cm for mild and 2.6 cm for severe postoperative Trichiasis). Conjunctival colonization with pathogenic bacteria was also associated with more severe postoperative Trichiasis (Cochran-Armitage trend test P = 0.001) and with reduced corneal sensitivity (trend test P < 0.0001). Symptoms of ocular irritation were not associated with previous Trichiasis surgery, postoperative Trichiasis, or eyelid contour abnormality. CONCLUSIONS These findings indicate that reduced corneal sensitivity accompanies trachomatous Trichiasis and suggest that reduced corneal sensitivity may play an important role in the harboring of pathogenic bacteria on the ocular surface.
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lower postoperative scar height is associated with increased postoperative Trichiasis 1 year after bilamellar tarsal rotation surgery
Ophthalmic Epidemiology, 2015Co-Authors: Shannath L Merbs, Beatriz Munoz, Sheila K. West, Majid S Othman, Kathleen C Oktavec, Erin F Perlini, Emily W GowerAbstract:ABSTRACTPurpose: To investigate the relationship between postoperative scar height and surgical success of the bilamellar tarsal rotation (BLTR) procedure, commonly used to correct Trichiasis secondary to trachoma.Methods: Using data from the Partnership for the Rapid Elimination of Trachoma surgical trial, comparing the new trachomatous Trichiasis (TT) clamp with standard BLTR instrumentation, 145 sequential participants (245 eyelids) at their 1-year postoperative visit were examined. We measured internal and external scar heights from the upper eyelid margin for nasal, central and temporal sections and compared these to recurrence location at 1 year. We calculated odds of location-specific postoperative Trichiasis and examined possible risk factors associated with postoperative Trichiasis.Results: A total of 77 eyelids (31%) had postoperative Trichiasis, which most commonly occurred centrally. Regardless of instrumentation used, the closer the internal scar was to the eyelid margin, the higher the propo...
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definitions and standardization of a new grading scheme for eyelid contour abnormalities after Trichiasis surgery
PLOS Neglected Tropical Diseases, 2012Co-Authors: Emily W Gower, Beatriz Munoz, Sheila K. West, Jennifer C Harding, Sandra D Cassard, Shannath L MerbsAbstract:Background Clear definitions of outcomes following Trichiasis surgery are critical for planning program evaluations and for identifying ways to improve Trichiasis surgery. Eyelid contour abnormality is an important adverse outcome of surgery; however, no standard method has been described to categorize eyelid contour abnormalities. Methodology/Principal Findings A classification system for eyelid contour abnormalities following surgery for trachomatous Trichiasis was developed. To determine whether the grading was reproducible using the classification system, six-week postoperative photographs were reviewed by two senior graders to characterize severity of contour abnormalities. Sample photographs defining each contour abnormality category were compiled and used to train four new graders. All six graders independently graded a Standardization Set of 75 eyelids, which included a roughly equal distribution across the severity scale, and weighted kappa scores were calculated. Two hundred forty six-week postoperative photographs from an ongoing clinical trial were randomly selected for evaluating agreement across graders. Two months after initial grading, one grader regraded a subset of the 240 photographs to measure longer-term intra-observer agreement. The weighted kappa for agreement between the two senior graders was 0.80 (95% CI: 0.71–0.89). Among the Standardization Set, agreement between the senior graders and the 4 new graders showed weighted kappa scores ranging from 0.60–0.80. Among 240 eyes comprising the clinical trial dataset, agreement ranged from weighted kappa 0.70–0.71. Longer-term intra-observer agreement was weighted kappa 0.86 (95% CI: 0.80–0.92). Conclusions/Significance The standard eyelid contour grading system we developed reproducibly delineates differing levels of contour abnormality. This grading system could be useful both for helping to evaluate Trichiasis surgery outcomes in clinical trials and for evaluating Trichiasis surgery programs.
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the trachomatous Trichiasis clamp a surgical instrument designed to improve bilamellar tarsal rotation procedure outcomes
Archives of Ophthalmology, 2012Co-Authors: Shannath L Merbs, Amir Bedri Kello, Sheila K. West, Hassan Gelema, Emily W GowerAbstract:The World Health Organization has endorsed the bilamellar tarsal rotation procedure to correct blinding trachomatous Trichiasis. Our field observations of bilamellar tarsal rotation have revealed some significant departures from this procedure as described in the World Health Organization manual. We designed the trachomatous Trichiasis clamp to address the shortcomings of the standard instrumentation and to help nonphysicians perform the procedure more safely, reproducibly, and successfully. The trachomatous Trichiasis clamp standardizes several aspects of the surgical technique that are not always performed consistently, providing guides for correct clamp and incision placement. A full-thickness eyelid incision can be made and sutures placed in a bloodless field. Two surgical technicians tested the trachomatous Trichiasis clamp in 10 patients and found that it was easier to use, shortened surgery time, allowed straighter and more precisely placed incisions, and offered excellent protection for the eye.
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Three-year outcomes of the surgery for Trichiasis, antibiotics to prevent recurrence trial.
Archives of ophthalmology (Chicago Ill. : 1960), 2011Co-Authors: Fasika A. Woreta, Beatriz Munoz, Wondu Alemayehu, Emily W Gower, Sheila K. WestAbstract:Trachoma is the leading infectious cause of blindness, accounting for 15.5% of blindness worldwide.1 It is caused by infection with the bacterium Chlamydia trachomatis, with years of repeated infection leading to a chronic follicular conjunctivitis, which may result in scarring of the eyelid and in-turned lashes rubbing the globe. This condition, known as trachomatous Trichiasis, may result in corneal scarring and eventual blindness.1 The World Health Organization (WHO) estimates that more than 6 million people are blind from trachoma. In regions where trachoma is hyperendemic, such as in Ethiopia, the prevalence of Trichiasis in adults has been reported to be as high as 7%.2 The WHO has endorsed a multifaceted strategy for eliminating trachoma by the year 2020; this strategy consists of surgical correction of Trichiasis, antibiotic use, facial cleanliness, and environmental improvement (SAFE).3,4 Bilamellar tarsal rotation is the current standard operation recommended by the WHO for correction of Trichiasis because it has been shown to be more effective than electrolysis or cryoablation.5 However, Trichiasis recurrence rates following surgery have been reported to be as high as 28% to 56% at 1 to 3 years in various studies.6-9 One-year data from a randomized trial of patients with Trichiasis (the Surgery for Trichiasis, Antibiotics to Prevent Recurrence [STAR] trial) demonstrated that a single 1-g dose of oral azithromycin compared with the administration of topical tetracycline twice per day for 6 weeks (control group) was effective in reducing the recurrence of Trichiasis by 33% 1 year after surgery.10 The specific objectives of our study were to determine the 3-year rates of Trichiasis recurrence in this trial and to assess whether the protective effect of azithromycin was still evident 3 years after surgery.
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3d images as a field grader training tool for trachomatous Trichiasis a diagnostic accuracy study in ethiopia
PLOS Neglected Tropical Diseases, 2019Co-Authors: Esmael Habtamu, Tariku Wondie, Zerihun Tadesse, Bizuayehu Gashaw, Hillary Rono, Temesgen Minas, Kelly E. Callahan, Jeremy Hoffman, David MacleodAbstract:Background Trachomatous Trichiasis (TT) will continue to develop among those people who have had repeated infections after active trachoma is controlled. Detecting and treating affected individuals will remain necessary for years; a long “tail” of incident cases is anticipated. As the prevalence of TT declines, there will be fewer cases available for training trachoma graders (TG), necessitating alternative methods. Methodology/Principal findings Prospective, diagnostic accuracy study assessing sensitivity and specificity of 3D and 2D photography as a tool for training TG to detect TT. Individuals with TT in Ethiopia were examined, and 2D and 3D clinical images taken. Images were independently graded by four graders for presence or absence of Trichiasis and compared to field grading. We recruited 153 participants. Clinical assessments and images were available for 306 eyes. Trichiasis was identified in 204 eyes by field grading. Image grading was performed on a selection of 262 eyes (131 with Trichiasis). Most eyes with Trichiasis had minor Trichiasis (94/131). Pooled sensitivity was 88.3% (3D) and 98.0% (2D); pooled specificity was 59.8% (3D) and 26.8% (2D). 3D photo grading was 33.0% more specific than the 2D photo grading (p = 0.0002). The overall Kappa scores were 0.48 (3D) and 0.25 (2D). We trained 26 novice TG in Ethiopia using 3D images. They were tested on a 3D images set and had 71.4% agreement (kappa 0.46), relative to an expert. They were then tested examining 50 people, and had 86.8% agreement (kappa 0.75). We also tested 27 experienced TG on the same cases (86.4% agreement, kappa 0.75). There was no difference in performance between groups (p = 0.76). All participants preferred 3D over 2D images for training. Conclusions/Significance The slightly higher sensitivity of 2D photos comes at considerable cost in specificity. Training with 3D images enabled novice TG to identify cases as well as experienced TG. 3D were preferred to conventional 2D photos for training. Standardized 3D images of TT could be a useful tool for training TG, in settings where there are now few TT cases.
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Trichiasis graders (a) practicing grading Trichiasis using 3D images, and (b) performing the intergrader 3D image test.
2019Co-Authors: Jeremy J. Hoffman, Esmael Habtamu, Tariku Wondie, Zerihun Tadesse, Bizuayehu Gashaw, Hillary Rono, Temesgen Minas, Kelly E. Callahan, David Macleod, Matthew J. BurtonAbstract:Trichiasis graders (a) practicing grading Trichiasis using 3D images, and (b) performing the intergrader 3D image test.
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3D images as a field grader training tool for trachomatous Trichiasis: A diagnostic accuracy study in Ethiopia - Fig 4
2019Co-Authors: Jeremy J. Hoffman, Esmael Habtamu, Tariku Wondie, Zerihun Tadesse, Bizuayehu Gashaw, Hillary Rono, Temesgen Minas, Kelly E. Callahan, David Macleod, Matthew J. BurtonAbstract:(A) False positives—distribution of the number of lashes considered to be touching from images, when no lashes were identified as touching by field grading. (B) False Negatives—distribution of the number of eyelashes touching the globe in cases of Trichiasis confirmed on field grading, which were classified as not having Trichiasis in the image grading (2D and 3D).
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oral doxycycline for the prevention of postoperative trachomatous Trichiasis in ethiopia a randomised double blind placebo controlled trial
The Lancet Global Health, 2018Co-Authors: Esmael Habtamu, Amir Bedri Kello, David Mabey, Mulat Zerihun, Tariku Wondie, Sintayehu Aweke, Zerihun Tadesse, Bizuayehu Gashaw, Chrissy H Roberts, Saul N. RajakAbstract:Summary Background Trachomatous Trichiasis is treated surgically to prevent sight loss. Unfavourable surgical outcomes remain a major challenge. We investigated the hypothesis that doxycycline might reduce the risk of postoperative Trichiasis following surgery in patients with trachomatous Trichiasis through anti-matrix metalloproteinase and anti-inflammatory activity. Methods In this randomised, double-blind, placebo-controlled trial, adults (aged >18 years) with upper lid trachomatous Trichiasis in association with tarsal conjunctive scarring were recruited through community-based screening and surgical outreach campaigns in Ethiopia. Individuals who had previously had eyelid surgery were excluded. Participants were randomly assigned (1:1), with random block sizes of four or six, to receive oral doxycycline (100 mg once a day) or placebo for 28 days immediately after Trichiasis surgery. Randomisation was stratified by surgeon. Patients, investigators, surgeons, and all other study team members were masked to study group allocation and treatment. Participants were examined at 10 days, and 1, 6, and 12 months after surgery. The primary outcome was the cumulative proportion of individuals who developed postoperative Trichiasis by 12 months. Primary analyses were done in all participants who attended at least one of the four follow-up assessments. Safety analyses were done in all participants who attended either the 10 day or 1 month follow-up assessments. This trial is registered with the Pan African Clinical Trials Registry, number PACTR201512001370307. Findings Between Dec 21, 2015, and April 6, 2016, 1000 patients with Trichiasis were enrolled and randomly assigned to treatment (499 patients to doxycycline, 501 patients to placebo). All but one participant attended at least one follow-up assessment. Thus, 999 participants were assessed for the primary outcome: 498 in the doxycycline group and 501 in the placebo group. By month 12, 58 (12%) of 498 patients in the doxycycline group and 62 (12%) of 501 patients in the placebo group had developed postoperative Trichiasis (adjusted odds ratio 0·91, 95% CI 0·61 to 1·34, p=0·63), with a risk difference of −0·5% (–4·5% to 3·5%). Significantly more patients in the doxycycline group had an adverse event than in the placebo group (18 [4%] of 498 vs six [1%] of 501; odds ratio 3·09, 95% CI 1·21–7·84; p=0·02). The most frequent adverse events in the doxycycline group were gastritis symptoms (n=9), constipation (n=4), and diarrhoea (n=4). Interpretation Doxycycline did not reduce the risk of postoperative Trichiasis and is therefore not indicated for the improvement of outcomes following trachomatous Trichiasis surgery. Surgical programmes should continue to make efforts to strengthen surgical training and supervision to improve outcomes. Funding The Wellcome Trust.
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Impact of Trichiasis surgery on daily living: A longitudinal study in Ethiopia
Wellcome Open Research, 2017Co-Authors: Esmael Habtamu, Mulat Zerihun, Paul M. Emerson, Tariku Wondie, Sintayehu Aweke, Zerihun Tadesse, Berhanu Melak, Bizuayehu Gashaw, Kelly Callahan, Robin L. BaileyAbstract:Background: Trachomatous Trichiasis (TT) may lead to disability, impeding productive activities, resulting in loss of income. This study was conducted to determine if Trichiasis surgery improves participation in productive and leisure activities, and ability to perform activities without difficulty or assistance. Methods: We recruited 1000 adults with Trichiasis (cases) and 200 comparison participants, matched to every fifth Trichiasis case on age (+/- two years), sex and location. The ‘Stylised Activity List’ tool, developed for the World Bank Living Standard Measurement Survey, was adapted to collect data on activity in the last week (participation in activity, difficulty with activity, requirement of assistance for activity), at baseline and 12 months later. All Trichiasis cases received Trichiasis surgery at baseline. Random effect logistic regression was used to compare cases and comparison participants. Results: There was strong evidence that Trichiasis surgery substantially improves the ability of Trichiasis cases to perform all the productive and leisure activities investigated without difficulty, with large increases in processing agricultural products, 21.1% to 87.0% (p<0.0001), farming, 19.1% to 82.4% (p<0.0001), and fetching wood, 25.3% to 86.0% (p<0.0001). Similarly, there was a significant increase in the proportion of cases who could perform activities without assistance, with the largest increases in animal rearing 54.2% to 92.0% (p<0.0001) and farming 73.2% to 96.4% (p<0.0001). There was no change in the proportion of comparison participants performing activities without difficulty or assistance. The change in most of the activities in cases was independent of visual acuity improvement and recurrent TT at 12 months. One year after Trichiasis surgery, the proportion of cases reporting ocular pain reduced from 98.9% to 33.7% (p<0.0001). Conclusions: Eyelid surgery for TT improves functional capabilities regardless of vision gains. These data lend strong support to the view that TT surgery improves function and contributes to improved household income and wealth.
