Elsevier

Ophthalmology

Volume 111, Issue 3, March 2004, Pages 578-584
Ophthalmology

Original article
Surgery for trichiasis by ophthalmologists versus integrated eye care workers: A randomized trial☆

https://doi.org/10.1016/j.ophtha.2003.06.030Get rights and content

Abstract

Objective

To study the outcome of bilamellar tarsal rotation (BTR) trichiasis surgery performed by ophthalmologists versus that done by integrated eye care workers (IECWs).

Design

Randomized prospective interventional trial.

Participants

Nine hundred eighty-two patients with various degrees of trachomatous trichiasis in central Ethiopia.

Methods

Trachomatous trichiasis patients in 3 woredas (districts) in central Ethiopia were enrolled. Trichiasis severity was graded. Patients were randomly assigned to surgery by 2 ophthalmologists and 2 IECWs. On the seventh day postoperatively, patients were evaluated for undercorrection or other complications. If trichiasis was present, it was considered a failure of surgery (technical failure), and patients were excluded from the follow-up study, but repeat surgery was performed. Those patients with good correction at the seventh day were examined again on the third and sixth months. Further follow-up evaluation is planned for the first, second, and third years postoperatively.

Main outcome measures

Recurrence rate, recurrence difference in the various grades, and difference between surgeries done by ophthalmic surgeons and those done by IECWs.

Results

In the third month of follow-up, it was possible to locate 713 (73.0%) of the operated patients. Eighty-one of 713 (11.4%) individuals and 94 of 1286 (5.4%) operated lids developed recurrent trichiasis in this period. There was a linear trend of recurrence with grading (severity) at baseline (χ2 = 22.017, P<0.001), but there was no difference in recurrence by age (χ2 =1.53, P = 0.9 at the third month; χ2 = 1.43, P = 0.9 at the sixth month). There was also no difference with regard to gender (0.38 < odds ratio < 1.14, P = 0.1). The recurrence observed in the group of individuals operated on by ophthalmologists at the 3-month follow-up was 47 (12.1%) lids, and the recurrence observed in the group operated on by the IECWs was 34 (9.9%) lids, with no statistically significant difference (χ2 =1.38, P = 0.24, 95% confidence interval [CI], −18% to 74%). At the 6-month follow-up, 43 (6.2%) persons had recurrence (95% CI, 4.4%–8%). There was no statistically significant difference between the 2 groups of surgeons at the 6-month point of follow-up examination (χ2 = 4.46, P = 0.2). The overall recurrence was 124 (14.3%) lids within the first 6 months.

Conclusion

Recurrent trichiasis is common, especially in cases where the degree of trichiasis is severe at baseline. This suggests that these patients may need surgical overcorrection to decrease the recurrence rate. The outcome of BTR surgery done by IECWs is similar to that of the ophthalmic surgeons. Because of these findings, we recommend that training of IECWs in trichiasis surgery may help to ameliorate the effects of the eye care worker shortage in developing countries.

Section snippets

Operational definitions

We employ the operational definitions of Melese and coworkers.22 The interobserver agreement level was high for the modified grading.

Results

Nine hundred eighty-two trichiasis patients were operated on; 90.6% were over 30 years of age, 3.2% were children younger than 15, and 77.2% were female. Out of the total of 1750 lids with trichiasis, based on the modified grading system, 1393 (79.6%) accounted for simple trichiasis (TT1); 355 (20.3%), entropion (TT2); and only 2 (0.001%), eyelid shortening or defective lid closure (TT3) (Table 1).

It was possible to measure VA in 956 (97.3%) of the patients from the total of 982 operated on.

Discussion

Eighty-eight percent of patients who came for surgery were between 30 and 74 years old. Other studies have also confirmed that the blinding complication of trachoma increases after middle age.3, 6, 4, 12 Women accounted for 77.2% of the patients. Different studies have revealed that women are affected more by blinding trachoma.3, 4, 8, 24, 25 We have not looked into the exact causes of low VA and blindness in these patients, but 39.6% of the patients had low VA (<6/18 to ≥3/60), and 10.6% were

Acknowledgements

The authors are grateful for the Gurage Zone Health Department's facilitation of the study.

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    • Cited by (0)

    ☆

    This research was supported by Pfizer, New York, New York.

    Manuscript no. 220300.

    The authors have no property or commercial interest to disclose.

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    Copyright © 2004 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.