Optimising the management of trachomatous trichiasis
Authors: Anthony W Solomon
Journal: The Lancet Global Health (2016)

Caused by repeated ocular infection with the bacterium Chlamydia trachomatis, trachoma results in blindness in the poorest of the poor.1Habtamu E Wondie T Aweke S et al.Trachoma and relative poverty: a case-control study.PLoS Negl Trop Dis. 2015; 9: e0004228Google Scholar Going blind from trachoma is painful:2Palmer SL Winskell K Patterson AE et al.‘A living death’: a qualitative assessment of quality of life among women with trichiasis in rural Niger.Int Health. 2014; 6: 291-297Crossref Scopus (25) Google Scholar eyelashes from scarred eyelids abrade the cornea, and alterations in the tear film make the cornea vulnerable to destructive secondary bacterial and fungal infections. Sufferers often pull out their own misdirected eyelashes if they are unable to access, unwilling to request, or unaware of the availability of the operations that might reposition those eyelashes and save their sight. In the 1937 instalment of his landmark seven-volume Textbook of Ophthalmology, Duke-Elder3Duke-Elder WS Textbook of ophthalmology. Volume II: clinical methods of examination, congenital and developmental anomalies, general pathological and therapeutic considerations, diseases of the outer eye. Henry Kimpton, London1937Google Scholar was moved to note that trachoma was “an immense subject, in the literature replete with hypotheses, discussions, polemics, in the world pregnant with suffering, disability and blindness”. Over the ensuing eight decades, in more than 50 countries,4WHOWHO Alliance for the Global Elimination of Blinding Trachoma by the year 2020. Progress report on elimination of trachoma, 2013.Wkly Epidemiol Rec. 2014; 89: 421-428Google Scholar the suffering, disability, and blindness have, regrettably, endured. The world is fortunate that a handful of committed academic groups have continued to develop and test key hypotheses, too—and, generally, to avoid polemics. But real progress in the science of interventions against trachoma occurs infrequently, in part because funding for research on neglected diseases like trachoma has been very limited. In The Lancet Global Health, the randomised controlled trial by Esmael Habtamu and colleagues5Habtamu E Wondie T Aweke S et al.Posterior lamellar versus bilamellar tarsal rotation surgery for trachomatous trichiasis in Ethiopia: a randomised controlled trial.Lancet Glob Health. 2016; (published online Jan 13.)http://dx.doi.org/10.1016/S2214-109X(15)00299-5Google Scholar does represent real progress. It is arguably the most important work on trichiasis (the condition in which eyelashes touch the eye) since Reacher and colleagues,6Reacher MH Munoz B Alghassany A Daar AS Elbualy M Taylor HR A controlled trial of surgery for trachomatous trichiasis of the upper lid.Arch Ophthalmol. 1992; 110: 667-674Crossref PubMed Scopus (151) Google Scholar, 7Reacher MH Huber MJ Canagaratnam R Alghassany A A trial of surgery for trichiasis of the upper lid from trachoma.Br J Ophthalmol. 1990; 74: 109-113Crossref PubMed Scopus (71) Google Scholar working in Oman more than two decades ago, established bilamellar tarsal rotation (BLTR) as the management option of choice. However, the trials in Oman did not include as a comparator the technique of posterior lamellar tarsal rotation (PLTR) which, despite a lack of head-to-head data to judge its efficacy against that of BLTR, has continued to be widely used in some programmes in Africa. The current work provides those long-awaited data. Habtamu and colleagues provide a meticulous comparison of BLTR and PLTR. They identified PLTR-experienced surgeons and, after training and certifying them in BLTR, allowed a run-in period of 6 months and required repeat BLTR certification before commencing recruitment for the trial, to ensure that each surgeon was technically competent and experienced at both procedures. Randomisation was stratified by surgeon, to reduce any effect of differential surgical skill. The design, conduct, and analysis of the trial were exemplary, including exceptionally high follow-up rates, demonstration of repeatability of outcome measurement, and development and use of a method to assess outcomes masked to randomisation status—overcoming the problem posed by the association of one technique (BLTR) with a visible scar on the outer surface of the eyelid. The difference in outcomes is compelling. 1 year after surgery, the rate of recurrent trichiasis was 22% in those who had undergone BLTR, and 13% in those who had undergone PLTR: an absolute risk difference of 9·50% (95% CI 4·79–14·16). This is an incredibly important finding for programmes, for which the very high incidence of postoperative trichiasis (exceeding 60% at 3 years in one study,8Khandekar R Mohammed AJ Courtright P Recurrence of trichiasis: a long-term follow-up study in the Sultanate of Oman.Ophthalmic Epidemiol. 2001; 8: 155-161Crossref PubMed Scopus (71) Google Scholar with substantial variation between locations9West ES Mkocha H Munoz B et al.Risk factors for postsurgical trichiasis recurrence in a trachoma-endemic area.Invest Ophthalmol Vis Sci. 2005; 46: 447-453Crossref PubMed Scopus (52) Google Scholar) has for a long time represented a major disincentive to sign-up by prospective patients. Extrapolating this recurrence reduction to the management of the millions of people who need trichiasis surgery worldwide4WHOWHO Alliance for the Global Elimination of Blinding Trachoma by the year 2020. Progress report on elimination of trachoma, 2013.Wkly Epidemiol Rec. 2014; 89: 421-428Google Scholar suggests that use of PLTR could help to avert hundreds of thousands of cases of recurrent disease: a presentation that affords a management challenge even for experienced oculo-plastic surgeons. The implication is that surgeons who are yet to be trained should be trained to undertake PLTR rather than BLTR. Whether highly BLTR-experienced surgeons should be asked to retrain in the alternative technique is a separate question that should be prospectively addressed. A committed alliance4WHOWHO Alliance for the Global Elimination of Blinding Trachoma by the year 2020. Progress report on elimination of trachoma, 2013.Wkly Epidemiol Rec. 2014; 89: 421-428Google Scholar of ministries of health, non-governmental organisations, donors, and academics is now working tirelessly to try to achieve the World Health Assembly's target of elimination of trachoma as a public health problem by 2020.10World Health AssemblyGlobal elimination of blinding trachoma. 51st World Health Assembly, Geneva, May 16, 1998. Resolution WHA51.11. World Health Organization, Geneva1998Google Scholar The work by Habtamu and colleagues provides added impetus to that effort. I declare no competing interests. Posterior lamellar versus bilamellar tarsal rotation surgery for trachomatous trichiasis in Ethiopia: a randomised controlled trialPLTR surgery was superior to BLTR surgery for management of trachomatous trichiasis, and could be the preferred procedure for the programmatic management of trachomatous trichiasis. Full-Text PDF Open Access