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Trichiasis Update. Kilimanjaro Centre for Community Ophthalmology Moshi, Tanzania. Epidemiology & magnitude Ultimate intervention goals & annual targets Surgical procedures Training of surgeons Strategies to improve uptake Outcome of surgery Scaling up surgery. Magnitude of the problem.

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Presentation Transcript
slide1

Trichiasis Update

Kilimanjaro Centre for Community Ophthalmology

Moshi, Tanzania

slide2
Epidemiology & magnitude
  • Ultimate intervention goals & annual targets
  • Surgical procedures
  • Training of surgeons
  • Strategies to improve uptake
  • Outcome of surgery
  • Scaling up surgery
slide4

Vision loss

No vision loss

Corneal opacity

No corneal opacity

Success

Failure

Surgery

No surgery

Trichiasis

No trichiasis

Conjunctival scarring

2%

Progression to vision loss in trachoma

6%

ultimate intervention goals for surgery uig s
Ultimate intervention goals for surgery (UIG-S)
  • Indicates the total number of surgeries that must be done to eliminate blinding trachoma
  • Dynamic figures (based on current estimates)
  • Total UIG-S can be put into annual targets (AIG-S)
ultimate intervention goals for surgery uig s6
Ultimate intervention goals for surgery (UIG-S)

Example from a national perspective:

  • Tanzania (2005) = 54,000 (167,000) people with TT (UIG)
    • 2005 AIG = 6,000
    • Estimated # of people receiving surgery = 2,700
    • Coverage = 45%
  • Ghana (2005) = 9,900
    • 2005 AIG = 1,500
    • Estimated # of people receiving surgery = 780
    • Coverage = 55%
including uig s into district implementation plans
Including UIG-S into “district” implementation plans

Annual intervention goals part of VISION 2020 implementation plan

surgical procedures
Surgical procedures
  • Full-thickness incision of the tarsal plate and rotation of terminal tarsal strip 180º
    • Bilamellar tarsal rotation procedure (BTRP)
    • Unilamellar tarsal rotation procedure (Trabut)
  • Other procedures
    • Cuenod Nataf procedure
    • Epilation (non-surgical, immediate management)
training of trichiasis surgeons
Training of trichiasis surgeons
  • Trainers  ophthalmologists/well-trained

ophthalmic nurse

  • Trainees  ophthalmic nurse
  • Training guidelines  national guidelines
  • Certification  check list
  • Instruments  surgical instruments list
training of trichiasis surgeons11
Training of trichiasis surgeons
  • Selection criteria
    • Prior surgical experience
    • Knowledge of sterile techniques
    • Experience giving injections
    • Experience in eye examinations
  • Expectations of surgical productivity
    • According to national guidelines (30/month in Tanzania)
factors associated with high productivity of trichiasis surgeons
Factors associated with high productivity of trichiasis surgeons
  • Good supervision
  • “Pro-active” system for ensuring access to surgery
  • Adequate instruments and consumables
  • [based at “district” hospital & dedicated to eye care services]

How many surgeons do we need to meet our UIGs?

surgical failure recurrence following surgery
Surgical failure & recurrence following surgery
  • Surgical failure (within 3-6 months)
    • Technical skills of surgeon
    • Sutures used (type=silk; and number=4+)
    • Range 10-15%
  • Recurrence (>6 months following surgery)
    • Conjunctival scarring
    • Age of the patient
    • Duration since surgery
    • Range 15-45%

No difference in outcome of surgery by ophthalmologists or trained nurses

quality of surgery
Quality of surgery
  • Defined as:
    • Few surgical failures (adequate eversion)
    • Good cosmesis
  • Good quality of surgery can be achieved through:
    • Training supported by certification
    • Routine supervision of surgeons
    • Use of appropriate (and well-maintained) instruments and consumables
implications of surgical failure recurrence following surgery
Implications of surgical failure & recurrence following surgery
  • Monitoring short-term outcome critical to correct surgical failure
  • Certification and supervision of surgeons important to maintain quality
  • Patient education to focus on the possibility of recurrence
who needs surgery
Who needs surgery?
  • Anyone with one or more lash touching the eye?
  • Epilation until more severe trichiasis develops?
  • Where contact with eye care services infrequent?
  • Surgery for mild disease technically easier and has better outcome
observations
Observations
  • In many (not all) settings, females have higher prevalence of active disease
  • Women account for 60-85% of trichiasis cases (2-3 times higher than men)
  • Blindness due to trachoma about 3 times higher in women compared to men.
is access to surgery equal for men and women
Is access to Surgery equal for men and women?
  • Burden of need primarily for women
  • Measurable?
    • Need baseline data to know burden by sex
    • Need to monitor separately for men and women
  • Current evidence:
    • Yes….if….

….there are community-based efforts to encourage/enable use of trichiasis surgical services

barriers to use of eye care services are different for men women
Barriers to use of eye care services are different for men & women
  • Cost of using service (access to financial resources)
  • distance to services (ability to travel and need for assistance)
  • knowledge of service (awareness and literacy)
  • perceived “value” (social support)
  • fear of a poor outcome (cosmesis)
scaling up trichiasis surgery
At VISION 2020 implementation “district” (1+ million)

Determine UIG and set annual targets

Integrate with other eye care (surgical) services

Ensuring certification, good supervision and support to surgeons (set targets for surgeons)

Active screening necessary; “bridging strategy” needed (dependency on specific/dedicated TT funding).

Monitoring of surgical failure & patient counseling implemented

Scaling up trichiasis surgery