Kilimanjaro Centre for Community Ophthalmology Moshi, Tanzania Trichiasis Update

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 Reference (year) Cases of active trachoma Trachoma blind Trachoma low vision WHO (1995)146 m6 m17 m Ransom & Evans (1996) 0.6 m2.9 m Frick (2000)3.7 m WHO (2003)81 m3 m

SurgeryNo surgery Conjunctival scarring TrichiasisNo trichiasisSuccess Failure Corneal opacity No corneal opacity Vision lossNo vision loss Progression to vision loss in trachoma 6% 2%

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-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%

Ultimate intervention goals for surgery (UIG-S) Gambia0 (surveillance only) Uganda90,000 Nigeria101,000 Pakistan (2 areas)27,000 Malawi? Kenya? Zambia?

Including UIG-S into district implementation plans RegionUIGAIG Kilimanjaro Arusha Manyara Shinyanga Mwanza Mara Annual intervention goals part of VISION 2020 implementation plan

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 Trainers ophthalmologists/well-trained ophthalmic nurse Trainees ophthalmic nurse Training guidelines national guidelines Certification check list Instruments surgical instruments list

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 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 (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 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 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? 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 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? 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 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)

Global surgical totals reported to WHO

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