Eyelid Contour Abnormalities Research Articles

The impact of modified incision height and surgical procedure on trichiasis surgery outcomes: Results of the maximizing trichiasis surgery success (MTSS) randomized trial.

Poor surgical outcomes remain a problem in trachoma-endemic countries working to reach elimination thresholds. Methods to improve outcomes could positively impact programmatic success. This parallel, three-armed clinical trial conducted in Ethiopia randomized individuals with previously unoperated trachomatous trichiasis (TT) to receive surgery utilizing one of three approaches: bilamellar tarsal rotation with a 3 mm incision height (BLTR-3), BLTR with 5 mm incision height (BLTR-5) and posterior lamellar tarsal rotation (PLTR). We followed participants for one year. The primary outcome was post-operative trichiasis (PTT). Secondary outcomes were eyelid contour abnormalities (ECA) and pyogenic granulomata. We randomized and operated on 4,914 individuals with previously unoperated TT (6,940 eyes). Primary analyses include 6,815 eyes with follow-up. Overall, 1,149 (16.9%) eyes developed PTT. The risk difference for PTT was minimal comparing BLTR-3 and PLTR (adjusted risk difference [aRD] 1.8% (98.3%CI: -0.5-4.2%)), but significantly higher for BLTR-5 surgeries compared to BLTR-3 (aRD: 6.7% (3.9-9.4%)) and PLTR (aRD: 8.6% (5.9-11.3%)). BLTR-5 had the lowest ECA (6.1% versus 9.6% BLTR-3, 11.2% PLTR) and granuloma rates (5.2% versus 6.5% BLTR-3 and 7.5% PLTR). One eyelid operated with PLTR experienced an eyelid margin division; four BLTR-3 and eight BLTR-5 eyelids experienced excessive bleeding. We do not recommend modifying the BLTR incision height of 3 mm. Overall, we did not find a significant difference in PTT between BLTR-3 and PLTR in terms of PTT or ECA. Registration number: NCT03100747; ClinicalTrials.gov Full study protocol available at (https://doi.org/10.15139/S3/QHZXWD).

The FLuorometholone as Adjunctive MEdical Therapy for Trachomatous Trichiasis Surgery (FLAME) Trial: Study Design.

To report the design of FL uorometholone as A djunctive ME dical Therapy for TT Surgery (FLAME) Trial. Parallel design, double-masked, placebo-controlled clinical trial with 1:1 randomization to fluorometholone 0.1% eyedrops twice daily or placebo twice daily for four weeks in eyes undergoing trachomatous trichiasis (TT) surgery; assessing the efficacy, safety, and cost-effectiveness of fluorometholone 0.1% in preventing recurrent postoperative trichiasis. Up to 2500 eligible persons with trachomatous trichiasis (TT) undergoing lid rotation surgery will be enrolled in Jimma zone, Ethiopia. Participants, surgeons, study field staff, and study supervisors leading operational aspects of the trial are masked to treatment assignment. Randomization is stratified by surgeon, which simultaneously stratifies by the district. The study visits are at baseline/enrollment, at four-week post-enrollment, six months, and one year (study exit). The primary outcome is cumulative one-year postoperative TT (PTT) incidence, defined as: ≥1 lashes touching the globe, evidence of epilation, and/or repeat TT surgery. Secondary postoperative outcomes include number of trichiatic lashes, location thereof (touching the cornea or not), evidence of post-operative epilation, entropion, changes in corneal opacity, IOP elevation, need for cataract surgery, visual acuity change from baseline, eyelid contour abnormality, granuloma, eyelid closure defect, and occurrence of adverse events. Health economic analyses center on calculating the incremental cost per case of PTT avoided by fluorometholone treatment. The FLAME Trial is designed to provide evidence of the efficacy, safety, and cost-effectiveness of adjunctive topical peri-/postoperative fluorometholone 0.1% therapy with trichiasis surgery, which is hypothesized to reduce the risk of recurrent trichiasis while being acceptably safe. Trial Registration: ClinicalTrials.gov # NCT04149210.

Diagnosis and Treatment of Lacrimal Gland Prolapse: A Narrative Review.

Lacrimal gland prolapse (LGP) is considered to be one of the causes for upper eyelid contour abnormality that should be recognized and treated properly to yield satisfactory outcomes in blepharoplasty. To describe current findings about the prevalence, pre- and intraoperative diagnosis of LGP and its treatment options. PubMed and Google Scholar were thoroughly searched for articles published describing the diagnosis and treatment of LGP. The reported prevalence of LGP by various authors varies between 10 and 60% based on their preoperative or intraoperative reports. Techniques such as dacryoadenopexy, modified dacryoadenopexy, and dacryoplasty have been described to secure the prolapsed lacrimal gland back into its original position. Additionally, creating a Whitnall's barrier has also been suggested as a method to reposition the gland. While all these surgical procedures have shown promising immediate results, there is a lack of published data on their long-term outcomes. Diagnosis and proper treatment of LGP could enhance the cosmetic results of upper eyelid blepharoplasty. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modified Levator Resection Technique for Moderate Congenital Blepharoptosis.

For moderate ptosis associated with fair levator function (LF), the levator resection is the most commonly used procedure. However, the levator resection technique still has some disadvantages, such as residual lagophthalmos (RL), undercorrection, conjunctival prolapse, and eyelid contour abnormality. To solve the above problems, our team have made modifications to the levator resection technique in three aspects: releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites. Fifty-seven patients (81 eyes) underwent the modified levator resection technique and were enrolled in the study. Preoperative data collected included age, sex, margin reflex distance 1 (MRD1), and LF. Postoperative data collected included MRD1, RL, patient satisfaction, complications, and length of follow-up. Mean MRD1 significantly increased from 1.45 ± 0.65 mm preoperatively to 3.57 ± 0.51 mm postoperatively. Mean LF significantly increased from 6.49 ± 1.12 mm preoperatively to 9.48 ± 1.39 mm postoperatively. Successful correction was obtained in 77 eyes (95.1%). Mean RL was 1.09 ± 0.57 and 72 eyes (88.9%) showed excellent or good eyelid closure function. Fifty-four patients (94.7%) were completely satisfied with the final result. Complications such as hematoma, infection, conjunctival prolapse, suture exposure, corneal abrasion, and keratitis were not found in any cases during follow-up. This modified levator resection technique introduced in this study is effective in correcting moderate congenital blepharoptosis, while minimizing RL, undercorrection, conjunctival prolapse, eyelid contour abnormality by releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites. This journal requires that authors 42 assign a level of evidence to each article. For a full 43 description of these Evidence-Based Medicine ratings, 44 please refer to the Table of Contents or the online 45 Instructions to Authors www.springer.com/00266 .

"Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis".

The conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos, eyebrow ptosis, eyelid contour abnormality, and under-correction. This article describes the authors' extended frontalis muscle advancement technique that takes extensive subcutaneous separation through the eyelid crease incision for the treatment of severe congenital blepharoptosis. A retrospective review was performed that included patients with severe congenital ptosis who underwent extended frontalis muscle advancement technique from April of 2019 to April of 2021. Preoperative evaluation included age, sex, and margin reflex distance 1 (MRD1), levator function, and lagophthalmos. Postoperative evaluation including correction result, closure function of eyelid, cosmetic result was performed at the last follow-up. From April of 2019 to April of 2021, a total of 102 patients (137 eyes) who underwent extended frontalis muscle advancement technique were included in the study. The mean postoperative MRD1 in unilateral and bilateral ptosis patients was 3.84 ± 0.60 mm and 3.86 ± 0.56, respectively, and 126 eyes (92.0 percent) showed successful correction. Postoperatively, the mean residual lagophthalmos was 0.88 ± 1.40 mm, and 127 eyes (92.7 percent) showed excellent or good eyelid closure function. The average score of cosmetic results was 8.29 ± 1.34, and 94 patients (92.2 percent) had an excellent or good cosmetic result. Extensive subcutaneous separation relieves the mutual restriction between the forehead skin and frontalis muscle. The extended frontalis muscle advancement technique is effective in correcting severe congenital ptosis, while minimizing under-correction, residual lagophthalmos, eyelid contour abnormality and eyebrow ptosis. Therapeutic, IV.

The conjunctival transcriptome in Ethiopians after trichiasis surgery: associations with the development of eyelid contour abnormalities and the effect of oral doxycycline treatment.

Background: Surgery to correct trichiasis is a key component of the World Health Organisation trachoma control strategy, however unfavourable outcomes such as eyelid contour abnormalities (ECA) following surgery are relatively common. This study aimed to understand the transcriptional changes associated with the early development of ECA and the impact of doxycycline, which has anti-inflammatory and anti-fibrotic properties, upon these transcription patterns. Methods: One thousand Ethiopians undergoing trichiasis surgery were enrolled in a randomised controlled trial following informed consent. Equal groups of randomly assigned individuals were orally administered with 100mg/day of doxycycline (n=499) or placebo (n=501) for 28 days. Conjunctival swabs were collected immediately prior to surgery and at one- and six-months post-surgery. 3' mRNA sequencing was performed on paired baseline and one-month samples from 48 individuals; 12 in each treatment/outcome group (Placebo-Good outcome, Placebo-Poor outcome, Doxycycline-Good outcome, Doxycycline-Poor outcome). qPCR validation was then performed for 46 genes of interest in 145 individuals who developed ECA at one month and 145 matched controls, using samples from baseline, one and six months. Results: All treatment/outcome groups upregulated genes associated with wound healing pathways at one month relative to baseline, however no individual differences were detected between groups. The summed expression of a highly coexpressed cluster of pro-fibrotic genes was higher in patients that developed ECA in the placebo group relative to controls. qPCR validation revealed that all genes in this cluster and a number of other pro-inflammatory genes were strongly associated with ECA, however these associations were not modulated by trial arm. Conclusions: The development of post-operative ECA is associated with overexpression of pro-inflammatory and pro-fibrotic genes including growth factors, matrix metalloproteinases, collagens and extracellular matrix proteins. There was no evidence that doxycycline modulated the association between gene expression and ECA.

Characteristics and perspectives of patients with postoperative trichiasis in Hadiya Zone, Ethiopia.

BackgroundPostoperative trachomatous trichiasis (PTT) is a challenge for trichiasis surgery programs. Little is known about PTT patients’ perceptions regarding outcomes and future disease management. This study aimed to understand the characteristics of PTT patients, how they managed trichiasis and their perceptions of prior surgeries and future surgery uptake.MethodsPatients with PTT were identified during an existing trichiasis screening program in Hadiya Zone, Ethiopia. A vision assessment and evaluation of the eyelids were conducted to determine distance vision, presence and severity of trichiasis and eyelid contour abnormalities. A questionnaire was administered to obtain information regarding patients’ perceptions of surgery and PTT management approaches. Descriptive statistics were used to characterize PTT and determine associations between PTT severity and patient perceptions.ResultsAmong 404 participants, most were female (79.7%) and aged 40–60 y (62.6%). In total, 514 eyelids had PTT, and nearly half had severe PTT (46.9%). Although >50% of participants were currently epilating to manage their PTT, the majority (82.8%) indicated that they wanted repeat surgery. Most participants indicated that pain persisted despite epilation. The majority (75.1%) indicated satisfaction with their prior surgery and 59.6% indicated that they would recommend surgery to others.ConclusionsThis study, which included a large proportion of severe PTT cases, indicated that individuals were generally satisfied with prior surgery and would prefer to have surgery again for PTT management.

Comparing the symmetry of upper eyelid following unilateral ptosis correction

BackgroundMargin Reflex Distance 1(MRD 1) only describes the central height of upper eyelid and relies on the examiner’s experience and disregards eyelid contour abnormalities. Therefore MRD 1 may not be sufficient for an acceptable result to evaluate the outcomes of ptosis surgery. The primary purpose of this study was to assess outcomes of unilateral ptosis correction based on parameters including degree of symmetry, MRD 1, peak height of the upper lid, temporal and nasal ocular surface area, and temporal/nasal area ratio with an objective, quantitative, and repeatable method.MethodsThis study was designed as a retrospective non-randomized case-control study. Medical records of the patients with unilateral ptosis between October 2015 and December 2020 were reviewed. Patients with unilateral ptosis who underwent surgical correction and levator function of 5 mm or greater were included in the study. Two groups were defined; ptotic eye was case group and contralateral eye was control group. Data analysis was performed Image J and Matlab softwares.ResultsThirty-four patients were included in the study. Mean age of patients was 58.8 ± 12.7 years (range 15–75 years). Mean follow-up time was 19.5 ± 7.3 months (range 8–40 months). Four patients were diagnosed with congenital ptosis and 30 patients aponeurotic ptosis. Mean preoperative degree of symmetry for overall eyelid contour was 36.6 ± 27.5% (range 1–92%). Mean postoperative degree of symmetry for overall eyelid contour was 72.4 ± 16.5% (range 55–92%). Temporal/Nasal (T/N) area ratios for contralateral normal eye was 1.19 pre-postoperative, and it was 1.11 preoperatively, 1.15 postoperatively for operated ptotic eye.ConclusionsThis study primarily demonstrated a quantitative, objective, and repeatable method to investigate the degree of symmetry after eyelid surgeries. Secondly, this study suggested that T/N ratio may not be a reliable parameter to evaluate the eyelid symmetry.

A New Surgical Technique for Postoperative Trachomatous Trichiasis.

The World Health Organization has identified management of postoperative trichiasis (PTT) as one of the key remaining areas of focus needed to eliminate blinding trachoma as a public health problem. We developed the Bevel-Rotation Advancement Procedure (B-RAP) to treat individuals who need repeat trichiasis surgery. Scarring caused by trichiasis surgery can cause the eyelid to become thick and distorted, making repeat surgery more difficult. To minimize eyelid thickness following B-RAP, a beveled incision of the tarsus is made allowing a marginal rotation of the eyelash fragment. Dissection between the anterior and posterior lamellae above the beveled incision and removal of scar tissue allows the marginal rotation to be combined with a posterior lamellar advancement to treat severely scarred eyelids with PTT and eyelid contour abnormalities (ECAs). Two surgeons performed B-RAP on 44 eyelids of 30 patients with PTT. The number of prior trachomatous trichiasis (TT) surgeries ranged from 2 to more than 4. At the 3-6 months postoperative visit, 37 eyelids (84%) had no recurrence of PTT. Three eyelids had central lashes touching; the remaining eyelids with recurrent PTT had nasal and temporal lashes touching. Fifteen eyelids (34%) had ECAs, but only 1 was severe. B-RAP was developed considering the altered eyelid anatomy found in the postsurgical eyelid with TT. Thinning of the eyelash fragment and removal of postoperative scar tissue improves the ability to advance and stabilize the eyelash fragment after external rotation. B-RAP shows promise as a procedure for improving outcomes of repeat trichiasis surgery.

Putting the Pieces Back Together: Optimizing Function and Appearance after Orbital Surgery.

Objectives To describe medical and surgical options and techniques for functional and aesthetic abnormalities after orbital surgery and multidisciplinary approaches that include the orbit. Design A review of current management options in outpatient clinics and ambulatory surgery centers with selected illustrative cases. The rationale for choosing specific medical and surgical interventions will be discussed with a focus on eyelid malposition and double vision. Setting Outpatient clinics and ambulatory surgery centers. Participants Patients with eyelid, orbital, eye muscle, and scalp contour abnormalities as a result of medical and surgical interventions for brain and/or orbital tumors. Main Outcome Measures Descriptive outcomes. Results A variety of medical and surgical options are available to optimize eyelid, orbit, extraocular muscle, and scalp structure and function.

Deep learning-based image analysis for automated measurement of eyelid morphology before and after blepharoptosis surgery

Background and aim Eyelid position and contour abnormality could lead to various diseases, such as blepharoptosis, which is a common eyelid disease. Accurate assessment of eyelid morphology is important in the management of blepharoptosis. We aimed to proposed a novel deep learning-based image analysis to automatically measure eyelid morphological properties before and after blepharoptosis surgery. Methods This study included 135 ptotic eyes of 103 patients who underwent blepharoptosis surgery. Facial photographs were taken preoperatively and postoperatively. Margin reflex distance (MRD) 1 and 2 of the operated eyes were manually measured by a senior surgeon. Multiple eyelid morphological parameters, such as MRD1, MRD2, upper eyelid length and corneal area, were automatically measured by our deep learning-based image analysis. Agreement between manual and automated measurements, as well as two repeated automated measurements of MRDs were analysed. Preoperative and postoperative eyelid morphological parameters were compared. Postoperative eyelid contour symmetry was evaluated using multiple mid-pupil lid distances (MPLDs). Results The intraclass correlation coefficients (ICCs) between manual and automated measurements of MRDs ranged from 0.934 to 0.971 (p < .001), and the bias ranged from 0.09 mm to 0.15 mm. The ICCs between two repeated automated measurements were up to 0.999 (p < .001), and the bias was no more than 0.002 mm. After surgery, MRD1 increased significantly from 0.31 ± 1.17 mm to 2.89 ± 1.06 mm, upper eyelid length from 19.94 ± 3.61 mm to 21.40 ± 2.40 mm, and corneal area from 52.72 ± 15.97 mm2 to 76.31 ± 11.31mm2 (all p < .001). Postoperative binocular MPLDs at different angles (from 0° to 180°) showed no significant differences in the patients. Conclusion This technique had high accuracy and repeatability for automatically measuring eyelid morphology, which allows objective assessment of blepharoptosis surgical outcomes. Using only patients’ photographs, this technique has great potential in diagnosis and management of other eyelid-related diseases.

Evaluation of Ocular Surface and Meibomian Glands in Patients With Scleroderma.

To evaluate the prevalence of dry eye and meibomian gland dysfunction in patients with scleroderma. A total of 32 patients with scleroderma (study group) and 31 healthy subjects (control group) were enrolled. Besides routine ophthalmologic evaluation, Schirmer 1 test, tear break-up time, tear osmolarity, ocular surface staining with fluorescein (Oxford score), and Ocular Surface Disease Index (OSDI) score, meibomian gland dysfunction evaluation (foamy tears, telangiectasia of the eyelid, eyelid contour abnormalities, and meibomian plugs), and meibography were performed. Sixty-four eyes of 32 patients with scleroderma and 62 eyes of 31 healthy individuals were evaluated. Mean ages of the study group was 48.34 ± 9.73 years (21-62 years) and of the control group was 45.84 ± 4.42 years (38-54 years) (P = 0.067). Mean duration of systemic sclerosis or scleroderma in study group was 9.78 ± 7.40 years (1-30 years). Mean tear break-up time was shorter in study group than that in the control group (P < 0.0005). No statistical differences were detected for osmolarity, OSDI score, and Schirmer 1 values between groups (P = 0.051, P = 0.053, and P = 0.358, respectively). The prevalence of grade 1 and higher Oxford score was higher in the study group (P < 0.0005). Upper meiboscores of grade 1 and higher were found to be more common in the study group than those in the control group (P = 0.036). The presence of foamy tears and telangiectasia of the eyelids were significantly higher in the study group (P = 0.002 and P = 0.002, respectively). OSDI score was the only significantly correlated data with disease duration (Spearman ρ coefficient = 0.396, P = 0.001). Evaporative type dry eye is more common in patients with scleroderma than the healthy population.

The conjunctival transcriptome in Ethiopians after trichiasis surgery: associations with the development of eyelid contour abnormalities and the effect of oral doxycycline treatment

Background: Surgery to correct trichiasis is a key component of the World Health Organisation trachoma control strategy, however unfavourable outcomes such as eyelid contour abnormalities (ECA) following surgery are relatively common. This study aimed to understand the transcriptional changes associated with the early development of ECA and the impact of doxycycline, which has anti-inflammatory and anti-fibrotic properties, upon these transcription patterns. Methods: One thousand Ethiopians undergoing trichiasis surgery were enrolled in a randomised controlled trial following informed consent. Equal groups of randomly assigned individuals were orally administered with 100mg/day of doxycycline (n=499) or placebo (n=501) for 28 days. Conjunctival swabs were collected immediately prior to surgery and at one- and six-months post-surgery. 3’ mRNA sequencing was performed on paired baseline and one-month samples from 48 individuals; 12 in each treatment/ECA outcome group. qPCR validation was then performed for 46 genes of interest in 145 individuals who developed ECA at one month and 145 matched controls, using samples from baseline, one and six months. Results: All treatment/outcome groups upregulated genes associated with wound healing pathways at one month relative to baseline, however no individual differences were detected between groups. The summed expression of a highly coexpressed cluster of pro-fibrotic genes was higher in patients that developed ECA in the placebo group relative to controls. qPCR validation revealed that all genes in this cluster and a number of other pro-inflammatory genes were strongly associated with ECA, however these associations were not modulated by trial arm. Conclusions: The development of post-operative ECA is associated with overexpression of pro-inflammatory and pro-fibrotic genes including growth factors, matrix metalloproteinases, collagens and extracellular matrix proteins. There was no evidence that doxycycline modulated the association between gene expression and ECA.

An Alternative Algorithm for Müller Muscle Conjunctival Resection Surgery for Blepharoptosis Management.

Objectives:To evaluate the surgical outcomes of Müller Muscle conjunctival resection surgery performed with an alternative formula.Methods:A total of 58 eyes of 58 patients with mild ptosis (≤2 mm) and levator function ≥8 mm who responded to 2.5% phenylephrine were enrolled in this study. Müller muscle conjunctival resection was performed between March 2016-March 2018, and the charts were reviewed retrospectively. Margin-reflex distance 1 was measured before and after five minutes following the instillation of phenylephrine. The amount of excision was 9 mm when the desired elevation was achieved. If the phenylephrine testing resulted in under-correction, 10 mm was resected, and in overcorrection, 8 mm resection was performed. Margin reflex distance and Schirmer test measurements were performed preoperatively and on the first, third and sixth months postoperatively.Results:The mean increase in margin-reflex distance 1 was statistically significant at the first, third and sixth months postoperatively when compared to preoperative values (p<0.05, Wilcoxon signed ranks test). Postoperative symmetry was achieved in 54 patients (93.1%) after six months. Compared to the preoperative values, changes in Schirmer-1 test results were not statistically significant at each visit after the procedure (p>0.05, Wilcoxon signed ranks test). None of the patients had keratopathy, eyelid contour abnormality, or symblepharon.Conclusion:Müller muscle conjunctival resection is an alternative procedure to external approach in patients with mild ptosis and good levator function. The algorithm used in this study resulted in a high success rate with high predictability.

Enhanced Fasanella-Servat Procedure for the Graded Repair of Blepharoptosis.

To describe in detail a technique for a modified Fasanella-Servat procedure that provides a simplified method for graded Mueller muscle excision with minimal and controlled tarsal excision. A retrospective study of 71 patients (102 eyelids) who underwent the modified Fasanella-Servat procedure is reported. Measurements include the preoperative, post-phenylephrine, and postoperative margin-to-reflex distance-1, and postoperative upper eyelid height symmetry as determined by the absolute difference between right- and left-sided margin-to-reflex distance-1. Postoperative complications are reported. The average increase in margin-to-reflex distance-1 was 2.4 mm with an average postoperative upper eyelid height symmetry of 0.4 mm. Postoperative asymmetry was 1.5 mm or less in 68 patients, a success rate of 96%. Four patients (6%) exhibited overcorrection, 2 of which required additional surgery. No lagophthalmos or notable eyelid contour abnormalities were seen. The modified Fasanella-Servat technique offers a simple method to isolate and resect Mueller muscle and a minimal segment of tarsus in a quantitative fashion, allowing for a graded repair of blepharoptosis and thereby decreasing the risk of postoperative overcorrection, lagophthalmos, and eyelid contour asymmetry whilst preserving the bulk of tarsus.

Predictors of Trachomatous Trichiasis Surgery Outcome

PurposeUnfavorable outcomes after trachomatous trichiasis (TT) surgery are undermining the global trachoma elimination effort. This analysis investigates predictors of postoperative TT (PTT), eyelid contour abnormalities (ECAs), and granuloma in the 2 most common TT surgery procedures: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR).DesignSecondary data analysis from a randomized, controlled, single-masked clinical trial.ParticipantsA total of 1000 patients with TT, with lashes touching the eye or evidence of epilation, in association with tarsal conjunctival scarring.MethodsParticipants were randomly allocated and received BLTR (n = 501) or PLTR (n = 499) surgery. Disease severity at baseline, surgical incisions, sutures, and corrections were graded during and immediately after surgery. Participants were examined at 6 and 12 months by assessors masked to allocation.Main Outcome MeasuresPredictors of PTT, ECA, and granuloma.ResultsData were available for 992 (99.2%) trial participants (496 in each arm). There was strong evidence that performing more peripheral dissection with scissors in PLTR (odd ratio [OR], 0.70; 95% confidence interval [CI], 0.54–0.91; P = 0.008) and BLTR (OR, 0.83; 95% CI, 0.72–0.96; P = 0.01) independently protected against PTT. Baseline major trichiasis and mixed location lashes and immediate postoperative central undercorrection independently predicted PTT in both surgical procedures. Peripheral lashes in PLTR (OR, 5.91; 95% CI, 1.48–23.5; P = 0.01) and external central incision height ≥4 mm in BLTR (OR, 2.89; 95% CI, 1.55–5.41; P = 0.001) were independently associated with PTT. Suture interval asymmetry of >2 mm (OR, 3.18; 95% CI, 1.31–7.70; P = 0.01) in PLTR and baseline conjunctival scarring in BLTR (OR, 1.72; 95% CI, 1.06–2.81; P = 0.03) were independently associated with ECA. Older age was independently associated with ECA in both PLTR (P value for trend < 0.0001) and BLTR (P value for trend = 0.03). There was substantial intersurgeon variability in ECA rates for both PLTR (range, 19.0%–36.2%) and BLTR (range, 6.1%–28.7%) procedures. In PLTR surgery, irregular posterior lamellar incision at the center of the eyelid (OR, 6.72; 95% CI, 1.55–29.04; P = 0.01) and ECA (OR, 3.08; 95% CI, 1.37–6.94; P = 0.007) resulted in granuloma formation.ConclusionsPoor postoperative outcomes in TT surgery were associated with inadequate peripheral dissection, irregular incision, asymmetric suture position and tension, inadequate correction, and lash location. Addressing these will improve TT surgical outcomes.

Outcome of trachoma lid surgeries in Jigawa state, Nigeria

AbstractBackground: Following the implementation of the SAFE strategy in Jigawa state, ophthalmic nurses trained as lid surgeons perform trichiasis surgery in the state. This study aimed to determine the early outcome of these surgeries with the specific objectives to determine the recurrence rate of trichiasis; the incidence of eyelid contour abnormality and incidence of eyelid closure defects 3–6 months postoperatively. Methods: A retrospective cohort study of patients operated for the first time between December 2012 and April 2013 in four zones in Jigawa state. Zones were selected based on the location of the most active surgeons. Patients were examined with torchlight for presence of recurrent trichiasis (TT recurrence), eyelid contour abnormality (ECA) and eyelid closure defects (ECD). Results: 133 eyes of 77 patients were examined; incidences recorded were TT recurrence 17.29% (95% CI 11.29–24.80%), ECA 18.93% (95% CI 12.64–26.67%) and ECD 5.3% (95% CI 2.15–10.62%). Incidence of poor outcome varied...

Interventions for trachoma trichiasis.

BackgroundTrachoma is the leading infectious cause of blindness. The World Health Organization (WHO) recommends eliminating trachomatous blindness through the SAFE strategy: Surgery for trichiasis, Antibiotic treatment, Facial cleanliness and Environmental hygiene. This is an update of a Cochrane review first published in 2003, and previously updated in 2006.ObjectivesTo assess the effects of interventions for trachomatous trichiasis for people living in endemic settings.Search methodsWe searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 4), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2015), EMBASE (January 1980 to May 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 May 2015. We searched the reference lists of included studies to identify further potentially relevant studies. We also contacted authors for details of other relevant studies.Selection criteriaWe included randomised trials of any intervention intended to treat trachomatous trichiasis.Data collection and analysisThree review authors independently selected and assessed the trials, including the risk of bias. We contacted trial authors for missing data when necessary. Our primary outcome was post‐operative trichiasis which was defined as any lash touching the globe at three months, one year or two years after surgery.Main resultsThirteen studies met the inclusion criteria with 8586 participants. Most of the studies were conducted in sub‐Saharan Africa. The majority of the studies were of a low or unclear risk of bias.Five studies compared different surgical interventions. Most surgical interventions were performed by non‐physician technicians. These trials suggest the most effective surgery is full‐thickness incision of the tarsal plate and rotation of the terminal tarsal strip. Pooled data from two studies suggested that the bilamellar rotation was more effective than unilamellar rotation (OR 0.29, 95% CI 0.16 to 0.50). Use of a lid clamp reduced lid contour abnormalities (OR 0.65, 95% CI 0.44 to 0.98) and granuloma formation (OR 0.67, 95% CI 0.46 to 0.97). Absorbable sutures gave comparable outcomes to silk sutures (OR 0.90, 95% CI 0.68 to 1.20) and were associated with less frequent granuloma formation (OR 0.63, 95% CI 0.40 to 0.99). Epilation was less effective at preventing eyelashes from touching the globe than surgery for mild trichiasis, but had comparable results for vision and corneal change. Peri‐operative azithromycin reduced post‐operative trichiasis; however, the estimate of effect was imprecise and compatible with no effect or increased trichiasis (OR 0.85, 95% CI 0.63 to 1.14; 1954 eyes; 3 studies). Community‐based surgery when compared to health centres increased uptake with comparable outcomes. Surgery performed by ophthalmologists and integrated eye care workers was comparable. Adverse events were typically infrequent or mild and included rare postoperative infections, eyelid contour abnormalities and conjunctival granulomas.Authors' conclusionsNo trials were designed to evaluate whether the interventions for trichiasis prevent blindness as an outcome; however, several found modest improvement in vision following intervention. Certain interventions have been shown to be more effective at eliminating trichiasis. Full‐thickness incision of the tarsal plate and rotation of the lash‐bearing lid margin was found to be the best technique and is preferably delivered in the community. Surgery may be carried out by an ophthalmologist or a trained ophthalmic assistant. Surgery performed with silk or absorbable sutures gave comparable results. Post‐operative azithromycin was found to improve outcomes where overall recurrence was low.

Patients’ Perceptions of Trichiasis Surgery: Results from the Partnership for Rapid Elimination of Trachoma (PRET) Surgery Clinical Trial

Purpose: While quality of life surveys have been conducted in trachomatous trichiasis (TT) surgery populations, little is known about patients’ perceptions of the surgical experience and outcomes.Methods: We interviewed a subset of Partnership for the Rapid Elimination of Trachoma (PRET) surgery trial participants 24 months after surgery. Questions focused on current ocular symptoms, perceived daily functioning, physical appearance, and overall perception of surgery. We stratified participants based on surgical outcomes: normal upper eyelid, postoperative TT, or eyelid contour abnormality (ECA) in one or both eyelids. We compared responses between sexes and surgical outcome groups using contingency tables and Fisher’s exact tests.Results: A total of 483 individuals participated and 86% were very satisfied with surgery results; 96% reported ocular symptom improvement. Participants with moderate to severe ECA or postoperative TT were more likely to report current ocular problems than those with normal eyelids (46% and 58% vs 34%, respectively; p = 0.01 for each comparison). The most common symptom among participants with moderate to severe postoperative TT was feeling lashes touching (blurred vision was the most common among participants with moderate to severe ECA). Overall, 83% stated surgery improved daily life; participants with ECA were less likely to report improvement than others (p = 0.002). Participants who had moderate or severe postoperative TT were least likely to state that they would undergo repeat surgery (80%), followed by participants with ECA (86%).Conclusions: Postoperative TT and ECA both reduced satisfaction with surgery, but appeared to influence different aspects of life. Improving surgical outcomes both by reducing recurrence rates and limiting ECAs are essential.

Trachomatous Trichiasis Clamp vs Standard Bilamellar Tarsal Rotation Instrumentation for Trichiasis Surgery

To determine whether a new surgical clamp reduces unfavorable postoperative outcomes. Patients with trachomatous trichiasis (TT) were randomized to surgery with standard bilamellar tarsal rotation (BLTR) instrumentation or the TT clamp and were followed up for 2 years. Postoperative TT, pyogenic granuloma formation, and eyelid contour abnormalities, combined and individually. A total of 1917 participants who had surgery (3345 eyes) were enrolled. Rates of at least 1 unfavorable outcome were similar for the participants who underwent surgery with the TT clamp and those who underwent surgery with standard BLTR (60.9% vs 63.0%, respectively; adjusted odds ratio [AOR] = 0.88; 95% CI, 0.66-1.18). Granuloma was less common in the TT clamp arm than in the standard BLTR arm (16.8% vs 22.4%, respectively; AOR = 0.67; 95% CI, 0.46-0.97). There was a trend toward increased postoperative TT in the TT clamp arm compared with the standard BLTR arm (43.2% vs 36.6%, respectively; AOR = 1.36; 95% CI, 0.96-1.93). The TT clamp decreased the risk of mild eyelid contour abnormalities compared with standard BLTR (9.1% vs 13.3%, respectively; AOR = 0.64; 95% CI, 0.42-0.97) and showed a trend for a decrease in moderate abnormalities (5.3% vs 7.8%, respectively; AOR = 0.63; 95% CI, 0.39-1.01). Overall, rates of unfavorable outcomes were similar between groups. Although our results are similar to other programmatic settings, such high rates of unfavorable outcomes are unacceptable; future research is needed to identify ways to improve TT surgery outcomes. A new clamp for TT surgery appears to offer protection against granuloma formation and some eyelid contour abnormalities, but it does not reduce postoperative TT. clinicaltrials.gov Identifier: NCT00886015.