Recurrent Trichiasis Research Articles

Azithromycin Prevents Recurrence of Severe Trichiasis Following Trichiasis Surgery: STAR Trial

Purpose: Trichiasis, the potentially visually disabling result of chronic trachoma, is a leading cause of blindness world wide. Surgery can repair trichiasis, but recurrence of severe trichiasis (lashes touching the cornea) following surgery is likely to have immediate vision threatening consequences. Azithromycin use post-surgery appeared to be beneficial against recurrences but there were a mix of severe, moderate, and mild trichiasis; the specific effect on prevention of severe, vision-threatening recurrence is unknown. This randomized, clinical trial determined if treating trichiasis surgical patients with oral azithromycin compared to usual care (topical tetracycline) resulted in a reduction in severe recurrence of trichiasis to one year. Methods: In a rural, trachoma hyperendemic district in Ethiopia, 1452 trichiasis patients age 18 or older presenting for surgery were randomly allocated to azithromycin, single 1 gram dose, versus topical tetracycline twice per day for six weeks. The outcome was recurrent severe trichiasis, defined as lashes touching the cornea, or more than 5 lashes touching the globe, to one year. Results: Patients randomized to receive azithromycin had significantly fewer severe recurrences, 4.2/100 person years overall, compared to those randomized to topical tetracycline, 7.9/100 person years (p < 0.01). Conclusions: A single dose of azithromycin has been shown to reduce severe post-surgical trichiasis recurrence rates to one year and should become standard post surgical treatment.

Unspectacular Redness of the Eyelid - Two Malignant Tumours

Chronic, non- or little pigmented reddish or brownish lesions on the lid margin and the surrounding skin are frequently underestimated and thus carry a clear risk of malignancy. A 61-year-old lady was referred with a chronic, reddish lesion in the medial third of the left lower lid after a topical therapy over a period of 4 months had not improved the situation. She noticed the lesion for the first time 10 previously. Recurrent trichiasis and a slight ulceration had developed during the last year. After an unclear result of the biopsy (2)/ (3) of the left lower lid were removed because of atypical cells ascending into the epidermis. A superficial spreading melanoma 0.4 mm depth in the Breslow classification was detected and right next to it a superficial basal cell carcinoma. The lid defect was reconstructed with a tarsoconjunctival flap and a free full thickness skin graft as described by Hughes. Chronic redness at or around the lid margin which does not respond to therapy should be biopsied as malignant tumours may well be hidden behind it.

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

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 (χ 2 = 22.017, P<0.001), but there was no difference in recurrence by age (χ 2 =1.53, P = 0.9 at the third month; χ 2 = 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 (χ 2 =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 (χ 2 = 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.

Amniotic membrane transplantation in entropion surgery.

To evaluate the role of amniotic membrane transplantation in the management of cicatricial eyelid entropion. Prospective, noncomparative interventional case series. Eighteen consecutive patients with cicatricial entropion. A gray line lid split procedure with vertical anterior lamella repositioning was performed on 25 eyelids (upper or lower) of 18 patients with moderate to severe cicatricial entropion. Preserved human amniotic membrane (AM) was used to cover the bare tarsus up to the lid margin and secured with running 7-0 Vicryl. Impression cytology of the AM was performed at various stages postoperatively to study the epithelialization process. (1) Reepithelialization of bare tarsus, (2) extent of tarsal shrinkage, (3) recurrence of entropion. All the AM grafts took well. The most common complication was hemorrhage below the graft, which occurred in six cases. Complete success with no lashes touching the globe was achieved in 22 of 25 (88%) lids after a minimum follow-up of 12.0 months. The mean follow-up was 17.8 months. Two cases (qualified success) had recurrent trichiasis treated successfully with electrolysis. One case with severe trachomatous upper lid entropion recurred 14 months after surgery. The AM accelerated the epithelialization of bare tarsus; this was demonstrated by lack of fluorescein staining and reversion to skin color within 2 to 3 weeks. However, AM could not prevent tarsal shrinkage. Impression cytology demonstrated that features of conjunctival epithelium were present for the first postoperative month, but this was gradually replaced by squamous metaplasia, with keratinization appearing as early as 3 weeks postoperatively. The use of AM in a lid split procedure for correction of cicatricial entropion helps the bare tarsus epithelialize rapidly and improves the initial cosmetic result of surgery.

Long-term follow-up of lid surgery for trichiasis in the Gambia: surgical success and patient perceptions.

Surgery is an important component of the SAFE strategy which has been shown to improve visual acuity. There are limited data on long-term surgical success and patient perceptions and satisfaction. A sample of patients from the Gambia who had undergone previous lid surgery for trichiasis were therefore examined for recurrence of trichiasis and interviewed for patient satisfaction. Health centre surgical records and community screening were used to identify patients who had undergone previous lid surgery. Consenting patients were examined and a questionnaire administered. Kaplan-Meier survival plots were constructed for recurrence of trichiasis. Sixty-five subjects were recruited. Median age at surgery was 50 years. Median time since surgery was 7 years. Fifty-two of 115 (45%) operated eyes were free of trichiasis at follow-up and 23 of 65 (35%) patients had not suffered recurrent trichiasis in an operated eye. Median time from surgery to recurrence of trichiasis was estimated as 10.0 years (95% CI 3.7-16.3). Recurrent trichiasis was not significantly associated with visual impairment or blindness at follow-up. The following patient perceptions were reported: satisfaction with surgery (88%), less discomfort than before surgery (93%), improved vision (83%), work easier (38%), worth the expenditure (94%), would recommend it to others (93%), had recommended it to others (38%), experienced intra-operative pain (26%) and experienced post-operative pain (26%). Factors affecting surgical success, including surgical technique and re-exposure to infection, are discussed. This study provides important preliminary data for programme planners but larger prospective studies are required.

Management of severe cicatricial entropion using shared mucosal grafts.

To retrospectively analyze our experience using nasal turbinate and hard palate mucosal grafts as shared buttress grafts between the upper and lower eyelid for reconstruction in severe cicatricial entropion. A horizontal tarsectomy is performed in the upper and lower eyelid approximately 2 mm posterior to the gray line. The distal tarsal segments are then dissected and rotated 180 degrees. A graft of nasal turbinate mucosa or hard palate mucosa measuring 1.5 x 3 cm is harvested. The graft is sutured to the cut edge of tarsus in the upper and lower eyelid. The rotated distal tarsal segment is stabilized against the graft using 5 mattress sutures. After 3 weeks, the graft is split by sharp dissection between the upper and lower eyelids. The medical records of 12 consecutive patients, representing 15 shared buttress grafts, were reviewed. There were 5 hard palate and 10 nasal turbinate mucosal grafts placed. Follow-up ranged from 2 months to 7 years. The amount of corneal stipple, as well as subjective patient comfort, improved after eyelid margin reconstruction in 12 of the 15 eyes. One patient's visual acuity improved by more than 2 lines after surgery. There were no cases of failure of graft survival and no complications directly related to the shared graft technique. Recurrent entropion and trichiasis were noted in 3 eyelids more than a year after graft placement, reflecting ongoing cicatrization in these eyelids. Hard palate mucosal grafts were irritating to the corneal surface, requiring removal of the epithelium using a diamond burr and bandage contact lens wear. Nasal turbinate mucosal grafts were better tolerated by the corneal surface and had the added benefit of mucous production. Eyelid reconstruction using nasal turbinate and hard palate mucosal tissues as a shared buttress graft is a viable treatment option for patients with severe cicatricial entropion. Resolution of trichiasis and mechanical corneal abrasion was noted in 13 (86%) of 15 patients with no specific complications related to the technique. The shared buttress technique successfully autostents the healing eyelid margins, makes good use of the large turbinate mucosal graft, and minimizes trips to the operating room. When the mechanical requirements of eyelid margin reconstruction do not require the sturdiness of hard palate mucosa, nasal turbinate mucosa is a preferable graft tissue because it is better tolerated by the corneal surface and produces mucous.

Therapeutic utilization of disposable lenses

Disposable lenses have become an integral part of the ophthalmic practice since their introduction. Since these lenses, for the most part, have been approved for extended wear, we present clinical data to support the use of such lenses in therapeutic cases. Over a period of 1 year, the following conditions were treated with disposable lenses: recurrent corneal erosions, bullous keratopathy, penetrating keratoplasty, leaking blebs, neurotrophic keratitis, corneal lacerations, and trichiasis. All lenses were disposed of weekly and worn in conjunction with medical treatment regimens. The results of this study indicate that Acuvue disposable lenses appear to be both viable and cost effective when used for therapeutic purposes and when compared with currently approved bandage lenses within the confines of our clinic.

Results of community-based eyelid surgery for trichiasis due to trachoma.

In many parts of Africa patients with upper-lid trichiasis due to trachoma have very limited access to ophthalmologists or hospital facilities. In order to reach these patients it is necessary for trained paramedical eye workers to operate on patients close to where they live. The results of trichiasis surgery performed by an ophthalmic nurse in Tanzania were evaluated. A total of 156 operations were performed on 94 patients over a 2 year period by an eye nurse in central Tanzania. One hundred and forty four eyes in 86 patients were followed for a minimum of 9 months (range 9-36; mean 25.5 months). One eye developed a wound infection and nine eyes developed minimal central notching of the upper eyelid, but without corneal exposure. Survival time analysis showed a probability of survival without recurrent trichiasis of 81% at 24 months (95% CI 74% to 88%) and 79% at 36 months (95% CI 71% to 87%). It is concluded that trichiasis surgery may be safely and effectively performed in the community by a trained ophthalmic nurse.

Use of Argon Laser Photocoagulation in the Treatment of Recurrent Trichiasis: Long-Term Results

We describe our technique and analyze the long-term results of the use of argon laser photocoagulation in the treatment of 92 eyes with recurrent trichiasis. In spite of an incidence of recurrences of 64.1% which had to undergo a new laser photocoagulation session, the final success rate of the method was impressive (91.3%). The number of misdirected cilia per lid seems to constitute an important factor which affects both the rate of recurrences and the success rate of the procedure.

The treatment of recurrent trichiasis with argon laser photocoagulation

We report our experience with the use of Argon laser photocoagulation for the treatment of recurrent trichiasis. A total of 28 lids (of 21 patients) with aberrant lashes were treated in our study. Each lash was treated with a beam of 50-200 micron (spot size), 0.2 s (time), and 1-1.2 Watt (power). Neither infiltration nor topical anaesthesia was used. The mean follow-up time was 6.57 months. Successful treatment with no evidence of recurrence was achieved in 67.9% of lids after one to two laser sessions. The remaining 32.1% of the lids required three to four sessions to achieve no recurrence of the condition. There was a significant correlation between the number of aberrant lashes per lid and the number of required laser sessions. Complete healing of the treated areas occurred within six weeks after treatment, with no vascularisation or distortion of the lid margin. Argon laser treatment appears to be a safe and effective alternative to the other recognised methods of therapy in selected cases.

Thermoablation treatment for trichiasis using the argon laser

This paper presents a brief review of the literature regarding current treatment modalities for trichiasis and their complications. The technique of Argon laser thermoablation of lashes is described. A total of 12 patients with recurrent trichiasis involving 15 eyelids were treated and the procedure was found to be effective in 12 eyelids (80%). The follow-up period was three to six months. The laser settings used were Argon blue-green wavelength, spot size 50 to 100 microns, exposure time 0.05 to 0.10 seconds and power 1200 to 2000 mW. Advantages of the technique were precise application and selectivity, lack of complications, non-requirement for infiltrative anaesthesia and ease of performance. Disadvantages were the need for up to three treatments in some patients and the technique only being suitable for treating small numbers (up to six) of lashes.

Lateral and medial fornix conformers. A new aid in the plastic repair of the conjunctival fornices.

LUBKIN AND HUGHES,1in 1959, recommended the use of slender, crescentic methacrylate conformers, designed to shape the upper and lower fornices during conjunctival repair. These have proven valuable when a normal globe is present. They are particularly helpful when mucosal grafts are used, as they serve to stretch the grafts somewhat and prevent the formation of redundant folds, with their consequent thickening and even necrosis. About four years ago, two more fornix conformers were added to the armamentarium, for the lateral and for the medial fornices, respectively, (Fig 1). These have been extensively used, have proved their worth, and are herewith presented. The results of the use of fornix conformers in a 53-year-old woman presenting a variant of essential shrinkage of the conjunctiva with recurrent symblepharon and trichiasis are shown in Fig 2; this depicts the refashioning of the right lower fornix using the inferior conformer after synechiolysis of