Understanding the spatial distribution of trichiasis and its association with trachomatous inflammation-follicular.

BACKGROUND: Whilst previous work has identified clustering of the active trachoma sign "trachomatous inflammation-follicular" (TF), there is limited understanding of the spatial structure of trachomatous trichiasis (TT), the rarer, end-stage, blinding form of disease. Here we use community-level TF prevalence, information on access to water and sanitation, and large-scale environmental and socio-economic indicators to model the spatial variation in community-level TT prevalence in Benin, Cote d'Ivoire, DRC, Guinea, Ethiopia, Malawi, Mozambique, Nigeria, Sudan and Uganda. METHODS: We fit binomial mixed models, with community-level random effects, separately for each country. In countries where spatial correlation was detected through a semi-variogram diagnostic check we then fitted a geostatistical model to the TT prevalence data including TF prevalence as an explanatory variable. RESULTS: The estimated regression relationship between community-level TF and TT was significant in eight countries. We estimate that a 10% increase in community-level TF prevalence leads to an increase in the odds for TT ranging from 20 to 86% when accounting for additional covariates. CONCLUSION: We find evidence of an association between TF and TT in some parts of Africa. However, our results also suggest the presence of additional, country-specific, spatial risk factors which modulate the variation in TT risk.

Periocular Manifestations of Afatinib Therapy.

Epidermal growth factor receptor tyrosine kinase inhibitor therapy has been increasingly employed in the treatment of a variety of tumors. The authors report the rarely documented side effect of trichiasis with the use of Afatinib in a patient with spinal chordoma and review-related literature. A 67-year-old lady was referred to the oculoplastic service with a 3-month history of ocular irritation and pain associated with blurred vision. She has a 4-year history of spinal chordoma treated with daily Afatinib 50 mg over the past 6 months. Clinical examination revealed trichomegaly and trichiasis affecting all 4 eyelids associated with blepharitis, conjunctival, and corneal abrasion on fluorescein staining. Hypertrichosis of the eyebrow bilaterally was also present. Afatinib and other epidermal growth factor receptor tyrosine kinase inhibitor-associated changes to eyelash and eyebrow hair is a result of epidermal growth factor receptor pathway activation in keratinocytes results in remodeling of the hair follicle. This results in the variation in the severity of clinical presentation of trichiasis.

A Simple New Technique for Treatment of Tarsal Kink Syndrome.

Congenital tarsal kink syndrome is a rare type of upper eyelid entropion associated with keratitis due to trichiasis. The authors describe a new technique for treatment of congenital horizontal tarsal kink syndrome by means of absorbable everting sutures via a posterior approach. A neonate was referred to eye clinic with right eye redness and corneal opacity since birth. Clinical examination revealed inversion of the eyelid margin with a horizontal kink in the tarsal plate and corneal ulcer. Surgical treatment resulted in successful correction of upper eyelid malpositioning, rapid resolution of the corneal ulcer with excellent anatomical outcome, visual development and cosmesis, with no evidence of recurrence after 6 years. Absorbable everting sutures via a posterior approach is a simple, minimally invasive, and effective surgical technique for treatment of congenital horizontal tarsal kink syndrome.

Correction of lower eyelid marginal entropion by eyelid margin splitting and anterior lamellar repositioning.

PURPOSE: There is a paucity of data in the literature on the surgical management of lower eyelid marginal entropion. In this study, the authors report outcomes of a surgical technique of eyelid margin splitting and anterior lamellar reposition in patients with lower eyelid marginal entropion. METHODS: The medical records for 30 eyelids from 22 patients with lower eyelid marginal entropion who had undergone eyelid margin splitting and anterior lamellar repositioning at Seoul National University Hospital from January 2004 to December 2012 were retrospectively reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, the complete resolution of symptoms, and acceptable cosmesis at the final follow up. RESULTS: The mean follow-up duration was 16.7 months. The split eyelid margin exhibited good wound healing in each case, but trichiasis recurred postoperatively in 3 of 30 eyelids, even though the eyelid margin was ultimately well positioned. That is, the overall success rate was 90%. Of the 3 eyelids with recurrent trichiasis, 2 required additional electrolysis to remove irritated cilia, but the other did not require to be treated. In the latter case, the trichiasis observed was fine, focal, and unaccompanied by symptoms or corneal lesions. There was no significant complication such as secondary ectropion or eyelid retraction. CONCLUSIONS: Eyelid margin splitting and anterior lamellar repositioning achieve success with a low rate of complications among patients with lower eyelid marginal entropion.

Ectropion, entropion, trichiasis.

Aim of this review was to describe ectropion, entropion and trichiasis and their therapy. These eyelid pathologies are characterised by common symptoms (redness, excessive tearing and irritation of the eye) and by altered balance of the anterior and posterior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly surgical. Parasurgical therapy may play a role as a temporary measure.

Explaining the continuing high prevalence of trachomatous trichiasis unknown to the health system in evaluation units: a mixed methods explanatory study in four trachoma-endemic countries.

BACKGROUND: We explored reasons for continuing higher-than-anticipated prevalence of trachomatous trichiasis (TT) unknown to the health system in population-based prevalence surveys in evaluation units where full geographical coverage of TT case finding was reported. METHODS: A mixed-methods study in Ethiopia, Kenya, Nigeria and Tanzania was conducted. We compared data from clinical examination, campaign documentation and interviews with original trachoma impact survey (TIS) results. RESULTS: Of 169 TT cases identified by TIS teams, 130 (77%) were examined in this study. Of those, 90 (69%) were a match (both TIS and study teams agreed on TT classification) and 40 (31%) were a mismatch. Of the 40 mismatches, 22 (55%) were identified as unknown to the health system by the study team but as known to the health system by the TIS team; 12 (30%) were identified as not having TT by the study team but as having TT by the TIS team; and six (15%) were identified as unknown to the health system in the TIS team but as known to the health system by the study team based on documentation reviewed. CONCLUSIONS: Incorrectly reported geographical coverage of case-finding activities, and discrepancies in TT status between TIS results and more detailed assessments, are the key reasons identified for continuing high TT prevalence.

Epilation for trachomatous trichiasis and the risk of corneal opacification.

PURPOSE: Eight million people have trachomatous trichiasis (TT). The World Health Organization (WHO) recommends entropion surgery for TT regardless of severity. However, epilation is widely practiced for treating minor TT (1-5 lashes touching the globe). We report the frequency and effectiveness of patient-initiated epilation and its relationship to corneal opacity. DESIGN: Cross-sectional baseline data of individuals recruited to 2 randomized, clinical trials. PARTICIPANTS: We included 2556 individuals (4310 eyes) with previously unoperated TT in ≥ 1 eye. METHODS: A single ophthalmologist examined all participants for signs of trachoma using WHO grading systems with additional assessment of entropion grading, location and number of trichiatic lashes, and evidence of epilation. A questionnaire enquired about epilation practices. MAIN OUTCOME MEASURES: The association between epilation and degree of corneal opacity. Epilation practices of TT patients. RESULTS: Central corneal scarring was present in 1436 (33%) eyes. Entropion was absent/mild in 2328 (54%) eyes, moderate in 1259 (29.2%), and severe in 723 (16.8%). The median number of lashes touching the eye was 2 (interquartile range, 1-5; range, 0-133). There was clinical evidence of epilation in 3018 (70%) eyes, of which 738 (24%) were successfully epilated (no lashes touching globe). Epilation was performed frequently (at least monthly in 3311 [76.8%] eyes), by someone other than the patient (92.8%), and using locally made forceps (88.9%). Controlling for age and degree of entropion, successful epilation was associated with less corneal opacity (odds ratio [OR], 0.61; 95% confidence interval [CI]. 0.43-0.88; P = 0.007). The association was only significant in patients with severe entropion (OR, 0.07; 95% CI, 0.02-0.25; P<0.005). CONCLUSIONS: We found an association between successful epilation and less central corneal opacity. This indicates the importance of preventing eyelashes from touching the cornea, particularly in individuals with severe entropion. This is a cross-sectional study; therefore, a causative relationship cannot be concluded. However, the results suggest that among patients who decline or are unable to access surgery, and perhaps in minor TT where the management remains controversial, the provision of high-quality forceps and epilation training may be beneficial. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Australian trachoma surveillance annual report, 2010.

Endemic trachoma continues to exist in remote Aboriginal communities in Australia. The National Trachoma Surveillance and Reporting Unit, established in 2006, is responsible for the collation, analysis and reporting of trachoma prevalence data and the documentation of trachoma control strategies in Australia. Data were collected from Aboriginal communities designated at-risk for endemic trachoma (defined as prevalence of 5% or greater among children) within the Northern Territory, South Australia and Western Australia. This report presents data collected in 2010. Aboriginal children aged 1-14 years were screened using the World Health Organization grading criteria to diagnose and classify individual cases of trachoma. Aboriginal adults aged 40 years or older were screened for trichiasis. Community screening coverage of the designated at-risk communities was 60% in 2010. Screening coverage of the estimated population of children aged 1-14 years and of adults aged 40 years or older in at-risk communities was 11.5% and 5%, respectively. Trachoma prevalence among children aged 1-14 years who were screened was 11%. Of the communities screened, 36% were found to have no cases of active trachoma and 55% were found to have endemic levels of trachoma. Treatment coverage of active cases and their contacts varied between jurisdictions from 64% to 90%. Trichiasis prevalence was 4% within the screened communities.

Ectrodactyly, ectodermal dysplasia, and cleft lip-palate (EEC) syndrome without clefting: a rare case report.

Ectrodactyly, Ectodermal dysplasia, and Cleft lip-cleft palate (EEC) syndrome is a rare ectodermal dysplasia presenting with various combinations of its three components. It is an autosomal dominant disorder with variable expression and penetrance. Patients have features of ectodermal abnormalities and a split hand/foot deformity of the limbs. We report a case of this rare disorder in a 40-year-old male who had ectrodactyly, ectodermal dysplasia, but no clefting of lips or palate.

Prospective audit of the phenotype, causes and correlates of trachomatous and non- trachomatous trichiasis in a peri-elimination setting.

PURPOSE: To explore the burden, clinical features and associations of trichiasis due to trachomatous and non-trachomatous aetiologies. METHODS: Consenting patients presenting with trichiasis of either eyelid (of one or both eyes) attending the outpatient department, cornea and oculoplasty clinics of a tertiary eye care hospital in New Delhi between August 2018 to March 2020 were included. A comprehensive examination including visual acuity and anterior segment evaluation and photography was performed. Grade of trichiasis, laterality, presence and grade of entropion, and information on corneal opacity, conjunctival scarring, Herbert's pits, and pannus, if present, were recorded in the case record form. RESULTS: Overall, 302 patients (454 eyes) with trichiasis were recruited. The most common attributed cause of upper eyelid trichiasis (276 patients, 405 eyes) was trachoma (26% of patients), followed by Stevens-Johnson syndrome (23%), blepharokeratoconjunctivitis (17%) and old age (10%). A total of 296/405 eyes (73%) had some form of corneal involvement. Trachoma was not identified as the cause of trichiasis in any eye with lower eyelid-only disease. CONCLUSION: Only about a quarter of upper eyelid trichiasis in this peri-elimination setting was attributed to trachoma. A distinction between trachomatous and non-trachomatous trichiasis is imperative to meaningfully determine whether elimination of trachoma as a public health problem has occurred. These data may have implications for population-based estimates of TT prevalence in India and other peri-elimination settings.

Trichiasis: characteristics and management options.

Trichiasis is a common disorder in which eyelashes or cilia arising from their normal position are misdirected toward the ocular surface. This condition frequently causes ocular surface irritation and commonly results from eyelid inflammation and scarring which disrupts the direction of growth of cilia follicles. The knowledge of eyelid and cilia anatomy is important to the success of the treatment. Management options include epilation, electrolysis, radiofrequency ablation, laser photoablation, cryotherapy and surgical removal of the offending cilia. Treatment is made by the clinician based upon the number, distribution and severity of the trichiasis. Recognition and management of the underlying cause of the trichiasis should also be addressed. Nevertheless, recalcitrant or recurrent cilia are not unusual despite a systematic approach to this condition. This article will briefly discuss trichiasis and the relevant eyelid and cilia anatomy. Subsequently, the current treatment modalities for trichiasis and their complications will be described.

Pilot Audit of Trichiasis Surgery Outcomes Using a Mobile App in the Republic of Chad.

PURPOSE: The purpose of the study was to assess the feasibility of a mobile data collection app for use in trichiasis surgical audits in the Melfi and Mangalme districts of the Guera region of the Republic of Chad and to perform a cost analysis to determine if the auditing mechanism could be implemented nationally. MATERIALS AND METHODS: Patients who underwent trichiasis surgery 6 months prior and who had follow-up 7-14 days after surgery were included in the study. Each surgeon had a sample of 20% of operated eyelids; nine surgeons with data for ≥20 eyelids were included. A trichiasis recurrence rate of ≥25% suggested that the surgeon needed retraining. Smartphones captured data using the data collection app, which transmitted data to an online server. Direct costs and supervision costs were collated and summed. RESULTS: There were 916 eyelids operated on; 170 patients (269 eyelids, 29% follow-up rate) participated in the audit. Twenty participants (11.8%) had recurrence. The mean recurrence rate among surgeons was 8.3% (standard deviation: 0.07%; range: 0%-17.9%). None had a recurrence rate of ≥25%; thus, no retraining was necessary. The total cost of the audit was US$15,111.25 ($12,882.28 in direct costs and $2,228.97 in supervision costs). CONCLUSIONS: The simple, easy-to-use, and low-cost mobile auditing mechanism is a practical solution for conducting surgical audits in remote and resource-limited settings and is undergoing national scale-up by the Chadian trachoma elimination program.

3D images as a field grader training tool for trachomatous trichiasis: A diagnostic accuracy study in Ethiopia.

BACKGROUND: Trachomatous trichiasis (TT) will continue to develop among those people who have had repeated infections after active trachoma is controlled. Detecting and treating affected individuals will remain necessary for years; a long "tail" of incident cases is anticipated. As the prevalence of TT declines, there will be fewer cases available for training trachoma graders (TG), necessitating alternative methods. METHODOLOGY/PRINCIPAL FINDINGS: Prospective, diagnostic accuracy study assessing sensitivity and specificity of 3D and 2D photography as a tool for training TG to detect TT. Individuals with TT in Ethiopia were examined, and 2D and 3D clinical images taken. Images were independently graded by four graders for presence or absence of trichiasis and compared to field grading. We recruited 153 participants. Clinical assessments and images were available for 306 eyes. Trichiasis was identified in 204 eyes by field grading. Image grading was performed on a selection of 262 eyes (131 with trichiasis). Most eyes with trichiasis had minor trichiasis (94/131). Pooled sensitivity was 88.3% (3D) and 98.0% (2D); pooled specificity was 59.8% (3D) and 26.8% (2D). 3D photo grading was 33.0% more specific than the 2D photo grading (p = 0.0002). The overall Kappa scores were 0.48 (3D) and 0.25 (2D). We trained 26 novice TG in Ethiopia using 3D images. They were tested on a 3D images set and had 71.4% agreement (kappa 0.46), relative to an expert. They were then tested examining 50 people, and had 86.8% agreement (kappa 0.75). We also tested 27 experienced TG on the same cases (86.4% agreement, kappa 0.75). There was no difference in performance between groups (p = 0.76). All participants preferred 3D over 2D images for training. CONCLUSIONS/SIGNIFICANCE: The slightly higher sensitivity of 2D photos comes at considerable cost in specificity. Training with 3D images enabled novice TG to identify cases as well as experienced TG. 3D were preferred to conventional 2D photos for training. Standardized 3D images of TT could be a useful tool for training TG, in settings where there are now few TT cases.

Assessment of trachoma in suspected endemic areas within 16 provinces in mainland China.

BACKGROUND: China used to be among the countries with a high prevalence of trachoma. At the launch of The Global Elimination of Trachoma (GET) 2020 campaign by the World Health Organization (WHO) in 1996, China was placed on the list of countries endemic for trachoma based on historical data. However, empirical observation and routinely collected eye care data were suggesting that trachoma was no longer a public health problem. To determine whether the GET 2020 goals had been met in P. R. China, we conducted a targeted assessment with national scope. METHODOLOGY/PRINCIPAL FINDING: Province assessment teams, trained in WHO Trachoma Rapid Assessment (TRA) methodology and in WHO simplified trachoma grading system, carried out assessments in 16 provinces (among them, 2 provinces conducted pilot assessment). Based on the published literature, including national and international reports, suspected trachoma-endemic areas within each province were identified. Within these areas, trachomatous inflammation- follicular (TF) assessments were carried out in at least 50 grade-one children in primary schools serving villages with the lowest socio-economic development. Trachomatous trichiasis (TT) and corneal opacity (CO) assessments were conducted among persons aged 15 and over in villages within the catchment area of the selected schools. Of 8,259 children examined in 128 primary schools in 97 suspected trachoma endemic areas, only 16 cases of conjunctivitis were graded as TF. 38 cases with TT were found among the 339,013 examined residents in villages surrounding the schools. Among these 97 suspected trachoma endemic areas in only three was the prevalence of TT more than 0.2%. CONCLUSIONS/SIGNIFICANCE: This large study suggested that trachoma was not a public health problem in 16 provinces that had been previously suspected to be endemic. These findings will facilitate planning for elimination of trachoma from PR China.

Vision stolen by a hidden thief: 5-Year retention of a bandage contact lens.

An 80 year-old male patient was prescribed a bandage contact lens on the left eye 5 years ago because of an injury on the eye by a wooden stick. He was never followed up to remove the contact lens. Two years ago, he suffered from gradually decreased visual acuity in the left eye. After removing the contact lens, his visual acuity gradually increased to 12/20 and the symptom revealed. Intraocular pressure, corneal endothelium density, corneal curvature, and the anterior chamber depth were within the normal range in the left eye, and were comparable with the right eye. Although no permanent damage was found in the patient, a strict follow-up procedure is strongly recommended for patients who receive a bandage contact lens.

Use of validated community-based trachoma trichiasis (TT) case finders to measure the total backlog and detect when elimination threshold is achieved: a TT methodology paper.

INTRODUCTION: The World Health Organization recommends TT surveys to be conducted in adults aged 15+ years (TT 15 survey) and certifies elimination of TT as a public health problem when there is less than 1 unknown case per 1,000 people of all ages. There is no standard survey method to accurately confirm this elimination prevalence threshold of 0.1% because rare conditions require large and expensive prevalence survey samples. The aim of this study was to develop an accurate operational research method to measure the total backlog of TT in people of all ages and detect when the elimination threshold is achieved. METHODS: Between July to October 2016, an innovative Community-based, Mapping, Mop-up and Follow-up (CMMF) approach to elimination of TT as a public health problem was developed and tested in Esoit, Siana, Megwara and Naikara sub-locations in Narok County in Kenya. The County had ongoing community-based TT surgical camps and case finders. TT case finders were recruited from existing pool of Community health volunteers (CHV) in the Community Health Strategy Initiative Programme of the Ministry of Health. They were trained, validated and supervised by experienced TT surgeons. A case finder was allocated a population unit with 2 to 3 villages to conduct a de jure pre-survey census, examine all people in the unit and register those with TT (TT all survey). Identified cases were confirmed by TT surgeons prior to surgery. Operated patients were reviewed at 1 day, 2 weeks and 3-6 months. The case finders will also be used to identify and refer new and recurrent cases. People with other eye and medical conditions were treated and referred accordingly. Standardised data collection and computer based data capture tools were used. Case finders kept registers with details of all persons with TT, those operated and those who refused to be operated (refusals). These details informed decision and actions on follow-up and counselling. Progress towards achievement of elimination threshold was assessed by dividing the number of TT cases diagnosed by total population in the population unit multiplied by 1,000. RESULTS: Narok County Government adopted both the CMMF approach and TT all survey method. All persons in 4,784 households in the four sub-locations were enumerated and examined. The total population projection was 29,548 and pre-survey census 22,912 people. Fifty-three cases of TT were diagnosed. The prevalence was 0.23% and this is equivalent to 2.3 cases per thousand population of all ages. Prior to this study, the project required to operate on at least 30 cases (excess cases) to achieve the elimination threshold of 1 case per 1000 population. CONCLUSION: The total backlog of TT was confirmed and the project is now justified to lay claim of having eliminated TT as a public health problem in the study area. TT all method may not be appropriate in settings with high burden of TT. Nomadic migrations affect estimation of population size. Non-trachomatous TT could not be ruled-out.

Trichiasis in ancient times.

Trichiasis, recognized since the time of Hippocrates, is a cause of ocular irritation that may result in scarring of the cornea and threaten sight. We have reviewed the original Greek medical texts made from the 1st to the 7th century ce and present the existing medical knowledge relating to trichiasis, including its clinical picture, cause, diagnosis, and treatment. Recognition of trichiasis as a stage of trachoma and its distinction from pseudotrichiasis gave the impetus for physicians of the era to use a significant number of pharmaceutical and surgical treatments.

The International Agency for the Prevention of Blindness (IAPB) Launches Essential Equipment List for Screening and Surgery for Trachomatous Trichiasis.

The International Agency for the Prevention of Blindness (IAPB) considers appropriate information as a vital resource in improving eye health in developing countries. IAPB consults panels of experts with considerable experience to identify good practices and assist with the compilation of Essential Equipment Lists. The first of the Essential Lists launched is the IAPB Essential Equipment List for screening and surgery for Trachomatous Trichiasis (TT). The list suggests a minimum set of items to perform high quality TT surgery under conditions prevalent in most endemic areas.

Population-Based Study of Trachoma in Guatemala.

PURPOSE: A prevalence survey for active trachoma in children aged under 10 years and trichiasis in women aged 40 years and older was carried out in four districts in the Sololá region in Guatemala, which is suspected of still having a trachoma problem. METHODS: Population-based surveys were undertaken in three districts, within 15 randomly selected communities in each district. In addition, in a fourth district that borders the third district chosen, we surveyed the small northern sub-district, by randomly selecting three communities in each community, 100 children aged under 10 years were randomly selected, and all females over 40 years. Five survey teams were trained and standardized. Trachoma was graded using the World Health Organization simplified grading scheme and ocular swabs were taken in cases of clinical follicular or inflammatory trachoma. Prevalence estimates were calculated at district and sub-district level. RESULTS: Trachoma rates at district level varied from 0-5.1%. There were only two sub-districts where active trachoma approached 10% (Nahualá Costa, 8.1%, and Santa Catarina Costa, 7.3%). Trichiasis rates in females aged 40 years and older varied from 0-3%. Trachoma was likely a problem in the past. CONCLUSIONS: Trachoma is disappearing in the Sololá region in Guatemala. Health leadership may consider further mapping of villages around the areas with an especially high rate of trachoma and infection, and instituting trichiasis surgery and active trachoma intervention where needed.

Assessment of a Novel Approach to Identify Trichiasis Cases Using Community Treatment Assistants in Tanzania.

BACKGROUND: Simple surgical intervention advocated by the World Health Organization can alleviate trachomatous trichiasis (TT) and prevent subsequent blindness. A large backlog of TT cases remain unidentified and untreated. To increase identification and referral of TT cases, a novel approach using standard screening questions, a card, and simple training for Community Treatment Assistants (CTAs) to use during Mass Drug Administration (MDA) was developed and evaluated in Kongwa District, a trachoma-endemic area of central Tanzania. METHODOLOGY/PRINCIPAL FINDINGS: A community randomized trial was conducted in 36 communities during MDA. CTAs in intervention villages received an additional half-day of training and a TT screening card in addition to the training received by CTAs in villages assigned to usual care. All MDA participants 15 years and older were screened for TT, and senior TT graders confirmed case status by evaluating all screened-positive cases. A random sample of those screened negative for TT and those who did not present at MDA were also evaluated by the master graders. Intervention CTAs identified 5.6 times as many cases (n = 50) as those assigned to usual care (n = 9, p < 0.05). While specificity was above 90% for both groups, the sensitivity for the novel screening tool was 31.2% compared to 5.6% for the usual care group (p < 0.05). CONCLUSIONS/SIGNIFICANCE: CTAs appear to be viable resources for the identification of TT cases. Additional training and use of a TT screening card significantly increased the ability of CTAs to recognize and refer TT cases during MDA; however, further efforts are needed to improve case detection and reduce the number of false positive cases.