Standard and modified glabellar flap for medial canthus reconstruction following mass removal in three dogs and two cats.

PURPOSE: To describe the surgical technique and clinical outcomes of the glabellar flap and its modification for the reconstruction of the medial canthus following resection of tumors in three dogs and two cats. METHODS: Three dogs (7-, 7-, and 12.5-year-old mixed breeds) and two cats (10- and 14-year-old Domestic shorthair) presented with a 7-13 mm tumor affecting the eyelid and/or conjunctiva in the medial canthal region. Following en bloc mass excision, an inverted V-shaped skin incision was made in the glabellar region (i.e., the area between the eyebrows in humans). The apex of the inverted V-shaped flap was rotated in three cases, whereas a horizontal sliding movement was performed in the other two cases to better cover the surgical wound. The surgical flap was then trimmed to fit the surgical wound and sutured in place in two layers (subcutaneous and cutaneous). RESULTS: Tumors were diagnosed as mast cell tumors (n = 3), amelanotic conjunctival melanoma (n = 1), and apocrine ductal adenoma (n = 1). No recurrence was noted in a follow-up time of 146 ± 84 days. Satisfactory cosmetic outcome with normal eyelids closure was achieved in all cases. Mild trichiasis was present in all patients and mild epiphora was noted in 2/5 patients, but there were no associated clinical signs such as discomfort or keratitis. CONCLUSIONS: The glabellar flap was easy to perform and provided a good outcome in terms of cosmetic, eyelid function, and corneal health. Postoperative complications from trichiasis appear to be minimized by the presence of the third eyelid in this region.

A New Surgical Technique for Postoperative Trachomatous Trichiasis.

INTRODUCTION: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.

Systematic review of the incidence of post-operative trichiasis in Africa.

BACKGROUND: Surgery for trichiasis is one of the pillars of the World Health Organization's strategy for global elimination of trachoma as a public health problem. A high incidence of post-operative trichiasis or other poor surgical outcomes could jeopardize these efforts. In this review, we aimed to summarize the reported incidence of post-operative trichiasis and other poor outcomes of trichiasis surgery in Africa. METHODS: We conducted a systematic literature search using PubMed, Academic Search Premier, Africa-Wide Information, CINAHL and Health Source Nursing through EBSCOhost, Web of Science, and the Cochrane Central Register of Controlled Trials. Reference lists of included studies were also reviewed to identify further potentially relevant publications. All observational and interventional studies that measured post-operative trichiasis in Africa as an outcome of trichiasis surgery were included. RESULTS: Thirty-five papers reporting on 22 studies (9 interventional,13 observational; total 13,737 participants) met the inclusion criteria. The reported incidence of post-operative trichiasis in the included studies ranged from 2% (at 6 weeks after bilamellar tarsal rotation) to 69% (at 3 weeks after anterior lamellar repositioning). The incidence varied by surgical procedure, study design, and length of follow-up. CONCLUSION: Trichiasis surgical outcomes should be improved. National trachoma programmes could benefit from identifying and adopting strategies to improve the performance and quality of their surgical service.

Interlamellar Autogenous Tarsal Graft for the Correction of Lower Eyelid Trichiasis Associated With Eyelid Margin Thinning.

PURPOSE: To evaluate the use of autogenous tarsal graft for surgical correction of lower eyelid trichiasis associated with eyelid thinning. METHODS: A total of 23 eyelids of 19 consecutive patients with trichiasis were operated with a variant of the Van Millingen procedure. The surgery consisted of interposing a 3-mm high fragment of autogenous ipsilateral upper eyelid tarsus corresponding to the trichiasis segment between the pretarsal anterior lamella and the lower tarsal plate. Preoperative assessment included quantification of eyelid thickness on the midpoint of the segment with trichiasis, biomicroscopy of the eyelid margin and location of the trichiasis. All patients were examined at 1, 3, 6, and 12 months after surgery. Eyelid thickness was measured at 1 month and 12 months of follow up. RESULTS: Preoperatively the mean thickness of the eyelid margin was 0.99 mm ± 0.06 standard error. One month postoperatively eyelid thickness increased to 2.08 ± 0.28 standard error, decreasing over time to reach 1. 48 mm ± 0.18 standard error 1 year after surgery, a value that did not differ from that of the control group. Small granulomas were diagnosed only in the early phases of the postoperative period. Trichiasis recurrence was seen in just 1 eyelid. Isolated abnormal lashes lateral or medial to the graft were present in 5 eyelids at the end of the study. CONCLUSIONS: Autogenous tarsal grafts placed parallel to the lower tarsus are a good option both to correct misdirected eyelashes and to restore normal lower eyelid thickness.

Outcomes of two surgical techniques for major trichiasis treatment.

The purpose of this article is to analyze the outcomes of two surgical techniques to treat major trichiasis. A retrospective chart review of 67 patients (89 eyelids) with major trichiasis was performed who underwent surgical treatment using one of two techniques: intermarginal split lamella with graft (ISLG group) or lid lamella resection (LLR group). There were 30 lids in the ISLG group with mean patient age of 71.8 years and 63.3% were females. There were 59 lids in the LLR group with mean patient age of 72.5 years and 52.5% were female. The minimum postoperative follow up was six months. Statistical analysis included descriptive measures, Goodman association test for contrasts between and within multinomial populations and nonparametric Mann-Whitney test for comparison between groups. P < 0.05 was considered statistically significant. The underlying causes of trichiasis were blepharitis (37.07%), chronic meibomitis (21.3%), multiple causes (20.2%), ectropion (11.2%), actinic keratosis (6.7%), or prior ocular surgery (3.3%). Postoperatively, in the ISLG group, there were 20% lids with complete success, 50% underwent laser or electrolysis, 16.7% required further surgery, and 13.3% were unsuccessful. Postoperatively, in the LLR group, there were 47.5% eyelids with complete success, 46.7% underwent laser or electrolysis, 6.8% required further surgery, and 5.1% were unsuccessful. There was a higher statistical chance of complete success with LLR (P < 0.05). LLR is superior to ISLG surgery for the treatment of major trichiasis. There is a greater chance of success with LLR and it is technically simpler.

Predictors of Trachomatous Trichiasis Surgery Outcome.

PURPOSE: Unfavorable 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). DESIGN: Secondary data analysis from a randomized, controlled, single-masked clinical trial. PARTICIPANTS: A total of 1000 patients with TT, with lashes touching the eye or evidence of epilation, in association with tarsal conjunctival scarring. METHODS: Participants 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 MEASURES: Predictors of PTT, ECA, and granuloma. RESULTS: Data 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. CONCLUSIONS: Poor 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.

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

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.

Trichiasis removal using dermatological punch: A case report.

Entropion, a common malposition of the eyelid, can lead to trichiasis and corneal damage. This article presents a clinical case in which, following initial surgery to correct entropion, the use of a dermatological punch was chosen to definitively eliminate persistent trichiasis. This relatively unknown yet effective approach proved to be a quick and straightforward alternative with positive outcomes, emphasizing the importance of considering innovative approaches to recurrent challenges in clinical practice.

The prevention and management of postoperative trachomatous trichiasis: A systematic review.

Among ocular infections, trachoma is the main cause of blindness. Repeated conjunctival Chlamydia trachomatis infections lead to trichiasis, corneal opacification, and visual impairment. Surgery is often needed to relieve discomfort and preserve vision; however, a high postoperative trachomatous trichiasis (PTT) rate has been observed in various settings. We wanted to know why, whether PTT rates could be reduced, and how to manage the PTT that occurs. We performed a search of the literature. Of 217 papers screened, 59 studies were identified for inclusion as potentially relevant, the majority having been excluded for not directly concerning PTT in humans. Preventing PTT is a major challenge. Only one published trial, the STAR trial in Ethiopia, has reported a cumulative PTT rate <10% one year after surgery. The literature on the management of PTT is sparse. Though no PTT management guidelines are available, high-quality surgery with a low rate of unfavorable outcomes for PTT patients is likely to require enhanced training of a smaller group of highly-skilled surgeons. Based on the surgical complexity and the authors' own experience, the pathway for patients suffering from PTT should be studied further for improvement.

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

BACKGROUND: Poor surgical outcomes remain a problem in trachoma-endemic countries working to reach elimination thresholds. Methods to improve outcomes could positively impact programmatic success. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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. TRIAL REGISTRATION: Registration number: NCT03100747; ClinicalTrials.gov Full study protocol available at (https://doi.org/10.15139/S3/QHZXWD).

Postoperative trachomatous trichiasis and associated factors among adults who underwent trachomatous trichiasis surgery in Ambassel District, North-East Ethiopia.

BACKGROUND: In Trachoma endemic countries, many people who underwent Trichiasis surgery faced a recurrence of the disease. Postoperative Trichiasis is a significant problem for patients and health care providers because it puts the eye at renewed risk of sight loss. Despite the low utilization of Trachomatous Trichiasis surgery and the high recurrence rate, evidence that elucidate why it recurs after surgery is limited. This study was aimed to assess the magnitude and associated factors of postoperative Trichiasis among 18 years and above individuals who underwent Trachomatous Trichiasis surgery between 2013 and 2019 in Ambassel District, Northeast Ethiopia, 2020. METHODS: The community-based cross-sectional study design was conducted from March 10 to March 23/2020 in selected kebeles of Ambassel District. The required sample size (506) was calculated using EPI-INFO Version 7. A multi-stage sampling technique was used to employ study participants. Data were collected through the interviewer-administered structured pre-tested questionnaire and entered into EpiData version 3.1 and then exported to SPSS version 23.0 for analysis. Bi-variable and multivariable logistic regression models were fitted to identify associated factors of Postoperative Trachomatous Trichiasis. RESULTS: Four hundred ninety two individuals participated in this study with a response rate of 97.2%. In Ambassel district, the prevalence of postoperative Trichiasis was 23.8% (95% CI = 19.9-27.8). Among associated factors of postoperative Trachomatous Trichiasis: age 50-59 (AOR = 3.34, CI = 1.38-8.1), 60-69 (AOR = 3.24, CI = 1.38-7.61), ≥70 years (AOR = 6.04, CI = 2.23-16.41), duration since surgery (AOR = 1.7, CI = 1.35-2.14), complication (AOR = 2.98, CI = 1.24-7.2), washing the face two times (AOR = 0.25, CI = 0.13-0.47), washing the face three and more times (AOR = 0.1, CI = 0.41-0.25), taking Azithromycin following surgery (AOR = 0.19, CI = 0.09-0.41), pre-operative epilation history (AOR = 2.11, CI = 1.14, 3.9) and having a knowledge about TrachomaTtrichiasis (AOR = 0.21, CI = 0.08-0.58) showed a statistical significant association. CONCLUSIONS: The prevalence of postoperative Trichiasis in Ambassel District was higher than most Ethiopian studies. Age, frequency of face washing, medication following surgery, duration since the last surgery, knowledge about trachoma, pre-operative epilation history, and complication after surgery were identified to be independent factors. To minimize postoperative Trachomatous Trichiasis stakeholders need to consider health education for patients, provision of Azithromycin after surgery, and proper training for integrated eye care workers.

[Treatment of trichiasis and distichiasis with a biopsy punch -- an effective and practical method for eyelash follicle excision]. / Behandlung der Trichiasis und Distichiasis mit Biopsiestanzen - eine effektive und praxisnahe Methode zur Wimpernbalgexzision.

Localised distichiasis and trichiasis with resulting keratopathy leads to considerable impairment for the patient. We present a new technique which enables the surgeon to excise the lash with its follicle to prevent regrowth in a single movement. The procedure does not need any preparation, leaving the lid with minimal concomitant trauma which prevents recurrence of trichiasis. The excision is done with a dermatological biopsy punch (Kai Europe GmbH, Solingen, Germany). The punch is placed on the appropriate place perpendicular to the lid margin where the punch is driven 3-4 mm parallel to the lash. Histopathological diagnosis should be obtained not only to prove the principle of this technique: the entire biopsy material should be handed over to the pathologist as distichiasis and trichiasis can be the first sign of lid tumours. The presented technique of hair follicle excision with a biopsy punch is extremely effective. Success can be proven by the results of histological work-up of the biopsy material.

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.

The impact of incorporating surgical simulation into trichiasis surgery training on operative aspects of initial live-training surgeries.

BACKGROUND: While surgical simulation is regularly used in surgical training in high-income country settings, it is uncommon in low- and middle-income countries, particularly for surgical training that primarily occurs in rural areas. We designed and evaluated a novel surgical simulator for improving trachomatous trichiasis (TT) surgery training, given that trichiasis is mostly found among the poorest individuals in rural areas. METHODOLOGY/PRINCIPAL FINDINGS: TT surgery programs were invited to incorporate surgical simulation with a new, high fidelity, low-cost simulator into their training. Trainees completed standard TT-surgery training following World Health Organization guidelines. A subset of trainees received three hours of supplemental training with the simulator between classroom and live-surgery training. We recorded the time required to complete each surgery and the number of times the trainer intervened to correct surgical steps. Participants completed questionnaires regarding their perceptions. We also assessed trainer and trainee perceptions of surgical simulation training as part of trichiasis surgery training. 22 surgeons completed standard training and 26 completed standard training plus simulation. We observed 1,394 live-training surgeries. Average time to first live-training surgery completion was nearly 20% shorter the simulation versus the standard group (28.3 vs 34.4 minutes; p = 0.02). Trainers intervened significantly fewer times during initial live-training surgeries in the simulation group (2.7 vs. 4.8; p = 0.005). All trainers indicated the simulator significantly improved training by allowing trainees to practice safely and to identify problem areas before performing live-training surgeries. Trainees reported that simulation practice improved their confidence and skills prior to performing live-training surgeries. CONCLUSIONS: A single high-fidelity surgical simulation session can significantly improve critical aspects of initial TT surgeries.

Improving data use in trachomatous trichiasis programmes: operationalisation of the TT Tracker.

Trachoma is a disease of the eye and the leading infectious cause of blindness worldwide. Years of repeated infections can cause in-turning of the lashes so that they rub against the eyeball, causing pain, discomfort and, if left untreated, blindness. This is known as trachomatous trichiasis (TT) and can be remedied by surgery. To improve oversight and reporting of TT outreach, Sightsavers developed a mobile phone application called the TT Tracker so that TT surgeons, assistants and supervisors can collect and analyse information about surgical outcomes and performance and determine when and where follow-up appointments are required. The TT Tracker is being used by seven national programmes. Examples of use and programme improvements from Nigeria, Benin and Senegal are discussed here.

Skin-redraping epicanthoplasty combined with the modified Hotz procedure to treat recurrent trichiasis in adults caused by congenital entropion.

OBJECTIVE: To report the efficacy of skin-redraping epicanthoplasty combined with the modified Hotz procedure for the management of recurrent trichiasis in adults caused by congenital entropion. METHODS: A retrospective chart review of nine recurrent trichiasis patients caused by congenital entropion was performed. All the patients were adults, and the follow-up period lasted more than 6 months. Success was defined as no recurrence of the trichiasis. RESULTS: The mean age of the patients was 22.7 ± 2.83 years, and the mean period of follow-up was 10.8 ± 4.15 months. The complete correction of trichiasis was observed in all patients, and there was no recurrence during the follow-up period. The ratio of the medial sclera area to the cornea area was enhanced from 0.25 ± 0.08 to 0.37 ± 0.11. Preoperatively, five patients were categorized as grade 2, and four patients were categorized as grade 3 of the Taylor classification, and all the patients were categorized as grade 0 after surgery. The preoperative severity of keratopathy was grade 3 in six patients and grade 2 in three patients. The preoperative lower lid horizontal skin fold heights were class 4 in six patients and class 3 in three patients. All the patients were grade 0 and class 1 after surgery. CONCLUSION: Skin-redraping epicanthoplasty combined with the modified Hotz procedure is reasonably successful in managing recurrent trichiasis in adults.

Gender differences in the surgical management of trachomatous trichiasis: an exploratory analysis of global trachoma survey data, 2015-2019.

BACKGROUND: Trachomatous trichiasis (TT) is a painful, potentially blinding eye condition that can be managed through epilation or surgery. Women are affected by TT approximately twice as often as men and are believed to face gendered barriers to receiving surgical care to prevent vision loss. METHODS: We used data from 817 cross-sectional surveys conducted during 2015-2019 in 20 African countries to estimate the prevalence difference (PD) between female and male eyes for four outcomes potentially indicating gender-related differences in TT management: (1) received surgery and developed postoperative TT (PTT), (2) never offered surgery, (3) offered surgery but declined it, and (4) offered epilation but never offered surgery. RESULTS: The prevalence was modestly elevated among female eyes compared with male eyes for having PTT (PD:1.8 [95% confidence limits (CL): 0.6, 3.0]) and having declined surgery for the eye (PD: 6.2 [95% CL: 1.8, 10.7]). The proportion offered epilation was similar by gender (PD:0.5 [95% CL: -0.4, 1.3]), while never having been offered surgery was somewhat more prevalent among male eyes (PD: -2.1 [95% CL: -3.5, -0.7]). CONCLUSIONS: Our results suggest potential gender differences in TT management. More research is needed to determine the causes and implications of the observed differences.