Information needed for evidence-based planning
for blinding trachoma (trichiasis) in Burkina Faso,
Cameroon, & Ethiopia
What do we know?
• Surgery output is currently significantly below that needed to address the TT backlog by 2020
• Growing realization that surgery quality and outcomes are not always as good as needed
• Research carried out in recent years provides evidence for improvements to:– Surgical procedure– Training and supervision– Service delivery
Evidence for action was compiled at a global scientific meeting held at KCCO Moshi in January 2012
• Surgical management
• Surgical training & quality
• Surgical output & uptake
Evidence for action…
1. Surgical
Management
2. Surgical Training &
Quality
3. Surgical Output &
Uptake
TT definitions• TT defined as– Any lash touching the
globe– Evidence of epilation
• Indications for surgical management– Any central lashes– Peripheral lashes that
touch the cornea– Requested by TT
patients
• Patients who refuse surgery should be offered other alternatives such as epilation
Surgical management
• Excellent results have been reported from clinical trials using bilamellar tarsal rotation (BLTR)
• Add special lid clamp/plate to BLTR
• WHO TT surgery manual & training of trainers manual (including Head Start).
• Follow WHO “Final Assessment of Trichiasis Surgeons” guidelines
• Epilation is an option if patient does not accept surgery (need to budget for and provide epilation forceps)
Improve surgical outcomes• Poor outcomes (post-operative TT) have been 15-
60% —most variation surgeon related
• Poor outcomes defined as:
– “Surgical failure” when TT present within 6 months of surgery
– “Recurrence”- if TT present only after 6 months post operative
• Conduct a post-operative follow-up within 6 months of surgery
• Re-operations have worse outcomes
– Should aim to avoid/but need intervention
TT Surgery & Follow up Form (in TT Outreach Manual)
Strengthen Training
Selection of TT surgeon (where using general health workers attrition of TT surgeons is generally high)
• Dedicated eye workers are more likely to be retained and are reported as doing most surgery
• Selection of trainees needs clear criteria - including binocular vision & manual dexterity
Training of trainers manual (“Final Assessment of TT Surgeons” included in yellow manual)
Strengthening Supervision
• Supervisors need training in how to supervise• TT surgeons need a supervisor who has
experience in TT surgery• Supervision should be both active and supportive• Supportive supervision
Supervision training as part of ToT
Increasing Output
• “Campaign” / “Outreach” surgical provision often accounts for 65-85% of total TT surgeries performed
• “Static” services alone will not be sufficient
• Training general health workers unlikely to deliver the volume of surgery needed
• In high prevalence areas use “dedicated teams”
• Priority to areas with highest UIG (camp approach)
TT Outreach Manual
Increasing Uptake (1)
• Mobilization and sensitization not sufficient to increase uptake
• Service needs to minimize the cost to the patient and “brought close to the TT patient”
• TT case finding & referral essential for effective and efficient camps
TT Case Finding Training manual
Increasing Uptake (2)
• All TT patients should have an “intervention” appropriate to their condition
• Good quality counseling of patients & family members needed
• While surgery should be offered, not all will accept it, therefore, other management options may be considered
TT Counseling manual
Trichiasis is a “time-limited” problem…and requires urgent intervention
Long term “sustainability” of the TT service is not the most important consideration
(different from cataract)