Assessing the Long-Term Outcome of the Two Most Commonly Used Surgical Procedures to Treat Trachomatous Trichiasis in Ethiopia: A Case Study

Trachoma is the leading cause of preventable and irreversible blindness worldwide, and is caused by repeated ocular infection with Chlamydia trachomatis (Ct). Over a million people globally have been blinded by trachoma and approximately 6 million have been left with severe visual impairment. The disease can therefore have major social and economic consequences on families and communities. Among the countries with the most serious trachoma problems worldwide, Ethiopia is the most severely affected, with an estimated 30 percent of the African continent’s trachoma burden. 

To achieve elimination of trachoma, the World Health Organization (WHO) advises endemic countries to implement the SAFE strategy which comprises Surgery (to address trachomatous trichiasis (TT), the late stage of the disease which can lead to blindness if untreated), Antibiotics (to reduce the bacterial load in a community through Mass Drug Administration (MDA)), Facial cleanliness (to reduce the spread of infection), and Environmental improvement (to promote improved sanitation and hygiene behaviors). 

The Amhara region in Ethiopia has a large burden of Ethiopia’s trachomatous trichiasis (TT) cases. TT cases have conjunctival scarring (TS) caused by recurrent Ct infection since childhood, which later causes eyelids to be distorted and eyelashes to scratch the cornea. TT is mainly treated through surgery. The two commonly used procedures for TT treatment are the Bilamellar Tarsal Rotation (BLTR) and the Posterior Lamellar Tarsal Rotation (PLTR) surgeries. To compare the two types of surgery, a study began in February 2018, following up from a randomized control trial (RCT) conducted four years prior on one thousand patients in the Amhara region of Ethiopia. The results of the study will allow the researchers to determine which one of the two TT surgical procedures gives the best outcome long-term. The one year follow-up of the RCT had shown that the PLTR was a better method with less recurrent trichiasis than in the BLTR group. The four-year follow-up will be used to confirm whether the results remain the same, and therefore offer recommendations to the international community regarding the optimal surgical method with which to train new TT surgeons. 

Using the study participants’ demographic information collected and updated during the last follow-up at 1 year after surgery, study participants are scheduled to come back for the four-year follow-up to the health facility where they had their surgery. Social mobilizations also generally take place in markets and churches in a community the weekend before the research team plans to go to a given health facility, and letters and messages are sent to study participants through relatives, neighbors, or local administrators. If participants are unable to come to the health facility due to distance or disability, they are provided with accommodations either by receiving a ride to the health facility or by having team members go to their home. 

Participant interview

When participants arrive at the site, they are greeted by a research team member, and are given general information about the purpose of the follow up and the procedure it entails. After obtaining a written consent, a data collector administers the survey. Upon completing the survey interview, each participant goes into the tent where visual acuity is measured using the “Peek” software on a smartphone. Participants then get a full ocular examination and have a close-up eye photograph taken.

Each community recognizes the research team upon their arrival for social mobilizations and data collections because of their symbolic red shirts that they have been wearing for several years; they refer to them as ‘demosh lebash’ or bloody/red shirts, and already know the teams purpose. According to one of the principal investigators of the study, Dr. Esmael Habtamu, the research team serves almost as a mobile eye care clinic. They do not only collect data for their study, but when necessary they also provide referrals for TT surgery or other ocular conditions, epilation if only few lashes are touching the cornea, medications such as antibiotics and eye ointments, and soap to promote face washing. Most study participants have access to some type of water source (wells, rivers, running water). Despite some of the sites and homes being difficult to reach, the projected completion of this follow-up study is May 2018; before the beginning of the rainy season which would make access to certain sites even more difficult.

 

Photos (Credit: Ahlam Awad Mohammed)

Top: An ophthalmic nurse conducting an eye exam

Bottom: A data collector administering the follow-up survey to measure the impact of trichiasis surgery on quality of life, activity, pain, and household poverty