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Kilimanjaro Centre for Community Ophthalmology Moshi, Tanzania

Trichiasis Update. Kilimanjaro Centre for Community Ophthalmology Moshi, Tanzania. Epidemiology & magnitude Ultimate intervention goals & annual targets Surgical procedures Training of surgeons Strategies to improve uptake Outcome of surgery Scaling up surgery. Magnitude of the problem.

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Kilimanjaro Centre for Community Ophthalmology Moshi, Tanzania

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  1. Trichiasis Update Kilimanjaro Centre for Community Ophthalmology Moshi, Tanzania

  2. Epidemiology & magnitude • Ultimate intervention goals & annual targets • Surgical procedures • Training of surgeons • Strategies to improve uptake • Outcome of surgery • Scaling up surgery

  3. Magnitude of the problem

  4. Vision loss No vision loss Corneal opacity No corneal opacity Success Failure Surgery No surgery Trichiasis No trichiasis Conjunctival scarring 2% Progression to vision loss in trachoma 6%

  5. Ultimate intervention goals for surgery (UIG-S) • Indicates the total number of surgeries that must be done to eliminate blinding trachoma • Dynamic figures (based on current estimates) • Total UIG-S can be put into annual targets (AIG-S)

  6. Ultimate intervention goals for surgery (UIG-S) Example from a national perspective: • Tanzania (2005) = 54,000 (167,000) people with TT (UIG) • 2005 AIG = 6,000 • Estimated # of people receiving surgery = 2,700 • Coverage = 45% • Ghana (2005) = 9,900 • 2005 AIG = 1,500 • Estimated # of people receiving surgery = 780 • Coverage = 55%

  7. Ultimate intervention goals for surgery (UIG-S)

  8. Including UIG-S into “district” implementation plans Annual intervention goals part of VISION 2020 implementation plan

  9. Surgical procedures • Full-thickness incision of the tarsal plate and rotation of terminal tarsal strip 180º • Bilamellar tarsal rotation procedure (BTRP) • Unilamellar tarsal rotation procedure (Trabut) • Other procedures • Cuenod Nataf procedure • Epilation (non-surgical, immediate management)

  10. Training of trichiasis surgeons • Trainers  ophthalmologists/well-trained ophthalmic nurse • Trainees  ophthalmic nurse • Training guidelines  national guidelines • Certification  check list • Instruments  surgical instruments list

  11. Training of trichiasis surgeons • Selection criteria • Prior surgical experience • Knowledge of sterile techniques • Experience giving injections • Experience in eye examinations • Expectations of surgical productivity • According to national guidelines (30/month in Tanzania)

  12. Factors associated with high productivity of trichiasis surgeons • Good supervision • “Pro-active” system for ensuring access to surgery • Adequate instruments and consumables • [based at “district” hospital & dedicated to eye care services] How many surgeons do we need to meet our UIGs?

  13. Surgical failure & recurrence following surgery • Surgical failure (within 3-6 months) • Technical skills of surgeon • Sutures used (type=silk; and number=4+) • Range 10-15% • Recurrence (>6 months following surgery) • Conjunctival scarring • Age of the patient • Duration since surgery • Range 15-45% No difference in outcome of surgery by ophthalmologists or trained nurses

  14. Quality of surgery • Defined as: • Few surgical failures (adequate eversion) • Good cosmesis • Good quality of surgery can be achieved through: • Training supported by certification • Routine supervision of surgeons • Use of appropriate (and well-maintained) instruments and consumables

  15. Implications of surgical failure & recurrence following surgery • Monitoring short-term outcome critical to correct surgical failure • Certification and supervision of surgeons important to maintain quality • Patient education to focus on the possibility of recurrence

  16. Who needs surgery? • Anyone with one or more lash touching the eye? • Epilation until more severe trichiasis develops? • Where contact with eye care services infrequent? • Surgery for mild disease technically easier and has better outcome

  17. Observations • In many (not all) settings, females have higher prevalence of active disease • Women account for 60-85% of trichiasis cases (2-3 times higher than men) • Blindness due to trachoma about 3 times higher in women compared to men.

  18. Is access to Surgery equal for men and women? • Burden of need primarily for women • Measurable? • Need baseline data to know burden by sex • Need to monitor separately for men and women • Current evidence: • Yes….if…. ….there are community-based efforts to encourage/enable use of trichiasis surgical services

  19. Barriers to use of eye care services are different for men & women • Cost of using service (access to financial resources) • distance to services (ability to travel and need for assistance) • knowledge of service (awareness and literacy) • perceived “value” (social support) • fear of a poor outcome (cosmesis)

  20. Global surgical totals reported to WHO

  21. At VISION 2020 implementation “district” (1+ million) Determine UIG and set annual targets Integrate with other eye care (surgical) services Ensuring certification, good supervision and support to surgeons (set targets for surgeons) Active screening necessary; “bridging strategy” needed (dependency on specific/dedicated TT funding). Monitoring of surgical failure & patient counseling implemented Scaling up trichiasis surgery

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