Trachoma: can trichiasis be treated with a sticking-plaster? A randomized clinical trial in China. A trial of surgery for trichiasis of the upper lid from trachoma. A controlled trial of surgery for trachomatous trichiasis of the upper lid. A randomized clinical trial of the success rates of bilamellar tarsal rotation and tarsotomy for upper eyelid trachomatous trichiasis. A randomised controlled trial of azithromycin following surgery for trachomatous trichiasis in the Gambia. Surgery for trichiasis by ophthalmologists versus integrated eye care workers: a randomized trial. Clinical cure of bacterial conjunctivitis with azithromycin 1%: vehicle-controlled, double-masked clinical trial. Should trichiasis surgery be offered in the village? A community randomised trial of village vs. health centre-based surgery. Randomised controlled trial of anterior-chamber intraocular lenses.
Trachoma is the most frequent cause of preventable blindness in the world. At the trichiasis/entropion stage, lid surgery is recommended, but many patients only use epilation, which does not prevent loss of vision. We developed a new treatment that should be more accessible than lid surgery and more effective than epilation: a sticking plaster that forces eyelashes back to their correct position. The first randomized controlled trial was conducted in Shanghai with 57 patients to compare the plaster method with epilation. After 3 months of follow-up, with no attrition, 67% of those treated by the new method presented a good clinical status, vs none of those treated by epilation (P < 0.001). The new treatment was well tolerated and lid function remained normal. Although our results show overwhelming benefit of this new, simple treatment for trachoma at the trichiasis stage, more research is needed at the primary health care level and in other settings to determine the potential use of the new method on a large scale and by nonspecialists. Three surgeons operated on upper eye lids of northern Omani villagers for trichiasis due to trachoma using a standardised protocol. The lids were graded as minor trichiasis, five or fewer lashes; major trichiasis, six or more lashes; and lid closure defect. Operative success was defined as no lash/eyeball contact and complete gentle lid closure. One hundred and sixty five lids with major trichiasis were allocated by random number tables to one of five operations: bilamellar tarsal rotation (Ballen), tarsal advance and rotation (modified Trabut), eversion splinting (grey line), tarsal advance (lid split), and tarsal grooving (Streatfield-Snellen) operations. Bilamellar tarsal rotation was significantly more successful than eversion splinting (chi 2 = 7.0, p less than 0.01); tarsal advance (chi 2 = 12.4, p less than 0.001), and tarsal grooving (chi 2 = 23.7, p less than 0.001), but not significantly more successful than tarsal advance and rotation (chi 2 = 2.9, p greater than 0.05). Two of 32 (6%) lids with lid closure defect were successfully treated with tarsal advance; trichiasis was relieved in nine and lid closure defect in 10. It is suggested that bilamellar tarsal rotation and tarsal advance and rotation are effective operations for major trichiasis, but tarsal advance is ineffective where trichiasis and lid closure defect coexist. The effectiveness of commonly used procedures to correct trachomatous trichiasis of the upper lid was examined in a clinical trial in Oman. Lids were graded as having minor trichiasis (five or fewer lashes), major trichiasis (more than five lashes), and defective lid closure. Randomly allocated surgery specific for lid grade was completed in 384 lids, of which 369 (96%) were followed up once or twice approximately 9 and 21 months after surgery. The definition of operative success included no evidence of trichiasis and complete lid closure. Tarsal rotation was the most effective operation and was successful in 80% of cases of minor trichiasis, compared with success rates of 29% for electrolysis and 18% for cryoablation. Tarsal rotation was successful in 77% of cases of major trichiasis, compared with a 41% success rate for tarsal advance and rotation. Surgery for major trichiasis produced a significant improvement in visual acuity in operated vs nonoperated fellow eyes in a regression model incorporating the between-eyes correlation of visual acuity. A randomized clinical trial study was conducted to compare the success rates of two surgical methods: Bilamellar Tarsal Rotation (BTR) and Tarsotomy (Transverse Tarsotomy and lid margin Rotation = TTR) for trachomatous trichiasis of the upper lid; where success was defined as no lash/eyeball contact in all positions of gaze, complete lid closure, no under or over correction. The study was conducted at Minellik II Hospital, Addis Ababa. Two hundred fifty six upper eyelids of 153 patients with entropion/trichiasis related to trachoma were enrolled in the two groups. Patients were randomly allocated for the BTR (124) and TTR (132) procedures. Out of these, 237 (92.6%) came for the third month follow-up. One hundred fifteen (48.5%) lids underwent BTR and the remaining 122 (51.5%) underwent TTR. In total, from 141 patients who came for the last follow up, 109 (77.3%) were females. BTR procedure was found to be successful in 25 (86.2%) of the eyelids with minor trichiasis and 74 (86.0%) of those with major trichiasis; the difference between patients who had had minor and major trichiasis (X2 = 0.08, P = 0.772) was not statistically significant. TTR was successful in 39 (95.1%) of the eyelids with minor trichiasis and 68 (84.0%) of those with major trichiasis, again no statistically significant difference was observed for minor and major trichiasis (X2 = 3.15, P = 0.379). There was no statistically significant difference in recurrence between BTR and TTR (X2 = 0.14, P = 0.711). Complications such as lid-notching, pyogenic granuloma, etc. were observed more in BTR than in TTR and this was statistically significant (X2 = 9.54, P = 0.002). In conclusion, the results show that TTR is equally successful in minor and major trichiasis and has fewer complications than BTR at three months of follow-up. Trachomatous trichiasis frequently returns following surgery. Several factors may promote recurrence: preoperative disease severity, surgeon ability, surgical procedure, healing responses, and infection. This study investigates whether enhanced control of infection, both of Chlamydia trachomatis and other bacteria, with azithromycin can improve surgical outcome in a trachoma control programme.
                Individuals with trachomatous trichiasis were examined and operated. After surgery patients were randomised to the azithromycin or control group. The azithromycin group and children in their household were given a dose of azithromycin. Antibiotic treatment was repeated at 6 months. All patients were reassessed at 6 months and 12 months. Samples were collected for C trachomatis polymerase chain reaction and general microbiology at each examination.
                451 patients were enrolled. 426 (94%) were reassessed at 1 year, of whom 176 (41.3%) had one or more lashes touching the eye and 84 (19.7%) had five or more lashes. There was no difference in trichiasis recurrence between the azithromycin and control group. Recurrent trichiasis was significantly associated with more severe preoperative trichiasis, bacterial infection, and severe conjunctival inflammation at 12 months. Significant variability in outcome was found between surgeons. Visual acuity and symptoms significantly improved following surgery.
                In this setting, with a low prevalence of active trachoma, azithromycin did not improve the outcome of trichiasis surgery conducted by a trachoma control programme. Audit of trichiasis surgery should be routine. To study the outcome of bilamellar tarsal rotation (BTR) trichiasis surgery performed by ophthalmologists versus that done by integrated eye care workers (IECWs).
                Randomized prospective interventional trial.
                Nine hundred eighty-two patients with various degrees of trachomatous trichiasis in central Ethiopia.
                Trachomatous trichiasis patients in 3 woredas (districts) in central Ethiopia were enrolled. Trichiasis severity was graded. Patients were randomly assigned to surgery by 2 ophthalmologists and 2 IECWs. On the seventh day postoperatively, patients were evaluated for undercorrection or other complications. If trichiasis was present, it was considered a failure of surgery (technical failure), and patients were excluded from the follow-up study, but repeat surgery was performed. Those patients with good correction at the seventh day were examined again on the third and sixth months. Further follow-up evaluation is planned for the first, second, and third years postoperatively.
                Recurrence rate, recurrence difference in the various grades, and difference between surgeries done by ophthalmic surgeons and those done by IECWs.
                In the third month of follow-up, it was possible to locate 713 (73.0%) of the operated patients. Eighty-one of 713 (11.4%) individuals and 94 of 1286 (5.4%) operated lids developed recurrent trichiasis in this period. There was a linear trend of recurrence with grading (severity) at baseline (chi(2) = 22.017, P<0.001), but there was no difference in recurrence by age (chi(2) =1.53, P = 0.9 at the third month; chi(2) = 1.43, P = 0.9 at the sixth month). There was also no difference with regard to gender (0.38 < odds ratio < 1.14, P = 0.1). The recurrence observed in the group of individuals operated on by ophthalmologists at the 3-month follow-up was 47 (12.1%) lids, and the recurrence observed in the group operated on by the IECWs was 34 (9.9%) lids, with no statistically significant difference (chi(2) =1.38, P = 0.24, 95% confidence interval [CI], -18% to 74%). At the 6-month follow-up, 43 (6.2%) persons had recurrence (95% CI, 4.4%-8%). There was no statistically significant difference between the 2 groups of surgeons at the 6-month point of follow-up examination (chi(2) = 4.46, P = 0.2). The overall recurrence was 124 (14.3%) lids within the first 6 months.
                Recurrent trichiasis is common, especially in cases where the degree of trichiasis is severe at baseline. This suggests that these patients may need surgical overcorrection to decrease the recurrence rate. The outcome of BTR surgery done by IECWs is similar to that of the ophthalmic surgeons. Because of these findings, we recommend that training of IECWs in trichiasis surgery may help to ameliorate the effects of the eye care worker shortage in developing countries. To analyze the effect of azithromycin 1% ophthalmic solution in DuraSite (InSite Vision, Inc, Alameda, California, USA) on bacterial conjunctivitis.
                Prospective, randomized, vehicle-controlled, parallel-group, double-masked multicenter clinical study.
                Eligible male or female participants with a clinical diagnosis of acute bacterial conjunctivitis were randomized to either 1% azithromycin in DuraSite or vehicle for five days. Infected eyes were dosed twice daily on days 1 and 2 and once daily on days 3 through 5. Conjunctival cultures were obtained at baseline, visit 2 (day 3 or 4), and visit 3 (day 6 or 7). The primary end point was clinical resolution of signs and symptoms (rating of zero on ocular discharge, bulbar and palpebral injection) at visit 3. Efficacy measures were clinical resolution and bacterial eradication as evaluated in the per-protocol population. Safety was assessed by adverse events, slit-lamp findings, and ophthalmoscopy.
                Two hundred and seventy-nine participants (n = 130, 1% azithromycin in DuraSite; n = 149, vehicle), age one to 96 years, were evaluated for efficacy. Clinical resolution with azithromycin ophthalmic solution was statistically significant compared with that of vehicle (P = .030) at visit 3. Bacterial eradication rates with azithromycin ophthalmic solution reached 88.5% at visit 3 (P < .001) and included some pathogens resistant to azithromycin in vitro. Overall, adverse event rates were similar in both treatment groups.
                Azithromycin 1% ophthalmic solution in DuraSite showed statistically significant differences in clinical resolution and bacterial eradication rates when compared with vehicle. Because it was well tolerated in this population, it may be a viable treatment option for children and adults with bacterial conjunctivitis. Surgery for trachomatous trichiasis prevents blindness and is advocated by the WHO as part of the SAFE strategy for the global elimination of trachoma. We conducted a randomised community trial to investigate the effect of providing surgery in villages on surgical uptake in The Gambia.
                56 villages from two divisions were assigned to eight pairs of clusters matched by geographical division and proximity. One cluster from each pair was randomly assigned to receive village-based surgery and the other cluster health centre-based surgery. Outcome measures were uptake rates and surgical results after 1 week and 3 months. The paired t-test was used to analyse the results.
                Overall uptake was 66% in the village-based clusters and 44% in the health centre-based clusters. Subjects in the village-based surgery arm had significantly shorter journey times (P = 0.01) and lower costs (P = 0.002). The mean difference in absolute acceptance rates of surgery was 20% better in village-based clusters (95% CI -9 to + 49%, P = 0.15), which would equate to an improvement of 45% (95% CI -20% to 120%) on the average acceptance rates of 44% in the health centre-based group.
                These results strongly suggest better surgical uptake when surgery is provided in patients' villages due to lower cost to the patient, time saved and less fear of the operation. There are an estimated 16 million people blind in both eyes with cataracts. Most live in rural areas of developing countries where surgical resources are scarce. There is no consensus on the most appropriate type of intraocular lens in situations where high-volume low-cost surgery is required. This study was undertaken to evaluate the safety of multiflex open-loop anterior-chamber lenses (ACIOLs).
                2000 people attending Lahan Eye Hospital, southern Nepal, with bilateral cataracts reducing vision to 6/36 or less were randomly allocated to receive standard surgery--intracapsular extraction (ICCE) with aphakic correction--or ICCE with an ACIOL in their first operated eye. The primary outcome was a visual acuity of less than 6/60 in the operated eye at 1 year follow-up. Visual acuity was measured for 91% of the cohort at 1 year. The sample size was estimated to detect a doubling in poor visual outcome from an estimated rate of 4% in the standard surgery (control) group.
                The median (range) time taken to do the surgery was 6.0 (3.0-17.2) min for the ACIOL group and 4.1 (2.4-10.3) min for the control group. 1 year after surgery, 5.0% of the ACIOL group and 5.4% of controls had functional vision less than 6/60 (OR 0.93 [0.60-1.43], p = 0.71). The causes of poor vision in the ACIOL and control groups were: correctable refractive error (22 and 29), uveitis/secondary glaucoma (13 and two), endophthalmitis (four and seven), pre-existing eye disease (four and five), retinal detachment (none and four), cystoid macular oedema (two and none), corneal ulcer (one and one), and corneal decompensation (none and one).
                This study provides evidence that, in rural areas of developing countries, multiflex open-loop ACIOLs can be implanted safely by experienced ophthalmologists after routine ICCE, avoiding the disadvantages of aphakic spectacle correction. Further follow-up is planned.
No trials show interventions for trichiasis prevent blindness. Certain interventions have been shown to be more effective at eliminating trichiasis. Full thickness incision of the tarsal plate and rotation of the lash-bearing lid margin through 180 degrees is probably the best technique and is preferably delivered in the community. The use of double-sided sticking plaster is more effective than epilation as a temporary measure. Surgery may be carried out by an ophthalmologist or a trained ophthalmic assistant. The addition of azithromycin treatment at the time of surgery does not appear to improve outcomes.