Cryotherapy for trichiasis in trachoma

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.

Management of trichiasis with lid margin split and cryotherapy

Purpose

To evaluate outcomes of lid margin split with cryotherapy to the anterior lid lamella for treating trichiasis.

Methods

This prospective study included 20 eyelids of ten patients with trichiasis who were treated with lid margin split and cryotherapy. All patients were followed up for 6 months.

Results

Eighteen eyelids (90%) were successfully treated, and two eyelids (10%) developed recurrence within the follow-up period.

Conclusion

Lid margin split with cryotherapy is an effective and safe method for treating trichiasis.

Trachomatous trichiasis and its management in endemic countries

Trichiasis is the sight-threatening consequence of conjunctival scarring in trachoma, the most common infectious cause of blindness worldwide. Trachomatous trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, trichiasis, and ultimately blinding corneal opacification. The disease causes painful, usually irreversible sight loss. Over eight million people have trachomatous trichiasis, mostly those living in poor rural communities in 57 endemic countries. The global cost is estimated at US$ 5.3 billion. The WHO recommends surgery as part of the SAFE strategy for controlling the disease.We examine the principles of clinical management, treatment options, and the challenging issues of providing the quantity and quality of surgery that is needed in resource-poor settings.

Eradicating blinding trachoma: What is working?

Trachoma remains the leading cause of preventable corneal blindness in developing countries. The disease is contracted in early childhood by repeated infection of the ocular surface by C. trachomatis. Initial clinical manifestation is a follicular conjunctivitis which if not treated on timely basis, may lead to conjunctival and eyelid scarring that may eventually result in corneal scarring and loss of vision. Over the past two decades, a remarkable reduction in the prevalence of active trachoma has occurred due to the World Health Organization's (WHOs) program GET 2020 for the elimination of trachoma with adoption of the SAFE strategy incorporating Surgery, Antibiotic treatment, Facial cleanliness and Environmental hygiene. However, patients who already had infection at young age may present with adnexal-related complications of trachomatous scarring that may cause corneal scarring and visual loss. These patients may present with evidence of trichiasis/entropion as well as eyelid retraction. Lacrimal complications may include nasolacrimal-duct obstruction, dacryocystitis and canaliculitis requiring intervention. In addition to the increased risk for corneal scarring, trichiasis/entropion may further increase the risks for microbial keratitis in patients who may have unrecognized dacryocystitis and canaliculitis. Female patients may have more trachomtous-related complications and may present at an early age. Available evidence indicates that SAFE strategy may be effective and on the right track towards achieving GET 2020 goal for the eradication of trachoma.

A critical review of the SAFE strategy for the prevention of blinding trachoma

Trachoma is an ocular disease caused by repeated infection with Chlamydia trachomatis. It is the leading cause of infectious blindness globally, responsible for 5.9 million cases of blindness. Although trachomatous blindness is untreatable, it is eminently possible to prevent and the World Health Organization promotes the use of the SAFE strategy (surgery to treat end-stage disease, antibiotics to reduce the reservoir of infection, facial cleanliness, and environmental improvement to reduce transmission of C trachomatis) for this purpose. In this review we have assessed the evidence base supporting the elements of the SAFE strategy. We find strong support for the efficacy of the surgery and antibiotics components, although the optimal antibiotic regimens have not yet been established. The evidence for an effect of health education and environmental improvement is weaker, and depends mostly on cross-sectional observational studies.

Direct internal eyelash bulb extirpation for trichiasis

PURPOSE

To evaluate the success of internal eyelash bulb extirpation in the management of trichiasis.

METHODS

The procedure was performed on 26 consecutive eyelids.

RESULTS

Our technique was successful in all cases, with no recurrence of signs or symptoms.

CONCLUSIONS

Internal eyelash bulb extirpation is a safe and effective technique to remove trichiatic lashes, while avoiding injury to the conjunctiva.

Anterior tarsal V-wedge resection for cicatricial entropion

PURPOSE

To determine the effectiveness of using a radiofrequency instrument to resect a V-shaped tarsal wedge for the correction of cicatricial upper eyelid entropion.

METHODS

Prospective evaluation of 16 upper eyelids of 11 consecutive patients.

RESULTS

The operation was successful in all 16 eyelids, with excellent cosmetic and functional outcomes.

CONCLUSIONS

Tarsal V-wedge resection is an effective alternative to other complicated techniques in the management of upper eyelid cicatricial entropion.

Cryotherapy for trichiasis in ocular cicatricial pemphigoid

Trichiasis is a common and potentially sight threatening complication of ocular cicatricial pemphigoid and is usually secondary to cicatricial entropion. This study aimed to assess the success and complications of eyelid cryotherapy for trichiasis in a group of patients with long term follow up. The case records of all patients with ocular cicatricial pemphigoid that attended the external disease clinic at Moorfields Eye Hospital from 1980 to 1992 were reviewed. Each eyelid was divided into three horizontal zones. Cryotherapy was delivered with an Amoilette cryoprobe for approximately 30 seconds. Failure of the cryotherapy was defined as a regrowth of the eyelashes within the treated zone that either required epilation for symptom control or caused keratopathy. Ninety two lid zones were treated, involving 25 lids of 12 patients. The cumulative chance of success decreased rapidly to 40% over the first year. Thereafter, the chance of success declined slowly to 34% at 4 years. Complications included lid notching (n = 2), tarsal atrophy (n = 1), altered lid contour (n = 1), and temporarily raised intraocular pressure (n = 1). All patients had quiescent disease at the time of the cryotherapy and no patients showed increased conjunctival disease activity after treatment. Six patients were taking systemic immunosuppression medication. When ocular cicatricial pemphigoid is quiescent, lid cryotherapy has an acceptable complication rate. The major reason for recurrence of the trichiasis was attributed to inadequate follicle freezing.

Argon laser treatment of trichiasis

The argon laser was used to treat trichiasis in 44 patients over a five-year period. During follow-up intervals of between one month and more than four years (mean, 13 months), ablation of misdirected cilia was accomplished with one treatment in 26 patients (59%). No complications were observed. Laser is less effective than cryotherapy for destroying aberrant eyelashes, but cryotherapy is less precise and incites greater posttreatment inflammation. Argon laser treatment is a useful option when only a few, scattered eyelashes require ablation or in patients with disorders such as ocular pemphigoid, in which the stimulation of inflammation is undesirable.