• Comprehensive Ophthalmology, Oculoplastics/Orbit

    This Current Insight outlines current evidence supporting surgical management strategies for trachomatous trichiasis.

    PLTR and BLTR: Two tried and tested techniques

    Published in the August 2017 issue of Ophthalmology, the study Predictors of Trachomatous Trichiasis Surgery Outcome compares 2 tarsal rotation surgeries: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR).

    Clinical trials have shown that PLTR and BLTR are more effective than alternative surgical procedures for the management of trachomatous trichiasis (TT) in trachoma-endemic settings. These tarsal rotation procedures are therefore recommended by the World Health Organization (WHO). 

    In particular, two trials examined the relative effectiveness of BLTR, tarsal advance and rotation, eversion splinting, tarsal advance (lid split), tarsal advance and grafting, and tarsal grooving. Both trials found the BLTR procedure to be superior than other strategies for the management of TT.1,2 Furthermore, BLTR can be readily taught to non-ophthalmologists, and can be easily and safely performed in rural health facilities. These are key advantages because, worldwide, most TT surgeries are delivered by non-physician health workers.

    ALR: An unknown entity

    To date, no randomized controlled trials have compared the anterior lamellar recession/repositioning (ALR) with either BLTR or PLTR for trachomatous trichiasis. One retrospective case series compared outcomes of BLTR and ALR procedures performed at different times. The study found a 46% risk of recurrance for BLTR and 17% risk for ALR, but these did not reach statistical significance.3 However, that study was limited by inconsistent follow-up times, a lack of surgeon standardization and an inadequate sample size, which make it difficult to draw meaningful conclusions.

    A prospective noncomparative study conducted in Egypt reported a 34% recurrence rate at 6 months after ALR.4 A prospective non-comparative series from Iran of 32 cases with upper lid cicatricial entropion found a 25% recurrance rate at 1 year for ALR combined with blepharoplasty (excision of excess anterior lamella) and supratarsal fixation.5 These recurrence rates are higher than those reported in a recent trial comparing PLTR and BLTR (13% and 22%, respectively, at 1 year).6

    In the aforementioned studies of ALR for TT, surgery was conducted by highly experienced surgeons; recurrence rates may be higher when performed by non-physician cadres with relatively limited training.7,8  Previous studies have consistently found that surgeon technique/ability is a crucial determinant of success.

    Drawbacks of ALR

    Critics have noted that ALR may not be sufficient for some phenotypes of TT because it does not address the posterior lamella. Therefore, it may prove ineffective in cases with severe posterior lamellar scarring and shortening, or cases with metaplastic lashes emanating from the posterior lamella, which occur commonly in trachoma.6,9-12 Because of this concern, ALR is usually reserved for cases with mild-to-moderate entropic trichiasis without metaplastic lashes emanating from the posterior lamella.

    The literature generally advises that ALR be modified and combined with other more complicated techniques for various phenotypes of trachomatous trichiasis.9 For instance, in cases of thickened tarsus, which is usually the case in TT patients, ALR should be combined with a tarsal wedge resection. For cases with lid retraction secondary to the scarred, shortened posterior lamella, ALR should be combined with dissection of the levator aponeurosis and Muller’s muscle, followed by advancing the tarso-conjunctiva.9 This individualized and tailored surgical approach may be suitable for highly skilled oculoplastic surgeons, but is not a practical strategy for nurses who manage a high volume of cases in trachoma-endemic settings. It would be difficult to tailor surgical procedures to the various stages of disease, given the current TT backlog that must be rapidly addressed to prevent ongoing incident visual impairment. Fortunately, the Ophthalmology paper and other studies of BLTR and PLTR have shown that these procedures are overall quite effective 'one size fits all' approaches that can be safely and effectively performed by trained non-physicians.  

    While some physicians suggest refraining from making an incision in the posterior lamella, there is no evidence to support this stance. By contrast, there is strong evidence to indicate that surgical procedures involving the posterior lamella should be employe for severe cases of TT with metaplastic lashes and major lid shortening. Specifically, tarso-conjunctival rotation procedures, such as the PLTR, can provide adequate 180° rotation of the lid margin.9,13-15

    Which surgery type is best?

    A recent trial result comparing PLTR with BLTR shows that PLTR is more effective against the full spectrum of TT cases, with a lower rate of postoperative trichiasis among cases of varying severity. The findings suggest that PLTR is preferable for use in the programmatic management of varied phenotypes of TT, and where surgeries are performed by non-physician cadres with limited training.6 It is worth noting that TT recurrence, when encountered, is almost always minor (less than five lashes). This dramatically reduces the risk of corneal scarring and blindness from  trichiasis.  

    In summary, the current literature indicates that tarsal rotation surgeries are superior to other approaches for the programmatic management of TT in trachoma-endemic settings. ALR has not been formally compared with tarsal rotation procedures, but is unlikely to be superior as it does not address the often-significant entropion caused by posterior lamella scarring.  

    References

    1. Reacher M, Huber M, Canagaratnam R, Alghassany A. A trial of surgery for trichiasis of the upper lid from trachoma. British Journal of Ophthalmology 1990; 74(2): 109-13.
    2. Reacher M, Muñoz B, Alghassany A, et al. A controlled trial of surgery for trachomatous trichiasis of the upper lid. Archives of Ophthalmology 1992; 110(5): 667-74.
    3. Barr K, Essex RW, Liu S, Henderson T. Comparison of trichiasis recurrence after primary bilamellar tarsal rotation or anterior lamellar repositioning surgery performed for trachoma. Clinical and Experimental Ophthalmology 2014; 42(4): 311-6.
    4. Ahmed RA, Abdelbaky SH. Short Term Outcome of Anterior Lamellar Reposition in Treating Trachomatous Trichiasis. Journal of Ophthalmology 2015; 2015: 568363.
    5. Aghai GH, Gordiz A, Falavarjani KG, Kashkouli MB. Anterior lamellar recession, blepharoplasty, and supratarsal fixation for cicatricial upper eyelid entropion without lagophthalmos. Eye 2016; 30(4): 627-31.
    6. Habtamu E, Wondie T, Aweke S, et al. Posterior lamellar versus bilamellar tarsal rotation surgery for trachomatous trichiasis in Ethiopia: a randomised controlled trial. The Lancet Global Health 2016; 4(3): e175-e84.
    7. Rajak SN, Collin JR, Burton MJ. Trachomatous trichiasis and its management in endemic countries. Survey of ophthalmology 2012; 57(2): 105-35.
    8. Burton MJ, Habtamu E, Ho D, Gower EW. Interventions for trachoma trichiasis. Cochrane Database of Systematic Reviews 2015; (11): CD004008.
    9. Kemp EG, Collin JR. Surgical management of upper lid entropion. The British journal of ophthalmology 1986; 70(8): 575-9.
    10. Rajak SN, Habtamu E, Weiss HA, et al. The Clinical Phenotype of Trachomatous Trichiasis in Ethiopia: Not All Trichiasis Is Due to Entropion. Investigative Ophthalmology & Visual Science 2011; 52(11): 7974-80.
    11. Rajak SN, Habtamu E, Weiss HA, et al. Absorbable versus silk sutures for surgical treatment of trachomatous trichiasis in Ethiopia: a randomised controlled trial. PLoS medicine 2011; 8(12): e1001137.
    12. Rajak SN, Habtamu E, Weiss HA, et al. Surgery Versus Epilation for the Treatment of Minor Trichiasis in Ethiopia: A Randomised Controlled Noninferiority Trial. PLoS Med 2011; 8(12): e1001136.
    13. Waddell K. A new clamp for bilamellar tarsal rotation for trachomatous trichiasis. Community Eye Health 2009; 22(69): 13.
    14. Kettesy A. ON GENESIS AND OPERATION OF THE CICATRICIAL (TRACHOMATOUS) ENTROPION OF THE UPPER LID. The British journal of ophthalmology 1948; 32(7): 419-23.
    15. Nasr AM. Eyelid complications in trachoma. I. Cicatricial entropion. Ophthalmic surgery 1989; 20(11): 800-7.