• Using data from a large randomized trial, investigators analyzed intra- and post-operative factors that are vital in shaping trichiasis surgery outcomes.

    Study design

    This secondary analysis included 1,000 patients with trachomatous trichiasis (TT) who underwent bilamellar tarsal rotation (BLTR) or posterior lamellar tarsal rotation (PLTR). Postoperatively, patients were evaluated for recurrent trichiasis, eyelid contour abnormalities and granuloma formation at 6 and 12 months by masked graders. 

    Outcomes

    Factors protective of postoperative TT recurrence included:

    • Extending the length of the incision medially and laterally for both PLTR and BLTR
    • Peripherally dissecting with scissors in PLTR and BLTR
    • External incision height of <4 mm in BLTR

    Contour abnormalities were more often observed with suture interval asymmetry of >2 mm in PLTR.  Irregular posterior lamellar incision at the center of the eyelid in PLTR resulted in granuloma formation. 

    Limitations and clinical significance

    This study compares 2 surgeries that are recommended by the World Health Organization (WHO) for the treatment of trachomatous trichiasis, the leading infectious cause of blindness worldwide. The study is well designed with adequate numbers to evaluate factors that influence the success of PLTR and BLTR. 

    In treating TT, one must extend the length of the incision medially and laterally for both PLTR and BLTR.  Doing so allows the distal segment to rotate adequately. Surgical incision height should be approximately 3 mm for both PLTR and BLTR, and the incision should be marked prior to anesthesia for BLTR. Sutures should be evenly spaced and tightened firmly. 

    However, despite the surgical pearls offered above, the overall failure rates of these surgeries are significant (at least 20%), causing one to question if these techniques are appropriate to treat this condition. Other studies have reported greater success with splitting the anterior and posterior lamella, followed by recession of the anterior lamella, therefore refraining from making an incision in the posterior lamella. Although it is understandable that the WHO has contributed significant resources to training individuals to perform BLTR and PLTR, one questions the rationale in teaching procedures that may be inferior to other alternatives. This study would be enhanced by including a group undergoing anterior lamellar recession in the treatment of TT.