Orbis International. Trachomatous Trichiasis (TT) Surgery. A procedure using new clamp method

Transcription

1 Orbis International Trachomatos Trichiasis (TT) Srgery A procedre sing new clamp method

2

3 Trachomatos Trichiasis (TT) Srgery: A procedre sing new clamp method Prodced by: Orbis International Ethiopia Zelalem Eshet, MD, Ophth. Program Consltant Alemayeh Sisay, MD, MPH, Ophth. Contry Director Dereje Zewde, MBA, Depty Contry Director Yilikal Adam, MD, Ophth. Consltant Ocloplastics Srgeon, Addis Ababa University, Department of Ophthalmology External Gabremaskal Habtemariam, PhD Wond Alemayeh, MD, MPH General Manager and Consltant ophthalmologist at Berhan Pblic Health and Eye Care Consltancy Editors Egene Helveston, MD Orbis International, Consltant Ophthalmologist and Cyber-Sight Director Lynda Smallwood Orbis International, Senior Manager Cyber-Sight

4 Febrary, 2014

5 Table of Contents Introdction Part I: Trachoma Backgrond Trachoma - Definition Stages of Trachoma Stage 1 - Folliclar Conjnctivitis Stage 2 - Conjnctival Scarring Stage 3 - Trachomatos Trichiasis Stage 4 - Corneal Scarring Trachoma Magnitde Global Sb-Saharan Africa Ethiopia Impact of Trachoma Orbis Involvement in Trachoma Control in Ethiopia Trachoma Control Project Objectives Strategies Employed by Orbis to Control Trachoma TT Srgery Mass Drg Administration (MDA) Facial Cleanliness Environmental Improvement Implementation of the SAFE Strategy Challenges of Trachoma Prevention in Orbis Project Areas The Way Forward Part II: Trachomatos Trichiasis (TT) Srgery The Eye Step 1: Placement of Anesthetic Drops in Cl-de-sac Step 2: Injection of Anesthetic Step 3: Insertion of Clamp Step 4: Incision of Lid Step 5: Inspection of Incision Step 6: Placement of Stres Step 7: Tying of Stres Postoperative Corse Conclsion

6

7 Introdction This manal is designed to show a techniqe for trachomatos trichiasis (TT) srgery sing a clamp that protects the cornea, maintains hemostasis, and provides markers for standardizing the srgical techniqe. As an introdction to the sbject, backgrond information abot trachoma is inclded. This will enable the reader to nderstand the scientific backgrond of trachoma, the magnitde of the problem, and the Orbis experience with trachoma control in Ethiopia. The first part is based primarily on experience in Ethiopia with Orbis spported programs. However, the activity described can be sed as a model for a program in any part of the world where trachoma and trachoma-related blindness is a problem. Moreover, this information is intended for any local organization or international grop interested in and dedicated to this work wherever it can be carried ot. This manal is prepared in two parts. The first part deals with backgrond information for trachoma and the second part describes a srgical techniqe for TT srgery that employs a newly designed clamp that promises to promote faster, and safer, srgery with more predictable reslts. Part 1: Trachoma Backgrond Trachoma - Definition Trachoma is one of the oldest infectios diseases known to mankind. It is cased by Chlamydia Trachomatis a microorganism which spreads throgh contact with eye discharge from the infected person (on towels, handkerchiefs, fingers, etc.) and throgh transmission by eye-seeking flies. Trachoma is more likely to occr when general hygiene and cleanliness is lacking, water spply is limited, and environmental control with management of waste is inadeqate. After years of repeated infection with trachoma casing chronic conjnctivitis, the ndersrface of the eyelid (tarsal conjnctiva) of an individal becomes so severely scarred that the eyelid margin and/or eye lashes trn inward. This leads to a condition called entropion which in trn creates a condition that is called trachomatos trichiasis with the lashes rbbing on the eyeball, abrading the conjnctiva and cornea, leading to scarring of the cornea (the clear front of the eye). If ntreated, this constant rbbing of the lashes on the cornea reslts in irreversible corneal opacity and eventally blindness. A child with trachomatos conjnctivitis 1

8 Stages of Trachoma Stage 1 - Folliclar Conjnctivitis Stage 2 - Conjnctival Scarring Folliclar conjnctivitis is the first stage of trachoma. The second stage of trachoma is characterized by linear scarring of the pper tarsal conjnctiva (Arlt's line) leading to in-trning of the pper lid (entropian). Also shown: pits at the sperior limbs (Heberts pits) a characteristic reaction with trachoma. Stage 3 - Trachomatos Trichiasis Stage 4 - Corneal Scarring The forth stage of trachoma is corneal scarring casing redced vision as shown in the right eye of this patient. The third stage of trachoma is in-trning of the pper lid casing the lashes to trn inward and abrade the cornea creating a condition called trachomatos trichiasis (TT) in adlts with trichiasis. 2

9 Trachoma Magnitde Global Trachoma affects over 162 million people worldwide. Taylor in pts the prevalence at 146 million active cases, 10.6 million with trichiasis, and 5.9 million blind. Trachoma, once endemic in most of the world, is responsible at present for more than 3% of the world s blindness. Fortnately this nmber contines to get smaller as a reslt of socio-economic development and crrent control programs for this disease. 2 In spite of this, trachoma contines to be hyper-endemic (active trachoma more than 40%) in many of the poorest and most remote areas of Africa, Asia, Central and Soth America, Astralia and the Middle East. In hyper-endemic areas, active disease is most common in pre-school children with prevalence rates as high as 60-90%. 2 Trachoma tends to strike the most vlnerable members of commnities who are women and children. Adlt women are at mch greater risk of developing the blinding complication of trachoma than are adlt men. This increased risk has been explained by the fact that women generally spend more time in close contact with children who are the main reservoir of the infection. Sb-Saharan Africa The constant close proximity of mothers to chronically infected children leads to a mch higher incidence of vision threatening trachoma in women. Trachoma has been declining in many areas of the world largely de to increased se of antibiotics and some improvements in sanitation and water spply as well as economic developments; however it remains the second leading case of blindness in Africa. While trachoma is prevalent throghot mch of sb-saharan Africa, accrate statistics are not readily available becase in some areas there is too little reliable information to even estimate the brden of disease (WHO 2006). The blk of research on trachoma has been carried ot in Tanzania, Ethiopia, Gambia, Mali, and Malawi where stdies have shown that women accont for abot 75% of all trachomatos trichiasis and sbseqent blindness de to corneal scarring. Althogh the prevalence of active disease is similar for boys and girls, adlt women tend to be more severely affected becase of the aforementioned interaction with infected children. In some areas trachoma is holoendemic meaning that every child has active trachoma and every adlt shows some evidence of conjnctival scarring. At any one time, rates of active disease for children in Yong woman with trachomatos trichiasis endemic areas can range as high as 50%. 3 3

10 Ethiopia Trachoma is the second leading case of blindness in Ethiopia exceeded only by cataract. According to the national srvey condcted in 2006, trachoma acconts for 11.5% of all blindness and 7.7% of people with low vision. It is estimated that over 138,000 people in Ethiopia are already blinded by this disease. 4 The prevalence of active trachoma (AT) in children age 1-9 is 40% for the whole contry ranging from 0.5% to 62.6% depending on the region. 4 It is forfold higher in rral children compared with those in an rban environment. This disparity is largely de to poor sanitation and inadeqate water spply seen predominantly in rral areas. Over 9 million children aged 1-9 years have active infection. 4 Flies which are a vector for the spread of trachoma clster on the face of this child with conjnctivitis. Prevalence of trachomatos trichiasis (TT), a chronic form of trachoma, is estimated to be 3.1% for Ethiopia. This means there are an estimated 1.3 million people age 15 and above who are at risk of blindness nless treated rgently. The Sothern Nation Nationality Peoples Region (SNNPR), where an Orbis Rral Program is located, is the third most poplated (~ 15 million) region in Ethiopia among the 9 regional states and two city administrations. It is located in the sothern part of the contry and has more than 45 different ethnic grops. The SNNPR has a prevalence of trachomatos trichiasis (TT) of 2%, which is one of the highest in the contry. 4 Trachoma patients waiting for examination at a clinic 4

11 Orbis works in 4 zones and one special Woreda (district) in the SNNP region with an estimated poplation of 6 million. The prevalence of active trachoma in this region is 33%, which is third in magnitde behind the Amhara and Oromia regions which are the two largest regional states of the contry. Map showing Ethiopia with demographic facts Impact of Trachoma Frick et al., in attempted to assess the economic impact of trachomatos visal loss sing national srvey data on trachomatos blindness or visal impairment occrring since It was conclded that contries with known or sspected blinding trachoma have 3.8 million cases of blindness and 5.3 million cases of low vision reslting in a potential prodctivity loss annally of 2.9 billion US dollars. Trachomatos vision loss reslts in 39 million lifetime disability adjsted life years. This nmber is inflenced by the fact that trachoma affects more women and yong adlts who make p an especially prodctive component of society. Women have been called the backbone of hosehold prodctivity in developing contries like Ethiopia. Considering this and the feasibility of sccessfl interventions, Orbis International lanched a program aimed at the control and evental elimination of blinding trachoma beginning 12 years ago in Ethiopia. 2 5

12 Orbis Involvement in Trachoma Control in Ethiopia The Orbis Ethiopia contry office was officially registered in Between 2000 and 2001, a comprehensive assessment of the extent of blindness and low vision, inclding the prevalence of trachoma, was condcted in the Grage zone to learn more abot the magnitde of eye health problems from trachoma. Training for nrses enabling them to perform trichiasis srgery was initiated in 2000 and a stdy of the otcome of srgeries done by these trained nrses known as Integrated Eye Care Workers (IECWs) compared with that done by ophthalmologists was condcted. It was determined that reslts of srgery done by these two grops were comparable. 6 In 2002 and 2003, Orbis International Ethiopia (Enemor Woreda), in collaboration with World Vision Ethiopia (Artma Frsi Woreda ) and The Carter Center (Ebnat Woreda) implemented the World Health Organization s initiatives known by the acronym SAFE as a strategy for the control of blinding trachoma and its effects: Srgery, Antibiotic, Facial cleanness and Environmental hygiene. This program was carried ot in three districts or Woredas - as they are locally called. Additional fnding for this effort was obtained from International Trachoma Initiative (ITI) and Pfizer. This Orbis initiated project was the first of its kind designed to implement the SAFE strategy in Ethiopia. It inclded mass treatment of the affected poplations with Zithromax donated by Pfizer and trachomatos trichiasis (TT) srgeries for affected individals along with edcation on face washing and environmental improvement for all at the commnity level. Records were kept and the program moved forward based on lessons learned. Map of SNNP Region showing Orbis project areas shaded 6

13 Trachoma Control Project Objectives The project objectives were aimed at addressing each of the for components of SAFE as follows: Srgery Train nrses to perform trichiasis srgery and carry ot primary eye care. Eqip and spply health centers to deliver trichiasis srgery and primary eye care service to redce backlog of trichiasis throgh both static and otreach services. Determine the recrrence of TT after srgery with and withot Zithromax treatment at time of srgery. Develop and standardize training and certification of trichiasis srgeons. Antibiotics Redce prevalence of active trachoma throgh antibiotic (Zithromax) treatment aimed at redcing the pool of infection and interrpting transmission, as well as providing treatment of active infections throgh mass distribtion at health facilities. Provide information and edcation activities to the poplation to create awareness on how to prevent trachoma throgh the se of antibiotics. Carry ot a variety of different stdies on ways to improve the distribtion of Zithromax and to determine the effectiveness of this treatment. Face Washing Increase the level of nderstanding and awareness abot the vale of face washing throgh edcation in schools and in the commnity by prodcing and distribting edcational materials. Upgrade local water sorces to enable a safe and adeqate water spply. Collaborate with other NGOs working on water and sanitation improvement. Environmental Improvement Raise awareness to increase tilization of appropriate sanitary methods for the hman and animal waste and hosehold rbbish. Constrct model hosehold latrines to be sed in the commnity. Constrct school and commnal latrines in selected areas. Strategies Employed by Orbis to Control Trachoma Orbis has employed the WHO endorsed SAFE strategy for control of trachoma as described above in the belief that redcing one or more of the factors in the transmission of the bacteria that cases trachoma, Chlamydia Trachomatis, will redce the prevalence of blindness from trachoma. It wold be best to simply prevent trachoma by encoraging better personal hygiene, improved environmental cleanliness, and by controlling the flies that serve as vectors of transmission. However, once trachoma is prevalent and is considered a pblic health problem, it is necessary to apply all for components of the SAFE strategy for control. 7

14 TT Srgery Trachoma cases blindness after repeated infections of the eye, reslting in scarring of the conjnctiva that sbseqently plls the eyelid margins inward (i.e. toward the globe of the eye). This then cases the eyelashes of the inverted eyelid margins to rb on the cornea. This is called Trachomatos Trichiasis or TT. Over time, the in-trned eyelashes rbbing the cornea reslts in opacity/scar development. This changes the cornea from a clear transparent window to one that will not allow normal passage of light throgh the cornea, redcing vision and eventally casing blindness. This problem is best dealt with before serios cornea damage enses. Trachomatos trichiasis can be reversed by performing srgery on the in-trned eyelid retrning it to the original (normal) position. Mass Drg Administration (MDA) The second component of the SAFE strategy is treatment of the entire affected commnities with a potent antibiotic known as Azithromycin (Zithromax). Mass treatment is indicated when the level of active trachoma in a district is 10% or higher as measred by trachoma folliclar index (TFI). TFI is the percentage of children with folliclar conjnctivitis from trachoma infection. The Mass Drg Administration (MDA) addresses two important isses: the pool of infection at the commnity level, and treatment of active infection. This helps individals to remain free of trachoma that is also controlled with positive personal hygiene practices. Facial Cleanliness The third component is facial cleanliness. This is an important part of trachoma control strategy. It is aimed primarily at eliminating transmission of the infecting agent from nclean faces by flies, and as a means of maintaining individals in a trachoma free state after initial treatment is received throgh MDA. This is a key component of trachoma control in that it redces the rate of re-infection with trachoma. Environmental Improvement The forth component is environmental improvement. This is an important strategy for controlling flies which transmit the infecting agent for trachoma and which florish in an nclean environment. Breeding of flies can be redced by proper disposal of refse throgh brying or brning and of hman and animal waste by sing latrines and other appropriate methods that eliminate breeding places for flies. Spplying abndant clean water is also a goal. Implementation of the SAFE Strategy Implementation of the SAFE strategy begins with bilding the capacity of rral eye care facilities starting with training of varios cadres of eye care workers. These workers inclde health professionals sch as nrses who will lead the rral primary eye care service, perform eyelid srgeries on patients with TT, and provide other treatment for active trachoma. Nrses who are trained for one month in primary eye care inclding TT srgery are called Integrated Eye Care Workers (IECWs). When one or two IECWs are trained per health center, TT srgery sets are provided (three per center); sterilization eqipment and spplies are also provided initially. In order to be more effective, it is necessary to integrate the primary eye care activities within the reglar health service to make it sstainable. 8

15 Teachers in primary schools are trained to inform their stdents abot the prevention of trachoma throgh personal and environmental hygiene. Commnity level eye care personnel sch as Health Extension Workers (HEWs) and volnteers sch as Commnity Health Agents (CHAs) and Women Grop Leaders (WGLs) are trained to teach commnity members abot trachoma and tell them abot preventive measres sch as face washing and environmental cleanliness. These commnity eye care workers also identify and refer patients to Primary Eye Care Units (PECUs) where they can receive medical and srgical treatment for trachoma as needed. All cadres mentioned above shold receive close spport inclding annal refresher training to keep them motivated and to help them stay crrent with methods to provide qality eye care. It is also important to prodce targeted and effective key messages that these commnity eye care workers can se to edcate commnity members. As part of the overall spport to commnities to practice the whole SAFE package, it is necessary to address the overall problems of sanitation, something otside of the sal expertise of a blindness prevention organization sch as Orbis. This can be addressed by collaboration with other agencies who deal with clean water and sanitation tilizing their expertise and resorces. Sccess in the eradication of blinding trachoma will reqire a team effort. Challenges of Trachoma Prevention in Orbis Project Areas Lack of awareness of eye problems associated with trachoma on the part of the poplation and the decision makers A large proportion of the poplation is naware that trachoma is a water washed disease, and one that can be prevented by personal hygiene inclding face washing with soap every day. Many people are not aware that trachomatos trichiasis (TT) can be treated and blindness prevented in some cases throgh srgical interventions. There is a need for local decision makers to acknowledge that lack of eye care is a significant health problem. Lack of sitable spplies of clean water and of adeqate sanitation In addition to the lack of overall awareness, clean water and adeqate sanitation facilities are lacking in many areas, especially rral villages. This problem is exacerbated by a lack of coordination between responsible agencies. Limited availability of eye care services The type and volme of services that are crrently available are inadeqate. This is mainly de to scarcity of trained eye care professionals, lack of infrastrctre and spplies, and insfficient allocation of bdget for eye care. Affordability The majority of the poplation affected with trachoma is rral and lives in a low socioeconomic stats. Hoseholds for the most part depend on sbsistence farming. Even if services are available, srgery or medical treatment is naffordable not only de to direct cost, bt also indirect costs associated with transportation, accommodation, and food for most patients. It is especially difficlt to obtain services when travel is reqired. 9

16 Scarcity and high trnover of trained eye care professionals in rral areas There is a scarcity of eye care professional in rral areas. Part of this is de to attrition of IECWs reslting from the lack of a career pathway for eye care providers that wold attract them to the job and make them remain in a given location. Limited ownership of programs by the government There is poor resorce allocation on the part of the government particlarly for hman resorces. This contribtes to inadeqate monitoring and evalation and allocation of fnds to cover operational costs for eye care services. The Way Forward 1. Training of more eye care professionals inclding volnteers: Ensre availability of at least two IECWs (or a sfficient nmber according to poplation) to provide primary eye care services in each of the existing health centers in all project areas. In addition, collaborate with all stakeholders while contining to explore ways in which primary eye care is inclded in the training for health professionals with an emphasis on prevention. Train every new gradate health professional to be skilled in providing basic eye care; this cold ensre continity of services. Emphasize recritment of new IECWs for ophthalmic nrse training. 2. Strengthening ownership of the program by partners: This will ensre sstainability of services throgh integration of eye care into the general health services, increasing financial allocation, and cost recovery. 3. Establishing linkage between rral eye care nits with higher level eye centers: Establish linkage of Primary Eye Care Units (PECUs) with Secondary Eye Care Units (SECUs) for technical spport, referral, and backp for the PECUs. The niversities shold provide backp spport to Secondary Eye Care Unit activities in all areas of eye health care. 4. Identify and collaborate with organizations working in the area of water and sanitation in the project areas: Strive to create a common nderstanding among all stakeholders on their roles for ensring availability of clean water and sanitation for preventing eye disease. Training eye care workers Performing TT srgery 10

17 Part II: Trachomatos Trichiasis (TT) Srgery Trachomatos trichiasis (TT) is the chronic seqel of active trachoma. Epilation (removal of lashes) and srgery to evert the lid thereby redirecting the lashes away from the cornea, are two methods for treatment of trachomatos trichiasis (TT). Epilation is often performed at the commnity level and is sally done by patients themselves. However after simply plling ot the lashes, the new lashes that replace those that are plled ot are often sharp and more damaging to the cornea than the original in-trned or the remaining non-epilated lashes. Althogh entropion can recr in some cases after srgery, this is crrently the method of choice for treating TT. The two most widely practiced srgical procedres are: bilamellar tarsal rotation (BTR) and tarsal plate rotation (TPR/tarsatomy). BTR srgery is the srgical procedre recommended by the WHO for trachomatos trichiasis. This srgery is being done by eye care professionals in many parts of the world. Recently a new design for the instrment sed to perform BTR srgery has been introdced. It incldes a plate to protect the cornea and provide a srface for a clamp that controls bleeding and which can have design featres that marks the incision site leading to more consistency. One sch instrment was introdced by Dr. Keith Waddell and is manfactred by Collton in the UK. Orbis International is crrently sing this new clamp at tertiary eye centers and at Orbis rral field facilities. In the last year, ten IECWs and two ophthalmologists sed the clamp for srgery done on more than 100 patients. There were no recrrences dring the specified follow p period. The feedback from srgeons sing this new clamp has been niform. Their experience compared with a free-hand techniqe originally recommended by the World Health Organization is smmarized as follows: Advantages of the new clamp: Srgery time is redced. The throgh and throgh lid incision is made in one step. Less srgical eqipment is needed. Protection for the globe is provided. Bleeding is redced. Srgeons have more confidence when performing the srgery. Disadvantages: Need to have different sizes for different age and size of palpabral fissre Prolonged clamp placement casing redced blood flow Not available on the local market Cost The srgeon inspecting the srgical instrments. 11

18 The Eye In a normal eye, the pper lashes have a slight initial downward crve before sweeping pward clear of the eyeball itself, away from the cornea and conjnctiva [Figre 1A]. The lashes nmber 200 to 300, forming two or three rows with two-thirds being in the pper lid. They serve to protect the eye by engaging foreign material and by initiating a protective blink reflex. The lashes regenerate two or three times a year and grow back rapidly if ct. The lashes originate in follicles at the anterior lid margin associated with sebaceos glands of Ziess [Figre 1B]. The lash line is external to the stiff tarsal plate that contains meibomian glands and forms the posterior half of the lid margin. Figre 1A. Normal front view of external eye Figre 1B. Normal sagittal view of the anterior eye When trachomatos trichiasis (TT) is present, a portion of the pper lid lashes are plled inward casing them to toch the cornea and conjnctiva, prodcing irritation and redness of the conjnctiva and a more serios breakdown of the corneal srface that can, after time, reslt in reaction in the cornea that prodces scarring in the form of a whitish irreglar opacity, blocking clear vision and eventally reslting in blindness in many cases [Figre 2]. The case of the pper eye lashes trning in is scarring and contractre of the pper tarsal conjnctiva that occrs after prolonged infection (conjnctivitis) cased by chlamydia trachomatis [Figre 3]. It is common for affected individals to plck ot the offending eyelashes with tweezers bt this affords only temporary relief becase the eyelashes grow back and often are stiffer and more damaging than originally. Figre 2. The front view of trachomatos trichiasis (TT) with the eyes open 12

19 Figre 3A. This patient has moderate bilateral trachomatos trichiasis with a great deal of irritation and discomfort, bt the cornea is not yet affected with a whitish scar. Figre 3B. This patient has trachomatos trichiasis in both eyes with a beginning corneal opacification on the right. This is the set p of the sterile instrment tray sed for TT srgery [Figre 4]. The necessary instrments and material inclde: 1. Gaze, 2. Fenestrated eye drape, 3. Irrigation bottle, 4. Syringe and needle for injection of anesthetic, 5. Forceps, 6. Bard-Parker handle and knife (#15), 7. Waddell clamp, 8. Scissors, 9. Needle holder, 10. Hemostat. Figre 4. Instrments for TT srgery 13

20 Step 1: Placement of Anesthetic Drops in Cl-de-sac After the patient s eye lids and pper face have been washed with soap and thoroghly rinsed, anesthetic drops are placed in the clde-sac [Figre 5]. These drops can be sed liberally making sre that several drops reach the tisse to be anesthetized. A typical agent wold be tetracaine hydrochloride 1% or proparicaine hydrochloride 0.5%. Figre 5. Local anesthetic eye drops are instilled immediately after washing the face. Step 2: Injection of Anesthetic Xylocaine (lidocaine) 1% is injected sbctaneosly jst above the lid margin to inclde the fll width of the pper lid [Figre 6]. A small gage #30 needle is preferred. Abot 1or 2 cc of agent is injected. Figre 6. Injecting 2-3 ml of 2% local anesthesia into the pper lid. 14

21 The Waddell clamp for bilamellar tarsal rotation was introdced in 2009 [Figre 7]. The prpose of this clamp is to make the procedre for treatment of trachomatos trichiasis safer and more predictable especially in the hands of technicians who in Ethiopia are called integrated eye care workers (ICEWs). This clamp has five distinct featres: 1) A thin solid plate inserted beneath the lid to protect the cornea and serve as a platform for the fenestrated pper arm of the clamp 2) A slightly raised shelf on this plate to limit and standardize the placement of the clamp in relation to the lid margin 3) A fenestrated plate that clamps on the lid sfficiently tightly to provide hemostasis with an open center to carry ot the srgery on the lid 4) A mark on the fenestrated plate 3 mm from the shelf sed to locate the site of the throgh and throgh lid incision 5) A locking screw to tighten the clamp secring the lid between the plates Figre 7. Waddelll clamp 15

22 Step 3: Insertion of Clamp The Waddell clamp* is placed with the pper lid between the two plates of the clamp [Figre 8]. Before closing, the lower plate is advanced ntil the shelf abts the lid margin. With the clamp closed, the marks on the lateral arms of the fenestrated pper plate indicate the location of the lid incision. * A similar clamp that is less expensive has been described and is crrently nder clinical trial. [Merbs, SL,et.al, The Trachomatos Trichiasis Clamp, Arch Ophthalmology, Vol 130 (no.2) Feb 2012, pp ] A B Figre 8. A) The plate of the clamp is slid beneath the pper lid and the fenestrated arm is on top of the pper lid. The clamp is advanced ntil the shelf on the lower plate abts the lid margin. B) When the screw of the clamp handle is tightened, the lid is sqeezed between the plates and the fenestrated ring stopping blood flow and creating a bloodless field. 16

23 Step 4: Incision of Lid With the Waddell clamp placed, an incision is carried throgh the fll thickness of the lid. The solid lower plate ensres protection of the cornea. Note the bloodless field made possible by the placement of the clamp. Scissors may be sed to extend the incision flly at either end [Figre 9]. A B Figre 9. A) A Bard-Parker scalpel with a #15 blade is sed to make an incision throgh the fll thickness of the lid 3 mm from the lid margin as indicated by the mark on the clamp. B) The incision is completed laterally with scissors. The incision shold be the width of the clamp opening. 17

24 Step 5: Inspection of Incision The incision is inspected before placement of stres [Figre 11]. Note that the field remains bloodless. Figre 11. Checking the completely incised eye lid Step 6: Placement of Stres Stres are now placed beginning with the needle entering at the pper conjnctival srface and passing throgh tarss exiting beneath orbiclaris. In the techniqe shown, a single heavy needle with an eye is sed with 4-0 black silk stre* [Figre 12]. The field remains bloodless while stres are being placed. * Some srgeons se absorbable stre to avoid the need to retrn for stre removal. Figre stre placed in the proximal segment of the tarss entering from the conjnctival side on a heavy ctting eyed needle. 18

25 After the first stre pass, the needle is re-loaded with the other end of the stre and a second arm of the stre is broght throgh the tarss from the conjnctival side in a mattress fashion [Figre 13]. A B Figre 13. A) The needle is removed and re-loaded with the other end of the stre and a similar pass is made. B) The first half of the mattress stre has been completed. Two additional stres are placed in a similar manner into the pper lip of the lid incision [Figre 14]. The start of a mattress stre in the pper margin of the incision is shown. Figre 14. Three mattress stres are now placed in the proximate segment of Tarss. 19

26 Each arm of the stres placed in the pper margin of the lid incision is loaded on the needle and the needle is passed throgh orbiclaris mscle exiting throgh skin jst above the lash line [Figre 15]. This procedre is repeated to complete the placement of the three mattress stres [Figre 16]. Figre 15. The stres are placed in the distal segment of the lid by passing sperficial to the tarss (throgh the mscle between the tarss and skin), completing placement of the mattress stres. A B Figre 16. A) One mattress stre has been completed. B) All three mattress stres are placed and are ready for tying. 20

27 The path of each stre is as follows: 1) Enter throgh the conjnctival srface of the pper margin of the incision; 2) Enter tarss, pass throgh the sbstance and exit between tarss and orbiclaris; 3) Enter the lower incision margin above the tarss at the level of the orbiclaris; 4) Exit throgh skin jst above the lash line. Figre 17. The essence of this procedre is to evert the distal lid by abtting the proximal tarss. Step 7: Tying of Stres Each of the mattress stres is tied secrely with a srgeon s knot* [Figre 18]. * A srgeon s knot is a modification of the sqare or reef knot. It differs by having an extra twist or a doble overhand knot in the first twist and a single on the second. This provides more friction and prodces a more secre knot. Figre 18. Tying the mattress stres secrely. 21

28 With all three knots tied secrely, the lid margin is everted [Figre 19]. Figre 19. Knots after tightly tying the stres. Note the path of the stres throgh conjnctiva and tarss at the pper limb of the incision and throgh orbiclaris and skin at the lower limb of the incision. This in effect everts the lid margin [Figre 20]. Figre 20. A) Shown in frontal view. B) Shown in sagittal plane. 22

29 Post Operative Corse After srgery the patient ses antibiotic ointment once or twice a day. An overcorrection is seen early, partly de to edema from se of the clamp and from the srgery itself. Stres are removed in one week [Figre 21]. A B C D E F Figre 21. The patient is shown: A) Pre-operative; B) Immediately post operative; C) Day one - post operative with lids open and closed; D) Day 7 - post operative before stre removal; E) Day 7 - post operative stre removal; F) Appearance of the lids after removal of the stres. 23

30 Conclsion Orbis trained integrated eye care workers (IECWs) who had been sing the free hand techniqe for trachomatos trichiasis (TT) srgery as recommended by the World Health Organization (WHO) were provided instrction in the se of the new Waddell clamp. After sccessflly completing the training, these workers and the ophthalmologist who trained them performed TT srgery on more than 100 patients in the corse of a year. After this experience the ICEWs reported the following: 1) srgery time was redced; 2) there was less bleeding; 3) the operators had more confidence; 4) the srgery was condcted in a more controlled and standardized manner; and 5) the chance of harming the cornea was eliminated becase of protection provided by the clamp. This experience in Ethiopia sggests that a techniqe for TT srgery that provides protection for the cornea, creates a bloodless field, and offers a way to standardize the procedre shold be considered by anyone doing this type of srgery. The Waddell clamp which tilizes the principle that provides all of these advantages is one sch clamp. Another clamp designed by Merbs that is lower cost and comes in different sizes is now ndergoing evalation. This manal is not intended to endorse a specific clamp bt instead to alert those who will be doing this type of srgery to consider sing some type of clamp that offers the advantages described here. References 1. Taylor HR. Trachoma: A Blinding Scorge from the Bronze Age to the Twenty First Centry, Victoria, Astralia: Haddington Press, World Health Organization (WHO). Prevention of Blindness and Visal Impairment: Trachoma. Available at: Accessed Jly 24, Lewallen S, Cortright P. Blindness in Africa: present sitation and ftre needs. Br. J. Ophthalmology 2001; 85: Berhane Y, et al. National srvey on blindness, low vision and trachoma in Ethiopia: Methods and stdy clsters profile (2006). Ethiop. J. Health Dev. 2007; 21(3): Frick KD, Hanson CL, Lacobson GA. Global brden of trachoma and economics of the disease, Am J Trop Med Hyg 2003; 69:(5 sppl): Alemayeh W, et al. Srgery for trichiasis by ophthalmologists verss integrated eye care workers: a randomized trial. Ophthalmology 2004; 111:

31

32 Copyright 2014