Surgery for trichiasis by ophthalmologists versus integrated eye care workers: a randomized trial.

Objective: To study the outcome of bilamellar tarsal rotation (BTR) trichiasis surgery performed by ophthalmologists versus that done by integrated eye care workers (IECWs).

Design: Randomized prospective interventional trial.

Participants: Nine hundred eighty-two patients with various degrees of trachomatous trichiasis in central Ethiopia.

Methods: 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.

Main Outcome Measures: Recurrence rate, recurrence difference in the various grades, and difference between surgeries done by ophthalmic surgeons and those done by IECWs.

Results: 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.

Conclusion: 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.