Letters. Epilation for trichiasis
In response to the letter by Dr Margreet Hogeweg in Issue 18 of Community Eye Health (1996; 9: 32), we have received two letters on epilation for trichiasis. Each reflects a different approach, based on the availability of services and resources in the community concerned. We would welcome further correspondence, experience and views from our readers.
With great honour, we hereby make a response to the letter from Dr Hogeweg, which we read with interest.
Epilation is easy to teach, affordable and can be made available in the community. Following epilation, however, the new eyelashes are sharper and tend to damage the cornea even more. The biggest problem is that if patients epilate their lashes now and then, they rarely turn up for the Bilamellar Tarsal Rotation Procedure (BTRP) until the lashes have grown again, causing further damage and pain. For these reasons and because we have all the facilities for BTRP, we have stopped doing epilation for trachomatous trichiasis.
In the central part of Tanzania a lot has been done concerning the problem of trichiasis. We have all the basic instruments required for BTRP. Patients are treated free because of well established collaboration between the Central Eye Health Foundation and other non-governmental organisations, e.g., Helen Keller International, Edna McConnell Clark Foundation, Christoffel Blindenmission and the Ministry of Health. In Dodoma Region alone, a total number of 5,762 patients with trachomatous trichiasis had surgery between January 1984 and June 1996.
The last 10 years have seen more than 40 people trained by our eye programme to carry out BTRP, firstly to cover the central part of the country and then 10 regions where trachoma is a problem. All are supplied with BTRP basic sets of instruments. We have followed up each of our trainees. A total number of 8,769 eye patients have received eye care through this plan, and bi-monthly reports are sent to us. Bilamellar Tarsal Rotation Procedures have been performed on 259 patients in the respective areas. The major problem is lack of transport to enable them to do outreach eye work.
The Bilamellar Tarsal Rotation Procedure is the long-term solution in dealing with trichiasis. A study of 150 patients with trachomatous trichiasis was carried out in our region in 1991. After BTRP, follow-up assessments were done at six months, nine months and 18 months to check whether any of the operated patients had recurrences. At the 18 month follow-up, 99% of patients showed no recurrences. Vision also improved from category 3 to category 0 (WHO visual categories) in the majority of patients. One patient died during the study from chest infection. If resources would be made available to us, we would like to do a five year follow-up on these patients as it is now exactly five years since we operated on them.
Plans are underway to reproduce this expertise for other regions. So far only 10 regions have been covered. More support is needed so these pioneers can train others and travel to remote areas around their working stations. Out of the 17 eye workers who attended the intensive workshop on BTRP, using the WHO training manual (WHO/PBL/93.29), 13 have trained one staff member each for their eye clinics. Thus, we have doubled the number within a year. The Central Eye Health Foundation is working on how to get more resources for this newly-trained group.
Village health workers (VHWs) are very good at identifying cases and arranging for trichiasis clinics in their respective villages. VHWs follow up their patients and, if there are any problems, they consult us. Compliance has been better during the last 10 years than before because those who improve tend to bring their family and friends to us for examination and subsequent treatment.
Epilation for trachomatous trichiasis is a temporary measure and, in our view, can be a dangerous one. We conclude that BTRP is the way to go in treating patients with trachomatous trichiasis.
Dr B B O Mmbaga DCEH PO Box 1323, Dodoma, Tanzania
Mr Sidney Katala CCEH PO Box 192, Kongwa, Dodoma, Tanzania
With great interest, I read Dr Margreet Hogeweg’s letter on Epilation for Trichiasis. I completely agree with her that surgery is neither available nor affordable for those communities that need it most. We charge 800 naira, the cheapest for surgery – that is, for the Bilamellar Tarsal Rotation Procedure, performed in both eyes. In fact, because trachoma is seen mostly among the poor, this amount is far too much for them to afford.
The issue of availability of this surgical service must also be considered. We in Mangu staff a rural medical centre and this is the only centre that runs mobile eye clinics in a state of more than 3 million people. The Government has two eye units in the state headquarters, Jos, but they hardly see any of these patients who need surgery. In fact a recent tour of the government eye clinics showed that basic instruments are just not available for the trained ophthalmic nurse to use.
From my experience I have found that where patients cannot afford to pay for surgery at the base hospital or the mobile eye clinic, I epilate the offending eye lashes free of charge. The patient shows tremendous appreciation and, if I come back after a week or a month, depending on the distance, the eyes are certainly dry, the discomfort gone and corneas clear. Let me add here that in the North Eastern State of Borno, in the Gwoza hills, the women especially go about with homemade epilation forceps around their necks. When you find anyone with home-made epilation forceps, their eyes are always quiet and corneas clear.
Musa Goyal CCEH Mangu Leprosy & Rehabilitation Centre, PMB 2127