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Vision Care News| Staff Reporter | August
24, 2006
Blinding-disease surgery is done safely in
villages, by non-physicians
(Dubai Health & News) Specially trained nurses and health
assistants are as effective as ophthalmologists in performing
vision-preserving surgery for a blinding disease called trachoma
trichiasis, a new review has found.
The review also found that village-based surgery was as safe and
effective as surgery performed in hospitals, while reducing travel time
and expense for patients.
Trachoma, an eye disease caused by bacterial infection, is the leading
cause of preventable blindness worldwide. The World Health Organization
estimates that 8 million people are visually impaired or blind due to
trachoma. Another 84 million are at risk of losing their eyesight due to
active infection with Chlamydia trachomatis, the culprit bacteria.
"There are multiple personal and societal barriers to surgery for
trachoma trichiasis," said lead author David Yorston, of the
Tennent Institute of Ophthalmology in Glasgow, Scotland. "By
delivering surgery in the community we can reduce the distance barrier,
but it is more difficult to eliminate the others."
The review appears in the July issue of The Cochrane Library, a
publication of The Cochrane Collaboration, an international organization
that evaluates research in all aspects of health care. Systematic
reviews draw evidence-based conclusions about medical practice after
considering both the content and quality of existing trials on a topic.
Although no region of the world has been untouched by trachoma, today
the disease is largely confined to developing countries where poverty,
crowding and a lack of clean water and hygiene fuel the transmission of
infection from person to person.
A single bout of infection is not enough to cause blindness. However,
with repeated infections, the inside of the upper eyelid becomes riddled
with scar tissue. As the scar tissue contracts, the eyelashes turn
inward and brush against the cornea. This is trichiasis.
Left untreated, the constant irritation of the cornea by the
inward-turning eyelashes - possibly in combination with secondary
bacterial infections - eventually leads to blindness. Even before vision
is destroyed, the disease is painful and disabling, confining many of
those afflicted to their homes.
The WHO is leading a global initiative to eliminate trachoma as a
blinding disease by 2020 with a four-part strategy called SAFE: surgery,
antibiotics, facial cleanliness and environmental hygiene. While the
final three parts of this strategy are targeted at preventing the spread
of trachoma, the first part is focused on improving the health and
well-being of those with trachoma trichiasis, who are at risk of going
blind.
In their review, the Cochrane researchers analyzed the findings from
seven studies that compared different approaches to treating trachoma
trichiasis.
Three of the studies compared different ways of performing surgery to
correct the inward rotation of the eyelids and prevent the eyelashes
from rubbing against the cornea. While one trial found that one type of
surgery was more effective than another, the other two trials showed
little difference.
"There is wide variation in outcomes between different
surgeons," said Yorston. "In view of this variation, I think
that either operation can be effective if the surgery is meticulous, but
neither operation will work if it is performed by a poorly supervised
surgeon with inadequate equipment."
A study conducted in Gambia found that patients who received
postsurgical azithromycin (the same antibiotic that is used for trachoma
prevention) did not have better outcomes compared to patients given the
usual postsurgical antibiotic, tetracycline eye ointment.
An Ethiopian study that evaluated whether ophthalmologists achieved
better surgical outcomes than specially trained ophthalmic assistants
found no significant differences in complications or recurrence of
trichiasis. And a study in Gambia that compared outcomes for
village-based and hospital-based surgery found that results were similar
in both settings. However, village-based surgery was less costly and
time-consuming for patients.
"I think it's completely appropriate for ophthalmic assistants to
do this surgery, and it's a good way to solve the shortage of
ophthalmologists," said Thomas Lietman, M.D., director of the WHO
Collaborating Center at the University of California, San Francisco.
"Since it's not intraocular surgery and the infection risk is low,
you don't need a great operating area. Community-based surgery wouldn't
be all that difficult to do."
A final randomized study compared results of two short-term nonsurgical
techniques for minimizing contact between the eyelashes and the cornea.
The more commonly used technique, called epilation, involves removing
the eyelashes. The alternative is to apply double-sided tape to force
the eyelashes away from the eyeball. This study found that the tape was
more effective as a temporary measure, but it had to be replaced weekly.
According to Lietman, there is reason to be optimistic that the WHO goal
of eliminating trachoma by 2020 can be achieved.
"I think we're on target and maybe even ahead of schedule," he
said. "Infection is being reduced with antibiotics, and lids are
being operated on, saving vision more immediately. Also, trachoma is
disappearing as areas get wealthier. War and unrest may be what prevents
the last few areas from being cleared in time for 2020."
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