Comment on: Recurrent upper eyelid trachomatous entropion repair: long-term efficacy of a five-step approach

To the Editor:

The recent paper by Diab et al. in this journal [1] describes a novel approach in a considerably under-investigated domain: surgical repair of postoperative trachomatous trichiasis (PTT) [2]. Like another recent proposal for managing PTT, published elsewhere by Merbs et al. [3], the procedure described by Diab tries to specifically address the rotation of the posterior lamella (PL). Diab suggests anterior lamella (AL) repositioning through a five-step AL rotation [1], while Merbs investigates bevel-rotation and advancement of the PL [3].

Both procedures look very promising addressing the weak spot of trachomatous trichiasis (TT) and PTT management: inadequate rotation of the tarsal plate. Diab’s approach may prove very effective for simple TT, but the rotation achieved is probably not sufficiently effective for all cases of PTT, i.e., presenting severe scarring, significant rotation or metaplastic lashes of the PL [4]. Merbs’ proposal addresses more effectively the rotation of the PL in PTT achieving good outcomes, if deployed by skilled hands. These surgical strategies should be individualized and tailored, however, for highly skilled oculoplastic surgeons working in state-of-the-art operating environments. In trachoma-endemic settings with nurses tasked to perform the surgery, it is possible that neither approach will even be practical at programmatic level. We have recently described difficulties encountered in Mali including selection criteria of surgeons, training, surgical equipment, and quality of theatre space [2]. Though at least one major study has shown that bilamellar tarsal rotation and PL rotation can be effectively deployed against TT by program-trained nurses as safe and effective ‘one size fits all’ solutions, the same is unlikely to be true for PTT [5]. We salute the thought and effort put into developing candidate approaches, but believe that we also need to consider development of the operating cadre: well-trained oculoplastic surgeons capable of individualizing the management for each patient.

To this end, there is an urgent need for sustainable capacity development to facilitate (1) appropriate surgical decision-making and (2) skilled implementation of those decisions on the table. We recommend an increase of the number of ophthalmologists in specialized training in trachoma-endemic countries and changes to the patient pathway, thus optimizing outcomes.

Author contributions

AK was responsible for writing and GN for reviewing the letter. The authors alone are responsible for the views expressed in the paper and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Competing interests

The authors declare no competing interests.