Reply re: “A New Surgical Technique for Postoperative Trachomatous Trichiasis”

To the Editor:

We would like to thank Drs. Diab and Allen for their thoughtful comments. They are correct that cutting the tarsus further shorten it. However, a vertically shorter tarsus is not inherently unstable. As oculoplastic surgeons, we routinely leave the tarsus shorter when we create a tarsal-conjunctival flap to reconstruct the lower eyelid, and the upper eyelid maintains its normal anatomic shape and position. Rather, it is the abnormal anatomy at the margin and the absence of a square posterior eyelid margin that makes the eyelid margin unstable. The B-RAP procedure helps to create a new posterior eyelid margin.¹

The “anatomic balance between the anterior and posterior lamellae with secondary relative vertical eyelid skin redundancy”² occurs with aging in general, creating the visually-significant dermatochalasis we frequently treat. Dermatochalasis can also cause eyelash ptosis. We agree that in the setting of trachomatous trichiasis (TT) or post-surgical TT (PTT), extra upper eyelid skin can contribute to recurrence of the entropion as the eyelid heals. It is for that reason that the sutures are placed above the eyelashes to stably fixate them in an externally rotated position while the eyelid is healing. We also advocate placing a higher suture in those patients where upper eyelid skin is touching the lashes at the time of B-RAP. That higher suture is placed from Muller’s muscle to the skin to fixate the eyelid crease. This is the same idea as the last step of the Diab’s five-step procedure where the skin incision is closed, incorporating the edge of the upper lid retractors.

The five-step technique described by Drs. Diab and Allen has been thoughtfully designed and has corrected PTT in their study. While their technique could easily be performed by an oculoplastic surgeon, steps like identifying and detaching the levator tendon and Muller’s muscle (referred to as “the upper eyelid retractors” in their manuscript) from the conjunctiva could be challenging for the average ophthalmic surgeon who does not perform ptosis repair. As the authors are aware, the majority of PTT cases occur in areas without many ophthalmic surgeons or even physicians. Surgical technicians manage the very large case burden of TT and PTT in countries like Ethiopia. It would be difficult to teach the five-step procedure to the technicians and equally as difficult for them to perform the procedure with the coarse forceps, needle holder and scissors found in their standard trachoma instrumentation kit. The goal of our study was to describe a surgery that could be completed with the standard TT surgery equipment by a TT surgical technician and be successful for a majority of PTT cases.