IAPB Essential List: Trachomatous Trichiasis

The Essential Lists:

ESSENTIAL LIST - Trachomatous Trichiasis Screening and Surgery

Trachoma is the world’s leading infectious cause of blindness, and is particularly common in the most vulnerable populations. Surgery for trachomatous trichiasis (TT) is one of the components of the WHO SAFE (Surgery, Antibiotics, Face Washing, and Environment) strategy to address trachoma.

This list offers suggestions for the minimum essential and desirable items required to screen for trachoma and perform high quality Trabut or Bilamellar Tarsal Rotation (BLTR) surgery under conditions prevalent in most endemic areas. The List reflects the procedures and requirements outlined in WHO documents Trichiasis Surgery for Trachoma (second edition, 2015) and is aligned with the conclusions and recommendations from the International Coalition for Trachoma Control preferred practices and the second Global Scientific Meeting in Trachomatous Trichiasis (December 2015).

The List provides general guidelines to facilitate planning / budgeting: recommends the amount needed per patient or eye care provider and indicates the typical quantity packaged for sale. To calculate the quantities required the Morbidity Management & Disability Prevention Project (MMDP) has developed a TT management procurement calculator.

Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Torch or Arclight or Wilson Smart Torch Magnifier with LED E
A focussed light source, preferably with magnification
One per screener
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Epilation forceps: reasonable cost high quality durable frames and rounded tips with non-cutting opposing edges E
Provide, with proper counseling and epilation training, to people with minor TT who refuse surgery
One per staff and to give to patients counseled
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Binocular 2.5x Loupe (8 inch focal length)   E   D internally   illuminated device 1pc per surgeon
Kidney Dish 0.5L 250mm x 36mm   E 2pcs
Galley Pot   E 1pc
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Autoclave or Pressure Cooker   E 1pc
Autoclave drums to fit inside autoclaves   E 3 pcs at least for
Kerosene stove   E
Rural areas where there is no electric power or there is power failure.
1/TT surgery team
Stainless Steel Sterilization Case (large)   E per TT set 1pc per surgeon / set
Wash basins   E
decontamination/ washing/rinsing prior to sterilization
3pcs
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Toothed forceps with 0.5mm teeth,   E.g. St Martins   E 1pc
Serrated forceps   E.g. Castroviejo   E   D:with tying platform 1pc
Small haemostat forceps (“mosquitos”) Straight   E   for securing drapes 1pc
Needle holder (with or without catch) e.g. Barraquer/Castroviejo/Troutman/Silcock Needleholder   E 1pc
Scalpel Handle No 3   E 1pc
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Trabut Lid Plate   E 1pc
Scissors Straight (strabismus)   E 1pc
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
TT-clamp or Waddell clamp A range of clamp sizes for different eyelid sizes
To use the largest and have smaller clamps available until the maximum that will fit is reached.
  E   In every TT set: include the size most commonly used in the region and one larger   D   At least three sizes available at outreach (most common size, larger and smaller)
Scissors (eg Westcotts curved tip spring scissors)   E 1pc
Trabut lid plate   D 1pc
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Scalpel Blades no 15   E
One blade per eyelid
1 pack: 100pcs
21G Sterile Disposable Needles   E 1 pack: 100pcs
5ml Sterile Disposable Syringe   E
If kept sterile, one syringe can be used for both eyes of the same patient under outreach conditions
1 pack: 100pcs
4/0 Vicryl coated sutures with 3/8 circle 19mm reverse cutting needle attached   E   Does not necessarily need to be double-armed.   For BLTR: One double-armed suture required for one patient.   For Trabut: 2 sutures required for unilateral procedures.   3 sutures required for bilateral procedures
Everting suture typically can be reused on second eyelid
1 pack: 12pcs.
4-0 Black Braided Silk Suture with mounted single armed 3/8 circle 19mm reverse cutting needle
reverse cutting needlemay decrease the likelihood of sutures pulling through tissue margin that may occur if cutting needles are incorrectly used or with a lot of force
  E
Less expensive alternative to Vicryl
1pack: 12pcs
Gauze Roll 90cm x 91m   E
Gauze roll to be folded into gauze pads by staff. Approximately 6-8 pads used per eyelid.
1 roll
Zinc Strapping 1.25cm or 2.5cm x 5m   E
Approximately 3 10cm pieces are used per eyelid.
5m   10 rolls: pack
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Trolley towel   E  
Soap/ hand sanitizer
Surgeons scrub using soap and running water only is currently recommended because brushes may cause micro abrasions
L E  
Non sterile gloves (Examination)   E  
Sterile surgical gloves   Most common sizes are 7 and 7.5
Keep a mix of sizes when multiple surgeons are involved to ensure use of appropriate glove size that fits the individual surgeon
  E
If kept sterile, one pair of gloves can be used for both eyes of bilateral patients. Gloves to be changed between patients.
1 pack: 50prs
Mask and cap for surgeons L E
Same cap and mask can be used throughout one day of surgery
1 pack
Sterile – reuseable or disposable - gown for surgeons
To ensure that sterile suture does not come accidentally in contact with the shirt of the surgeon
  E Depending on the number of patients per day: two in the morning and one in the afternoon
Sterile Drape – disposable, made of sterilized paper   Alternative to the sterile cotton drape  
Sterile Drape – made of cotton approx. 1x1 metre, with a central hole approx 6cm diameter
This size hole gives enough exposure of the surgical site without unnecessarily exposing for e.g. the nose
L E   1 per patient 1 drape
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Chlorine solution   Strong disinfectant L E  
Detergent powder and brush L E
For cleaning the surgical area and instruments prior to sterilization
 
Sharps box   Containers/ plastic bags to separate the other waste can be useful L E
1 per surgeon at each surgery location. The total number depends on the surgeon productivity and the number of services planned during the period the procure
 
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Amethocaine hcl 0.5% or Tetracaine 0.5% Eye Drops (or similar)   E   One 10 ml bottle for about 100 eyes (2 drops per eye) 1 bottle: 10ml
Lidocaine 2% hcl + adrenaline (1:100000 epiniphrine)   E   One 50 ml bottle for about 20 eyes 1 bottle: 50ml
Lidocaine   E for patients with high blood pressure  
Povidone Iodine 10% Solution   E   Approximately 30-60 ml per eye for Skin Preparation 1 bottle: 200ml
70% Alcohol
Mainly used for disinfection of the surgeon’s hands after the surgical scrubbing.
L E 1 bottle: 1000ml
Sterile Distilled Water or normal Saline L D 1 bottle: 1000ml   1ltr/30lids
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Azithromycin Tabs 250mg for the reduction of infection and risk of post-op TT recurrence   E   Around TT surgery give one dose of Azythromycin tablets (4 tabs per adult) Unit: 1 Bottle of 500 tabs
Blister packs of 4tabs are available to purchase outside of the donation programme. National programs can apply to the International Trachoma Initiative (ITI) and include it into the their annual drug donation programme requests
Tetracycline 1% Eye Ointment or Chloramphenicol 1% Eye Ointment for the general prevention of postoperative infection   1 pack: 25 x 5g tubes 1 tube of per patient.   Only give tube to patient if Azithromycin is not being used.
Paracetamol   E   Pain relief for patients post-surgery. Recommend 2 doses per patient.  
TRAINING AND REFERENCE RESOURCES
Publication / Manual Published by Where available
Training/ reference resources for screening and grading of trachoma
Overview of Trachoma Medscape e-medicine http://bit.ly/19wir1s
Trachoma Toolkit – Implementing the SAFE Strategy for Trachoma Control The Carter Center http://bit.ly/18Pb0Ir
Trachoma Action Planning. A planning guide for the national elimination of blinding trachoma. ICTC (2015) In English and French
Training Curriculum for Trichiasis Case Finders ICTC (2015) In English and French
Trachoma Simplified Grading card WHO http://bit.ly/18Pb5Mg
Trachoma Grading Self Directed Learning CERA The University of Melbourne Resources
Training/ reference resources for screening and grading of trachoma
Global Scientific Meeting on Trachomatous Trichiasis (Eng, Fre, Port) ICTC (2012) In English, French and Portuguese
Second Global Scientific Meeting on Trachomatous Trichiasis (2015) PDF in English
Trachomatous Trichiasis and Its Management in Endemic Countries Surv Ophthal (2012) http://1.usa.gov/1dhFWhA   Surv Ophthalmo2012: 57-341(2): 105–135
Tracking Geographic Coverage of TT Management Services (Eng and Fre) HKI (2016) MMDP Project Resources
Organizing trichiasis surgical outreach. A preferred practice for program managers (Eng and Fre) ICTC (2015) In English and French
TT management procurement calculator (Eng, Fre) HKI (2016) MMDP Project Resources
Trichiasis Counselling Guide (Eng, French) ICTC (2016) In English and French
Epilation Counseling and Training Guidance (Eng and Fre) HKI (2016) MMDP Project Resources
Training/ reference resources for TT surgical training
WHO Trichiasis surgery for trachoma – 2nd ed (Yellow Book) (Eng, French) WHO (2015) WHO Resources
Supportive Supervision for Trachomatous Trichiasis Programmes ICTC 2017 PDF in English
Trachomatous Trichiasis Surgery – Surgery Training DVD. A Step By Step Guide to Trachoma Surgery ICEH http://bit.ly/1hIl6xd
The HEAD START training device uses a mannequin head as a base. Bases are reusable.See MMDP Project Resources and CEHJ Journal Resources Wake Forest School of Medicine Each trainer should have a base. It is recommended to have one trainer per 2 trainees. A minimum of one extra base is useful so that trainees can practice individually while the trainers continue to work with other trainees.
Disposable HEAD START eyelid cartridges are inserted to practice surgery Wake Forest School of Medicine 15 cartridges each for new trainees   10 cartridges each for refresher training.   For each cartridge (surgery) the sutures and blades for that procedure are also required.
Monitoring of surgical quality, patient satisfaction, and data quality during the 3-6 month period following trichiasis surgery (Eng and Fre) HKI (2016) MMDP Project Resources
The Outcome of Trachomatous Trichiasis Surgery in Ethiopia: Risk Factors for Recurrence PLoS Negl Trop Dis. (2013) http://1.usa.gov/1gjMktH   PLoS Negl Trop Dis. 2013 August; 7(8): e2392

IAPB wishes to acknowledge and thank the following experts and organisations for their inputs and support in putting this list together:

  • Agatha Aboe, Global Trachoma Programme Advisor, Sightsavers
  • Wondu Alemayehu, Consultant Ophthalmologist and Technical Advisor, The Fred Hollows Foundation
  • Amir Bedri Kello – Community Eye Health Consultant, Light for the World
  • Matthew Burton, Senior Lecturer, London School of Hygiene and Tropical Medicine
  • Paul Courtright, Director, KCCO
  • Rènée du Toit, Independent eye health consultant, South Africa
  • Paul Emerson, Director, International Trachoma Initiative
  • Emily W. Gower, Associate Professor, Gillings School of Global Health, University of North Carolina
  • Philip Hoare, Procurement Manager, IAPB UK
  • Martin Kollmann, CBM Senior Advisor for Neglected Tropical Diseases
  • Richard Le Mesurier, Medical Director, The Fred Hollows Foundation
  • Caleb Mpyet, Department of Ophthalmology, Jos University Teaching Hospital, Nigeria
  • Saul Rajak, Honorary Lecturer, London School of Hygiene and Tropical Medicine and Consultant Ophthalmologist, Brighton and Sussex University Hospital
  • Virginia Sarah, Chair of the International Coalition for Trachoma Control
  • Anthony Solomon, Medical Officer for Trachoma, WHO
  • Emily Toubali, Director MMDP Project
  • Sheila West, El-Maghraby Professor of Preventive Ophthalmology, Dana Center for Preventive Ophthalmology
Trachoma surgery for symptoms relief by Anton Vurdaft.

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