Both eyes together: The benefits of bilateral TT
Persuading patients who have already received surgery for trachoma trichiasis on one eye to return for treatment on the second would appear, at first, to be an easy sell.
The patient has already had any fears about the safety of the procedure laid to rest, and has first hand experience of restored sight and the reduced pain that treatment can result in. But a Sightsavers – led consortium in Kenya found that in some areas the take up rate for surgery on the second eye was as low as 14%, despite patients having received counselling and stated their intention to return for the follow-up operation.
When questioned, patients cited lack of time, the cost of travelling to the outreach clinics, or lack of an escort to accompany them for their decision not to return. In West Pokot county, where the situation has transformed over the past two years and 100% of patients requiring bilateral surgery now receive it, staff recognised that something needed to be done about the attrition rate.
“We realised we were losing many patients,” says Michael Limang’ole, the surgeon in charge of eye health services for the county. “We suspected that the majority had become comfortable following the treatment of one eye, and did not see the need to bother coming back for the second eye, especially now that they had less pain.”
Two years ago, the team devised a strategy to encourage patients to receive the surgery on both eyes at the same time when appropriate, eliminating the need to return for follow up surgery. Outreach staff from the same communities as the patients build up trust with them in order to persuade them of the advantages.
Sarah Olalo, a project officer with the Fred Hollows Foundation, was part of the Sightsavers – led team exploring why the take up rate for bilateral surgery was so strikingly different in West Pokot.
“An interesting aspect that I observed is that the team has made it a “silent” rule to raise awareness on bilateral TT,” says Sarah. “However, surgery is not done on any bilateral TT patient who refuses to consent to surgery in both eyes, but included instead in the area CHV’s follow up list. The CHV is then assigned to follow up the patient at home and counsel him/her to return for surgery on the other eye, with frequent updates to the surgical team. On checking the follow-up list, it shows almost 100% positive outcome.”
Not only do patients save time and money by removing the need for a second operation, but the outreach team only have to do one surgical preparation per patient, and can provide follow up reviews for both eyes at the same time. However, as Sarah warns, the budget will need to reflect the number of eyes to be operated on, as opposed to the number of patients.
“The cost of drugs and consumables for surgery will increase when you plan and budget for a number of people then perform bilateral TT surgeries. In the case of West Pokot, the cost of drugs and consumables increased by about 60% per outreach clinic.”