Relationship between immediate post-operative appearance and 6-week operative outcome in trichiasis surgery

Abstract

Background: Surgical technique, including suture placement and tension, is believed to contribute to the outcome of bilamellar tarsal rotation surgery for trachomatous trichiasis. However, the immediate post-operative appearance that minimizes the chance of recurrence and other adverse outcomes has not been investigated.

Methodology/principal findings: To explore whether the degree of correction immediately after surgery is predictive of surgical outcome at the 6-week post-operative visit, photographs taken immediately after surgery were used to predict surgical outcomes, including the severity of eyelid contour abnormality and trichiasis recurrence. Both eyelid contour abnormalities and recurrence were accurately predicted from the immediate post-operative photographs by an experienced oculoplastic surgeon 85% and 70% of the time, respectively. Participants with a "slight over-correction" that resulted in no eyelid contour abnormality and no recurrence were used to identify immediate post-operative contours that lead to a successful surgical outcome.

Conclusions/significance: The immediate post-operative eyelid contour is an important indicator of post-operative success of BLTR surgery. Based upon our findings, we developed a Surgery Photocard. This card illustrates some examples of immediate post-surgical appearances, which led to a successful outcome, as well as sub-optimal appearances, which led to poor surgical outcomes. The card also provides suggestions for improving the appearance by adjusting the suture placement or tension based upon standard oculoplastic principles.

Figure 1. Replacement of sutures corrects nasal under-rotation.

A) An immediate post-operative photograph of a participant with under-rotation of the nasal aspect of the upper eyelid margin fragment; B) the same eyelid after replacement of the rotating sutures; C) the same eyelid at the 6-week visit without recurrence (the lashes seen nasally are from the lower eyelid).

Figure 2. Replacement of sutures corrects eyelid margin over-rotation.

A) An immediate post-operative photograph of a participant with over-rotation of the eyelid margin fragment; B) The same eyelid after replacement of the rotating sutures; C) the same eyelid at the 6-week visit with a mild ECA.

Figure 3. Immediate post-operative photographs used to correctly predict recurrence.

Immediate post-operative photographs in 6 participants used to correctly predict A–B) nasal, C–D) central, and E–F) temporal recurrence at 6-weeks post-operatively. Arrows show area of under-rotation and subsequent recurrence.

Figure 4. Immediate post-operative photographs used to correctly predict eyelid contour abnormalities (ECAs).

A, C) Immediate post-operative photographs in 2 participants that were used to correctly predict ECAs in the corresponding 6-week photographs, (B) moderate ECA and (D) severe ECA.

Figure 5. Surgical Photocard, side A, to assist surgical technicians with immediate post-operative assessment.

Surgical Photocard, side A showing the immediate post-operative photographs of 4 participants without recurrence and normal contours at 6 weeks. This degree of “slight over-correction” likely represents the ideal immediate post-operative appearance to minimize both recurrence and ECAs.

Figure 6. Surgical Photocard, side B, to assist surgical technicians in assessing and modifying the immediate post-operative eyelid position.

Surgical Photocard, side B showing (upper left) a participant with immediate post-operative over-rotation and (upper right) the resulting severe ECA at 6 weeks and instructions as to how to improve the over-rotation; and (lower left) a participant with immediate post-operative under-rotation and (lower right) the resulting nasal recurrence at 6 weeks and instructions as to how to improve the under-rotation.