Training a Surgeon

Requirements of a Trainee operating room management and post- ophthalmic technician / assistant / nurse operative evaluation who is also trained in the use of the • A trainee cataract surgeon should • Videos of the they have microscope and other equipment have, at least, basic knowledge of the performed themselves maintenance and operating room eye and some experience in ocular • A video on standard cataract surgical management. surgery techniques • A commitment to improvement which • A microscope Requirements of a Surgical should provide the necessary motivation, • Two cataract surgical sets Instructor/Trainer enthusiasm and determination that is • 100 IOLs. required A trainer should be or have: • A trainee cataract surgeon should have A Cataract Training Centre • A highly skilled surgeon binocular single vision • An aptitude for teaching and training • Should be comfortable with the use of A Centre should have: • The necessary time and patience needed the microscope • Adequate physical space for surgical skills transfer • A trainee in cataract surgery should be • Adequate equipment, good quality • Ready to take over the moment a able to master and practise the safest and instruments and consumables, as patient’s safety is at risk. simplest techniques. requested and required References • ‘Wet’ laboratory for the trainees to Equipment and Training Materials familiarize themselves with the 1 Rao G N. Human Resource Development. J Comm Eye Health 2000; 13: 42–43. A trainee should be given a kit containing instruments and microscope 2 Thomas R. Kuriakose T. Surgical Techniques the following: • Audio- for the recording of for a Good Outcome in Cataract Surgery: , for learning, monitoring and Personal Perspectives. J Comm Eye Health 2000; 13: 38–39. • A curriculum of the cataract surgery further reference 3 Cook C. How to Improve the Outcome of training attended with information on • Careful ophthalmic instrument Cataract Surgery. J Comm Eye Health 2000; 13: sterilization, pre-operative assessment, maintenance and care by a trained 37–38. ❏ Review Article Training in Trichiasis S u r g e r y Sidney J Katala CCEH tive Health authorities. They are required to have: Senior Ophthalmic Nursing Officer Trichiasis Surgery Trainer • Previous experience in eye Senior Technical Advisor for Eye Health examination Helen Keller International • Experience in giving injections PO Box 192 • K n o w l e d g eo fs t e r i l es u r g i c a l Kongwa, Dodoma Region te c h n i q u e s Trichiasis surgery might have prevented blindness.... Tanzania • Previously observed eye surgery. Photo: Murray McGavin

Introduction Two weeks is the minimum time recommended to train a trichiasis surgeon. tion of mobile eye clinics (community- based) It is estimated that each village in central • Demonstrate assessment Tanzania has between 5 – 25 persons with Objectives of Training in Trichiasis methods in-turned due to trachoma. Half Surgery • Demonstrate skills in trachoma grading of these people constantly epilate their eye- • Implement SAFE interventions as part lashes to ease the irritation and pain from At the end of the course the trainee should of comprehensive eye care. in-turned eyelashes. be able to: Handouts Aims • Perform the tarsal rotation method for trichiasis Handouts on the following topics, to sup- The aims of training in trichiasis surgery • Complete at least 5 supervised port teaching sessions, are distributed to are to teach: operations to receive certification participants during the training period: • Follow-up trichiasis patients and • Identification of patients needing recognise any complications trichiasis surgery 1. Primary Health Care. • Complete reports and keep records of • A good and safe surgical procedure 2. The 8 Elements of Health Care. trichiasis surgery • The principles and practice of competent 3. The 5 Principles of Primary Health • Assess competence and improve follow-up. Care. surgical skills, under supervision 4. Anatomy of the Eye (main emphasis on • Recognise the barriers to trichiasis the upper ). Selection of Trainees surgery and how these can be overcome 5. Checklist of Supplies and Materials. Trainees are recommended by their respec- • Assist in the planning and implementa- 6. Sterilization Methods. 22 Community Eye Health Vol 15 No. 42 2002 Training in Trichiasis Surgery

7. Record Keeping. Mobile Eye Clinic: Procedure 8. The SAFE Strategy. for Trichiasis Patients

Incision and Stitching Exercises During the mobile eye clinic, pri- ority should be given to: The trainer demonstrates the procedure. It • patients with trichiasis is then practised on oranges and bananas. • people who are blind The steps include: • patients with painful red eyes. • Incising the ‘eyelid’–orange peel or Patients with trichiasis are sent banana immediately for visual acuity • Everting and incising the ‘ testing. These patients are then and tarsal plate’–inside of orange peel guided to the operating area. The • Completing the incision with scissors outpatient form is carried with the Bilamellar tarsal rotation procedure (BTRP) training • Suturing the ‘eyelid’. patient into the operating area. in session Numbers are written on the out- Photo: Sidney Katala Handling Surgical Instruments patient form so that surgical teams will Preparations: know how many patients to expect. a) Clean the skin surrounding the eye with The key skills in which each participant The following procedures are followed: must be competent are: an antiseptic solution. • Identify who will take the patient home b) Amethocaine eye drops instilled on the • Holding the needle holder in the and make sure all the procedures are eye (or similar topical anaesthetic). dominant hand understood, the need for return in 7 days c) Scrub the hands with soap and water for clearly stated, and verbal consent at least 5 minutes. given d) Put on sterile gloves (gloves must be • Written consent is advised worn). • Before the patient lies on the e) Clean the patient’s face and eyes. operating table, the surgical team checks the fitness of the Surgical procedure: patient for surgery (checking blood pressure, allergies to a) A local anaesthetic injection is given drugs, shortness of breath, heart into the upper lid (ask the patient to problems, mental state…) look down). • The patient is asked if they have b) Usually 3 mls are sufficient (never consumed any alcohol that day. inject more than 5 mls in any single If so, trichiasis surgery should operation). be postponed c) An operation is performed seated at the head of the patient. Stitching exercises on an orange • Community health workers Photo: Sidney Katala and/or the advance team should d) For better visibility, a magnifying advise patients of this require- loupe is used and a flashlight held by • Mounting the needle (with suture) on the ment during the preparation an assistant. needle holder screening, before the days of the e) The eyelid is ‘fixed’. • Making sure the needle holder holds the clinic f) The upper eyelid is incised (incision of needle one-third away from the tip • After surgery, the patient takes the skin and muscle must be parallel to • Holding the toothed dissecting forceps the outpatient form and follow- the lid margin and 3 mm above it, the with the other hand up requirements are explained to entire distance between the haemo- • Holding the edge of the distal skin edge the patient. stats). and inserting a needle with suture g) Eversion of the eyelid is then done. • Holding the skin on the proximal side, Normally, trichiasis surgery is and pushing the needle through the skin performed on one eye at a time. • Pulling the suture and making the first, The second operation can take second, and third knots place when the sutures of the first • Cutting the two ends of the suture eye are removed after eight days. material (about 0.5mm long above the Some patients may choose to wound; this helps when removing delay the second operation until sutures). the first eye is completely healed.

After everyone has successfully mastered The Trichiasis Surgical incision and suturing skills, they each Procedure: Bilamellar Tarsal receive their own surgical kits for the field Rotation Procedure (BTRP) visits. The trainer reviews the schedule for the With sterile instruments and other field visits and reviews the sterilization supplies at hand, the procedure should be done following these Trichiasis screening with the aid of a magnifying procedures for surgical kits during the loupe in rural central Tanzania visits and at the end of each day. steps: Photo: Sidney Katala Community Eye Health Vol 15 No. 42 2002 23 Training in Trichiasis Surgery

Constraints to Surgery Trichiasis Surgery for Trachoma 1. People do not know that this is a A previous issue of the Journal problem that can be solved. (J Comm Eye Health 1994; 7: 21–26) 2. People are afraid of the operation. describes in detail the surgical BTRP – 3. Communities lack transport to take based on the World Health patients to the hospital or clinic. Organization/ Edna McConnell Clark 4. The number of people who are able to Foundation publication do the surgery is limited. (WHO/PBL/93.29) by Mark Reacher, 5. Bad service by service providers, e.g., Allen Foster, Janey Huber & Brent bad language, etc. Severe trichiasis Bauer. Photo: Murray McGavin 6. The cost of surgery in some hospitals is Some copies of this issue of the Journal not affordable to most patients. are still available and will be sent on request while stocks last. Graduation and Certification h) Incision of the conjunctiva and tarsal Editor plate, through its full thickness, paral- Each participant is given: lel to the lid margin and 3mm above Summary of Follow-up Care 1. A Certificate after successfully perform- it, the entire distance between the i n gt h eo p e r a t i o n s – u n d e rs u p e r v i s i o n . haemostats. Day 1: Lid surgery patients advised of 2. A copy of the WHO Manual ‘Trichiasis i) The incision is then united by inserting time to return for follow-up care. Surgery for Trachoma – The Bilamellar the points of the closed scissors into Day 2: Patient returns to meet health Tarsal Rotation Procedure’. the incision in the conjunctival–tarsal worker, who removes eye patch, plate, through remaining intact mus- cleans wound and applies tetra- cle, and out through the skin-muscle cycline eye ointment. Any patient incision. with excessive bleeding, swelling j) Open the scissors while still held and/or severe pain should be across the lid: the blunt aspect of the referred immediately. blades will spread apart intact mus- Day 3–7: Patients continue to cle–repeat until it is a full thickness see health worker on daily basis – hole. to have the wound cleaned and to k) Remove the haemostats. have tetracycline eye ointment l) Complete the incision medially ap p l i e d . and laterally using the scissors. Day 8: Mobile eye team returns m) Suturing the eyelid is then done using – sutures are removed. 4/0 silk or chromic catgut. This is to Surgery for upper eyelid trichiasis At the end of the trichiasis opera- re-attach the distal fragment in an out- Graphic: Hugh Lugg wardly rotated position, so that the tion day, the principal trainer Photos: Mark Reacher & John DC Anderson reviews follow-up procedures for eyelashes no longer rub on the . 3. 100 tubes of tetracycline. This is achieved by anchoring sutures patients who have undergone co m m u n i t y - based trichiasis surgery with community 4. 24 sutures, a surgical set for minor oper- on the conjunctival surface of the ations, and other supplies as available. proximal fragment, and running them health workers or their equivalents. Each communityhealth worker should receive a 5. A set of bi-monthly reporting forms to over the distal tarsal plate to exit be used within their health system. through the skin near the eyelashes, list of the trichiasis patients. Each patient is given tablets of paraceta- thus drawing the lash margin outwards Further Reading and upwards. mol to be taken as needed for pain relief, once in the morning and once in the 1 Johnson G J, Minassian D C, Weale R. The evening. Epidemiology of 1998. pp 132–135. 2 Reacher M, Foster A, Huber J. Trichiasis Surgery for Trachoma: The Bilamellar Tarsal Overcoming Fears Rotation Procedure. WHO/PBL 1998. 3 Ballen P H. A simple procedure for the relief of Patients who are afraid of having trichiasis and of the upper lid. Arch trichiasis surgery receive coun- Ophthalmol 1964; 72: 239 – 240. selling. Fear of the injection, 4 Reacher M H, Munoz B, Alghassany A, Daar A, Elbualy M, Taylor H. A controlled trial of cutting, pain and bleeding are surgery for trachomatous trichiasis of the upper most often the concerns expres- lid. Arch Ophthalmol 1992; 110: 667– 674. sed. Patients are asked to speak to someone who has had the opera- ✩ ✩ ✩ tion and will talk about his/her experience. Example of a Trichiasis Register Date No: Name Sex Address VR VL TT situation Remarks An outreach eye clinic in central Tanzania Photo: Sidney Katala

24 Community Eye Health Vol 15 No. 42 2002