Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Trachomatous Trichiasis Surgery

Trachoma is the leading infectious cause of blindness, and trachomatous trichiasis (TT), in which lashes scratch the globe, leads to corneal opacity, visual impairment and blindness [S5] [S8]. WHO's SAFE strategy puts Surgery for trichiasis first [S5]. Postoperative trichiasis (PTT) is the main programme challenge [S9].

Key points - Full-thickness incision of the tarsal plate with rotation of the lash-bearing margin is the best-supported technique, preferably delivered in the community; trained ophthalmic assistants achieve outcomes comparable to ophthalmologists [S5]. - Posterior lamellar tarsal rotation (PLTR) had less PTT than bilamellar tarsal rotation (BLTR) in one large RCT and a real-world study; a later RCT found no meaningful difference between PLTR and BLTR with a 3 mm incision [S6] [S11] [S10]. - Single-dose oral azithromycin after surgery reduced recurrence by one third compared with topical tetracycline in one RCT [S1]; pooled evidence is imprecise [S5]. - Oral doxycycline and topical fluorometholone did not reduce PTT in large RCTs [S7] [S12]. - For minor TT, good-quality epilation is a reasonable second-line option where people decline or cannot reach surgery [S4] [S3].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Lashes touching the cornea with corneal opacity or reduced vision: the pathway to blindness [S8].
• Postoperative trichiasis: pooled prevalence 19% across endemic regions, higher than WHO's recommendation [S8].
• Women: odds of trichiasis are 1.82 times those in men; women must be deliberately targeted for surgery [S2].

Recognise it

• TT follows repeated conjunctival Chlamydia trachomatis infection [S9].
• Trial definitions: one or more lashes touching the globe or evidence of epilation, with tarsal conjunctival scarring [S6]. Minor TT was defined as fewer than six lashes touching the eye [S4].
• PTT was more common in older adults and in major (versus minor) trichiasis [S8].

Confirm it

• Count lashes touching the globe and look for evidence of epilation and tarsal conjunctival scarring [S6] [S12].
• Record visual acuity and corneal opacity; trials measured both [S3] [S4].
• Follow up after surgery to detect PTT: trials examined at 6 and 12 months [S6].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / community, trained epilator)

• Identify TT in the community and refer for surgery; community-based surgery increased uptake with comparable outcomes compared with health centres [S5].
• Epilation for minor TT: in a 1300-person Ethiopian RCT, epilation with good forceps by a trained person failed more often than surgery over 24 months (13.2% vs 2.2%) but gave comparable visual acuity and corneal outcomes [S3]. At four years, most epilation-only participants controlled their TT, with no difference in vision or corneal opacity change [S4]. The authors recommend surgery whenever possible, with epilation for those who decline or lack access [S3].

Tier B (trained TT surgeon or general eye clinic)

• Procedure: PLTR or BLTR are both WHO-recommended [S6]. In the Ethiopian RCT of 1000 participants, recurrent TT by 12 months was 22% after BLTR vs 13% after PLTR [S6]. In a real-world programme, 1-year PTT was 8.2% with PLTR vs 21.4% with BLTR [S11]. In the MTSS RCT (4914 participants), PTT did not differ meaningfully between BLTR with a 3 mm incision and PLTR, while a 5 mm BLTR incision increased PTT; the authors do not recommend changing the 3 mm incision [S10]. Continuing BLTR may be appropriate for surgeons already trained in it [S11].
• Sutures: absorbable sutures gave comparable outcomes to silk with less granuloma formation [S5].
• Lid clamp: reduced lid contour abnormalities and granuloma [S5].
• Azithromycin: single-dose oral azithromycin (1 g) reduced recurrence compared with topical tetracycline (6.9 vs 10.3 per 100 person-years), as reported in [S1]; treating household members added no benefit [S1]. Follow your national trachoma programme formulary.
• Not recommended: oral doxycycline 100 mg for 28 days did not reduce PTT (12% in both arms) and caused more adverse events [S7]; fluorometholone 0.1% twice daily for 4 weeks was safe but not efficacious or cost-effective (PTT 13.4% in both arms) [S12].

Tier C (specialist centre or programme lead)

• Managing PTT: the literature is sparse and no management guidelines exist; good PTT outcomes probably require enhanced training of a smaller group of highly skilled surgeons [S9].
• Programme quality: periodic surgeon training, close follow-up and health education are recommended [S8]. Only one trial has reported cumulative PTT below 10% at one year [S9].

Refer when

Pitfalls

• Using a 5 mm BLTR incision: more PTT [S10].
• Prescribing doxycycline or fluorometholone to prevent PTT [S7] [S12].
• Overlooking women in case-finding [S2].
• Offering epilation as the first choice when surgery is accessible [S3].

Evidence notes

• Conflict to check: the Cochrane review pooled two older studies favouring bilamellar over "unilamellar" rotation [S5], whereas later trials favour PLTR or show equivalence [S6] [S10] [S11]; the abstract does not define the unilamellar procedure.
• [S11] was not randomised; PLTR surgeons were less experienced and operated on more severe lids.
• Most trials come from Ethiopia, which may limit generalisability.
• No trial was designed to show that surgery prevents blindness, although several found modest improvement in vision [S5].
• Funding: Wellcome Trust [S6] [S7]; National Eye Institute and AbbVie [S12].
• Not covered by these sources: surgical training curricula, anaesthesia, lower lid TT, argon laser and electrolysis.

Related articles

• Trachoma: SAFE strategy and elimination
• Entropion and Ectropion

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.