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Anthony Siame^1,2 and Kangwa I. M. Muma^1,3

¹Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia

²Kasama General Hospital, Chongwe, Zambia

³University Teaching Hospitals – Eye Hospital, Lusaka, Zambia

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ABSTRACT

 A 55-year-old female patient presented at Kasama General Hospital’s Eye Clinic with painful eyes, excessive tearing, foreign body sensation and blurred vision in both eyes. After examination the patient was diagnosed with Trachoma Trichiasis (TT), ectropion, exposure keratitis and facial nerve palsy. Patient underwent simultaneous multiple management involving Tarsal Plate Rotation (TPR), ectropion correction, physiotherapy and was treated for keratitis successfully.

INTRODUCTION

Normally, the upper and lower eyelids close tightly, protecting the eye from damage and preventing tear evaporation. If the edge of one eyelid turns inward (entropion), the eyelashes rub against the eye, which can lead to ulcer formation and scarring of the cornea. If the edge of one eyelid turns outward (ectropion), the two eyelids cannot meet properly, and tears are not spread over the eyeball [1]. These conditions are more common among older people due to increased tissue relaxation with age, eye changes caused by infection, surgery, or injury and people who have blepharospasms. Ectropion may occur in people with facial nerve palsy [2]. These eyelid pathologies are characterised by common presentation such as redness, tearing, irritation of the eyes and altered balance of the anterior and posterior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly surgical [3].

Trachoma is the leading infectious cause of blindness world-

wide. Overall it is the eighth commonest blinding disease [1].

Trachoma is caused by the obligate intracellular bacterium C.

trachomatis. Recurrent episodes of conjunctival infection and the

associated chronic inflammation it causes initiate a scarring

process that ultimately leads to irreversible blindness. There is a

worldwide effort underway to try to control blinding trachoma;

this is lead by the World Health Organization (WHO) with the

Global Alliance for the Elimination of Blinding Trachoma

(GET2020).

It is estimated that approximately 1.3 million people are blind

from this disease and probably a further 1.8 million have low

vision [2]. Trachoma is endemic in more than 50 countries,

predominantly in sub-Saharan Africa, the Middle East, and Asia

[3]. The burden of trachoma on affected individuals and

communities can be huge both in terms of the disability it causes

and the economic costs that result. In this paper we review the

available data on the prevalence of the disease and estimates of its

burde

CASE SCENARIO

A female patient aged 55years came to the eye clinic from Kasama village with complaints of tearing, eyelashes rubbing onto the cornea, pain, redness and poor vision for one year. The patient reported history of epilation to relieve pain. On examination visual acuity was 6/12 Right eye and 6/36 Left eye. The eyelashes were rubbing on the cornea and there was dryness of the eye. The conjucntiva was injected and patient was in pain. The face was drawn on the left side due to facial nerve palsy on the right side (Fig 1). Diagnoses of Bilateral trachoma trichiasis (TT), Bilateral ectropion, Facial palsy affecting left side and Bilateral keratitis was made.

Surgical correction involved Tarsal plate rotation and blepharoplasty. Medical management with antibiotics and physiotherapy was initiated.

Consent for publishing this case and patient’s pictures was obtained from the patient herself.

Fig 1: Showing facial asymmetry

DISCUSSION

All cases of trachoma trichiasis including ectropion should be subjected to corrective surgery of the eyelids. If left unattended to, these conditions can lead to an impaired optical function of the ocular surface through chronic irritation of the conjunctiva and the cornea [4]. The patient discussed in this case report had a rare presentation of trichiasis and ectropion that complicated to keratitis [5,7]. It was determined that early intervention was required in order to stabilise the tear film and to prevent recurrent corneal abrasions, corneal ulceration, corneal opacities and eventually vascularization as well as scarring of the cornea and conjunctiva as suggested by other researchers [6].

To address these multiple eye problems, a combination of Tarsal Plate Rotation (TPR) and blepharoplasty was conducted to correct entropion and ectropion respectively. Following surgery, there was improvement of the patient’s vision and the pain was no longer there. The causes of ectropion include Facial nerve palsy and involutional. Normally, these two causes occur independent of each other. Strangely this patient had both situations occurring simultaneously. This posed a challenge in the management of such a combination of the two conditions. However, this was skilfully excuted to the satisfaction of the patient. This demanded good planning and teamwork as other disciplines were involved. Keratitis was treated with tetracycline eye ointment and the patient equally responded well. Unfortunately, in literature there was no information regarding management of such combination of conditions. The management purely depended on experience and extensive consultation.

 CONCLUSION

This case report shows that one can have multiple occurrence of ocular conditions with atypical presentation. Management of such a combination of ocular conditions requires experience, collaboration and skilfulness.  

REFERENCES

1. Matthew J. B. et al,British Medical Bulletin (2007) Vol 84,issue 1 pages 99-116 London, United Kingdom
2. James Garrity, MD, Entropion and Ectropion (2019); page1, Kenilworth, NJ, USA).    
3. Minerva Chirurgica, Journal of Surgery (2013); page 1, University of Turin, Italy.
4. Mwale.c. et al, Ophthalmic epidemiology, Trachoma Prevalence in 67 Districts of Zambia (2018);2-3, Lusaka-Zambia
5. Michael giese, Northwest Eye Surgeon Insight Journal (2015) 1-4, Seattle, USA.
6. Stefanyszyn, M.A., Pathology of Entropion and Ectropion, presented at the Washington Hospital Centre Silver Jubilee Oculoplastic Symposium (March 25, 1983),2-4, Washington D.C.
7. Seunghyun Lee, Helen Lew, Department of Ophthalmology, Management of Facial nerve palsy patients, 2018;3-4, Seongnam, Korea.

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