Ndalela Ndalela1, 2 and Kangwa I. M. Muma1, 3
1 Levy Mwanawasa Medical University, Department of Ophthalmology, School of Medicine and Clinical Sciences, Lusaka, Zambia.
2 Senanga General Hospital, Eye Department, Senanga, Zambia.
3 University Teaching Hospitals- Eye Hospital, Lusaka, Zambia.
Abstract:
Trichiasis a medical term for abnormally positioned eyelashes that grow back toward the eye, touching the cornea or conjunctiva. This can be caused by infection, inflammation, autoimmune disorders, congenital defects, eyelid agenesis and trauma such as burns or eyelid injury. Trachomatous trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, trichiasis, and ultimately blinding corneal opacification. It is the leading cause of infectious blindness in the world. A 24-year-old female patient presented to Senanga’s Mata Rural Health Centre (RHC) where she was referred for eye check up due to a chronic eye condition she had. The patient was a confirmed psychiatric case. Examination revealed severe misdirected eyelashes, cornea opacities and tearing bilaterally. A diagnosis of Trachoma Trichiasis was made. Despite the mental illness, Trachoma Trichiasis surgery was performed successfully, and the patient healed well.
Introduction:
Trachoma is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis which leads to Trichiasis after a chronic phase [1]. Trachomatous trichiasis (TT) is referred to as a cicatricial entropion of the upper eyelid which results into inward turning of eyelashes rubbing on the cornea causing constant pain and light intolerance [2]. If Left untreated, this condition can lead to corneal ulceration resulting in corneal opacification and eventually visual impairment or blindness [3]. TT can affect anyone regardless of their mental state. Mentally ill patients tend to be uncooperative, restless, mobile, illogical and impulsive making it difficult to handle them [4]. While it is necessary to gain understanding that TT can occur in either mentally ill or sound patients, Tarsal Plate Rotation Surgery remains the reliable option for Trachoma Trichiasis Management in our Zambian setting [5].
Case Scenario:
A 24-year-old female mentally ill patient presented to Senanga District Health TT Case management team with complaints of loss of vision, painful eyes, tearing, headache, foreign body and pricking sensation in her eyes which had been there for more than eight years. The mental illness had also been there for eight years. The patient was the eighth and last-born child. The patient had had the eye condition for over 8 years for which she received traditional medicines and all sorts of concoctions such as herbs mixed with fertilizer or sugar. Whenever she visited the nearest health facility situated 25 km away, she was only given some unknown eye ointments. Despite her being a known psychiatric patient, she was not on any anti-psychotic treatment as access to a psychiatric facility was a challenge to the family.
On account of being a mentally ill patient, her mother consented for her surgery and use of her information in any medical/clinical publication.
Though difficulty to handle due to her mental state, her visual acuity was checked, and findings were; light perception in both eyes.
Other examination findings were; entropion, turned in eye lashes touching the globe (Figure 1), mucopurulent discharge, upper tarsi scaring, cornea opacities in both eyes, hyper photosensitivity and failure to open her eyes. The face was dirty, and she was generally in a poor state of hygiene. Her Blood Pressure was 110/70mmHg.
Fig1: Showing bilateral ectropion and house flies on the face
Considering her mental status, she was subjected to retroviral test and Rapid Plasma Reaction (RPR) in order to rule out other causes of mental illness. Both tests were negative.
She received her trachoma surgery after sedation with Diazepam intravenously. Both eyes were operated in one sitting in order to avoid going through the same challenges the next time. Local anaesthesia (lignocaine 2% with Adrenaline) was then infiltrated in her eyelids. Posterior Lamellar Tarsal Plate Rotation (Trabut) was successfully performed. After surgery, tetracycline eye ointment was applied in both eyes and thereafter padded for 24 hours. Painkillers were given to her and the following day the eye pads were removed. On her first day post operatively, her visual acuity improved to hand movements. One week follow up was done and her visual acuity was 6/36 in both eyes. A week after surgery, the patient seemed oriented in time and place although she exhibited inappropriate behaviour and she was a bit cooperative and calm. The TPR surgery outcome was successful as shown in figure 2 below.
Fig 2: Showing successful outcome of TPR surgery at 2 weeks
Discussion:
Classically, the sequalae of trachoma trichiasis is visual impairment due to cornea opacities [6]. The patients with TT who are mentally stable are easier and straight forward to manage because of their being cooperative and heading to instructions. This is a clear demonstration that illnesses can affect anybody without considering mental status. Due to her mental state, it is possible that she could have had severe Trachoma infection which could have complicated with TT at a tender age of 24. Such people do not need sedation or general anaesthesia (GA) to undergo an operation. This patient was young and mentally ill. She presented with all sorts of challenges as outlined above. She had to be sedated for the surgery to take place. GA could have been the best option, but the place where surgeries were conducted from had no GA facilities.
Trachomatous visual impairment and blindness, which result from corneal opacification, have generally been thought of as irreversible [7]. On the contrary, the patient recovered good sight of 6/36 in both eyes after surgery.
As a result of the unpredictability of mentally ill patients a more individualized management approach with them is cardinal and their management needs patience, tolerance and good clinical acumen [4, 8]. In this case, the patient had to be sedated for the TPR surgery to be carried out.
Patients with mental illness can have significant and rapid mood and behavioural changes as well as sudden, volatile and aggressive outbursts which can be both verbal and physical. Therefore, staff members who interact with the patient are at risk of being victims of outburst [4, 9] hence proving difficulty to handle when conducting surgical management of TT. Equally in this case, the patient was aggressive, uncooperative that she had to be handled skilfully by the team to be sedated and for surgery to be done successfully. Despite all these challenges, the patient was managed successfully with some endurance.
Conclusion:
Surgery to correct TT is a key component of all trachoma blindness control programmes in endemic countries. Therefore, mental state of an individual should not be a barrier to accessing TT surgery. World Health Organization recommends that TT surgery should be performed when the opportunity arises.
References:
1. World Health Organization (2012) Global WHO alliance for the elimination of blinding trachoma by 2020. Weekly Epidemiological Record 87: 161–168. Pmid: 22574352
2. World Health Organization (2014) WHO Alliance for the Global Elimination of Blinding Trachoma by the year 2020. Progress report on elimination of trachoma, 2013. Pmid: 25275153
3. Paul E, et al, (2006), https://www.cartercenter.org/documents/2302.pdf; Implementing the SAFE Strategy for Trachoma Control
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6. Bailey R., et al, (1999), The duration of human ocular Chlamydia trachomatis infection is age dependent. Epidemiol Infect.123:479–486. [PMC free article]
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8. Barry and Nilsson (2019), https://www.lexology.com>library: Challenges for Staff in Mental Health Wards.
9. Jo-Ann and Karen-Leigh (2014), https://www.researchgate.net>publicatiton>264393712; Challenges in Acute Care of People with Co-morbid Mental Illness. The Research Gate