Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
| Name | Class |
|---|---|
| University of Pennsylvania | OTHER |
| London School of Hygiene and Tropical Medicine | OTHER |
| Berhan Public Health and Eye Care Consultancy PLC | OTHER |
Not provided
Not provided
Not provided
Not provided
This study aims :
The investigators are pursuing an agenda to evaluate a new potentially cost-effective approach to improving trichiasis surgery outcomes: perioperative topical anti-inflammatory therapy. Inflammation-whether induced by the trachoma disease process or surgery itself-most likely contributes to progressive cicatrization leading to failure of lid rotation surgery in a clinically important proportion of TT cases. The investigators hypothesize that adjunctive topical fluorometholone therapy following trichiasis surgery will reduce the risk of recurrent trichiasis and will be acceptably safe. The rationale for the efficacy aspect of this hypothesis is that interruption of inflammation postoperatively would reduce postoperative scarring/contracture driven by ongoing disease-driven inflammation and/or surgically-induced inflammation thus reducing the incidence of TT recurrence (post-operative TT) and other inflammation-related outcomes.
Not provided
Not provided
Not provided
Not provided
| Label | Type | Description | Intervention Names |
|---|---|---|---|
| fluorometholone | Experimental | Fluorometholone 0.1% eyedrops, one drop twice daily for four weeks |
|
| Artificial Tears | Placebo Comparator | one drop two times daily for four weeks |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Fluorometholone 0.1% Oph Susp | Drug | fluorometholone 0.1% one drop twice daily for four weeks, beginning with one drop just before trachomatous trichiasis surgery on the upper lid. |
| Measure | Description | Time Frame |
|---|---|---|
| Incidence of Postoperative TT by One Year, as Determined by Trained Study Team Members | The primary outcome measure is the postoperative recurrence of trachomatous trichiasis (TT), defined as one or more eyelashes in the upper eyelid touching the globe or evidence of epilation (lash stubs) in the upper eyelid on examination, or a history of repeat trichiasis surgery at any time in the upper eyelid during the one year follow-up period after the baseline surgery. | 12 months |
| Measure | Description | Time Frame |
|---|---|---|
| Efficacy Measure 1 - Entropion | Presence and extent of entropion of the upper eyelid | 1 year |
| Efficacy Measure 2 - Reoperation | Number of study eyes undergoing reoperation for postoperative trichiasis |
Not provided
Inclusion Criteria:
Exclusion Criteria:
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
| Name | Affiliation | Role |
|---|---|---|
| John H Kempen, MD MPH MHS PhD | Massachusetts Eye and Ear Infirmary/Harvard Medical School | Study Chair |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Oromia Health Bureau | Addis Ababa | Addis Ababa | Ethiopia |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 41539314 | Derived | Kempen JH, Abashawl A, Mohammed AA, Dodson S, Alemayehu W, Jin F, Gemechu A, Mengesha AA, Kumsa DA, Chen Y, McWilliams K, Tulu B, Abdela G, Megersa A, Cheru T, Mohammad G, Succar T, Bunya VY, Frick KD, Maguire MG, Burton MJ, Ying GS; FLAME Trial Research Group. Evaluation of fluorometholone as adjunctive medical therapy for trachomatous trichiasis surgery (FLAME): a parallel, double-blind, randomised controlled field trial in the Jimma Zone, Ethiopia. Lancet Glob Health. 2026 Mar;14(3):e395-e406. doi: 10.1016/S2214-109X(25)00493-0. Epub 2026 Jan 12. | |
| 40737343 |
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
Not provided
| ID | Title | Description |
|---|---|---|
| FG000 | Artificial Tears | Placebo comparator - one drop two times daily for four weeks |
| FG001 | Fluorometholone | Fluorometholone 0.1% eyedrops, one drop twice daily for four weeks |
| Title | Milestones | Reasons Not Completed | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
|
Not provided
| ID | Title | Description |
|---|---|---|
| BG000 | Artificial Tears | Placebo comparator - one drop two times daily for four weeks |
| BG001 | Fluorometholone | Fluorometholone 0.1% eyedrops, one drop twice daily for four weeks |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Age in years |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Incidence of Postoperative TT by One Year, as Determined by Trained Study Team Members | The primary outcome measure is the postoperative recurrence of trachomatous trichiasis (TT), defined as one or more eyelashes in the upper eyelid touching the globe or evidence of epilation (lash stubs) in the upper eyelid on examination, or a history of repeat trichiasis surgery at any time in the upper eyelid during the one year follow-up period after the baseline surgery. | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 12 months | Study eyes | Study eyes |
|
From enrollment until end of follow-up, up to 1 year
Not provided
Not provided
| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Artificial Tears | Placebo comparator - one drop two times daily for four weeks |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| GOITRE | Endocrine disorders | Systematic Assessment |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| ECTROPION | Eye disorders | Systematic Assessment |
Not provided
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| John Kempen, MD, MPH, PhD, MHS | Massachusetts Eye and Ear | +1-617-573-4494 | john_kempen@meei.harvard.edu |
Not provided
| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot | Yes | No | No | Study Protocol | Jun 29, 2023 | Nov 24, 2025 | Prot_000.pdf |
| SAP | No | Yes | No | Statistical Analysis Plan | Aug 10, 2024 | Nov 24, 2025 | SAP_001.pdf |
Not provided
| ID | Term |
|---|---|
| D005128 | Eye Diseases |
| D005141 | Eyelid Diseases |
| D058457 | Trichiasis |
Not provided
Not provided
Not provided
| ID | Term |
|---|---|
| D005469 | Fluorometholone |
| D065346 | Lubricant Eye Drops |
| ID | Term |
|---|---|
| D011244 | Pregnadienediols |
| D011245 | Pregnadienes |
| D011278 | Pregnanes |
| D013256 | Steroids |
| D000072473 |
Not provided
Not provided
| The Fred Hollows Foundation, Ethiopia |
| UNKNOWN |
| The Fred Hollows Foundation, Australia | UNKNOWN |
This is a 1:1 randomized, double-masked, placebo controlled clinical trial
Not provided
Not provided
Patients, surgeons, and study staff at field site are masked to the assigned treatment group of the subject.
|
| Artificial Tears | Drug | Artificial tears (placebo) given one drop twice daily for four weeks, beginning with one drop just prior to trachomatous trichiasis surgery on the upper lid. |
|
|
| 1 year |
| Efficacy Measure 3 - Lashes | Number and location of trichiatic lashes from the upper eyelid touching the globe | 1 year |
| Efficacy Measure 4 - Health Economic Analysis | Marginal cost per case of postoperative trichiasis avoided (Cost-effectiveness in the use of Fluorometholone 0.1%) | 1 year |
| Safety/Adverse Outcomes 1 - Corneal Opacity | Presence and grade of corneal opacity in study eyes | 1 year |
| Safety/Adverse Outcomes 2 - Overcorrection | Presence of overcorrection in study eyes | 1 year |
| Safety/Adverse Outcomes 3 - Eyelid Abnormalities | Presence of eyelid notching/eyelid contour abnormalities in study eyes | 1 year |
| Safety/Adverse Outcome 4 - Lid Closure Defect | Presence of lid closure defect in study eyes | 1 year |
| Safety/Adverse Outcomes 5 - Granuloma | Presence of granuloma in study eyes at 1 year | 1 year |
| Safety/Adverse Outcomes 6 - Pain Level | Pain scale score ranges from 5 (least pain) to 20 (most pain) | 1 year |
| Safety/Adverse Outcomes 7 - IOP in mmHg | Intraocular pressure (IOP) elevation ≥ 10 mmHg from baseline in study eyes at week 4 | 4 weeks |
| Safety/Adverse Outcomes 8 - Cataract Surgery | Occurrence of cataract surgery in study eyes | 1 year |
| Safety/Adverse Outcomes 9 - TT in Non-study Eye | Cumulative incidence of TT in the fellow eye by one year | 1 year |
| Safety/Adverse Outcomes 10 - Adverse Events | Adverse events attributed to study treatment by one year | 1 year |
| Patient-reported Outcomes 1 - Patient Satisfaction | Patient satisfaction level in regards to the trichiasis surgery outcome measured on a likert scale for satisfaction (from very dissatisfied to very satisfied) | 1 year |
| Patient-reported Outcomes 2 - Cosmetic Outcome | Patient satisfaction level in regards to the cosmetic outcome of the trichiasis surgery measured on a likert scale for satisfaction (from very dissatisfied to very satisfied) | 1 year |
| Patient-reported Outcomes 3 - Health Utility | Quality of life assessed using the tool EuroQol 5 Dimensions (EQ-5D) comprising mobility, self-care, usual activities, pain/discomfort and anxiety/depression dimensions and assessed on five levels from no problems to extreme problems | 1 year |
| Additional Variables 1 - Visual Acuity | Visual acuity with presenting correction in study eyes | 1 year |
| Derived |
| Kempen JH, Chen Y, Abashawl A, Mohammed AA, Dodson S, Alemayehu W, Gemechu A, Mengesha AA, Kumsa DA, Succar T, McWilliams K, Jin F, Bunya VY, Maguire MG, Burton MJ, Ying GS; FLuorometholone as Adjunctive MEdical Therapy for Trachomatous Trichiasis Surgery (FLAME) Trial Research Group. Outcomes of posterior lamellar tarsal rotation vs bilamellar tarsal rotation for trachomatous trichiasis. PLoS Negl Trop Dis. 2025 Jul 30;19(7):e0013152. doi: 10.1371/journal.pntd.0013152. eCollection 2025 Jul. |
| 39656933 | Derived | Mohammed AA, Abashawl A, Dodson S, Alemayehu W, Gemechu A, Abateneh A, Kumsa D, Succar T, Chen Y, McWilliams K, Bunya VY, Maguire MG, Burton MJ, Ying GS, Kempen JH; FLuorometholone as Adjunctive MEdical Therapy for Trachomatous Trichiasis Surgery (FLAME) Trial Research Group. The FLuorometholone as Adjunctive MEdical Therapy for Trachomatous Trichiasis Surgery (FLAME) Trial: Study Design. Ophthalmic Epidemiol. 2024 Dec;31(6):611-619. doi: 10.1080/09286586.2024.2415052. Epub 2024 Dec 10. |
| 39006430 | Derived | Mohammed AA, Abashawl A, Dodson S, Alemayehu W, Gemechu A, Mengesha AA, Kumsa D, Succar T, Chen Y, McWilliams K, Bunya VY, Maguire MG, Burton MJ, Ying GS, Kempen JH; FLuorometholone as Adjunctive MEdical Therapy for Trachomatous Trichiasis Surgery (FLAME) Trial Research Group. The FLuorometholone as Adjunctive MEdical Therapy for Trachomatous Trichiasis Surgery (FLAME) Trial: Study Design. medRxiv [Preprint]. 2024 Jul 7:2024.06.26.24308549. doi: 10.1101/2024.06.26.24308549. |
| Other |
|
| BG002 | Total | Total of all reporting groups |
| Study Eyes |
|
| Standard Deviation |
| Years |
| Participants |
|
| Sex: Female, Male | Count of Participants | Participants | Participants |
|
| Laterality of TT Surgery | Count of Participants | Participants | Participants |
|
| Reading ability: unable | Count of Participants | Participants | Participants |
|
| Self-reported pain or discomfort | Count of Participants | Participants | Participants |
|
| Ocular Surface Disease Index (OSDI) ocular symptoms score | Ocular Surface Disease Index (OSDI) ocular symptoms score. OSDI ocular symptoms score based on three OSDI questions. Score ranges from 0-100, higher score indicates worse ocular symptoms. | Mean | Standard Deviation | scores on a scale | Participants |
|
| Ocular Surface Disease Index (OSDI) total score | Ocular Surface Disease Index (OSDI) total score. OSDI total score range 0-100, higher score indicates worse symptoms. Total score is based on 12 questions related to ocular symptoms, environmental trigger, and vision-related function. | Mean | Standard Deviation | scores on a scale | Participants |
|
| Type of TT surgery | Type of trachomatous trichiasis surgery | Count of Units | Study Eyes | Study Eyes |
|
| Presenting Visual Acuity | Count of Units | Study Eyes | Study Eyes |
|
| Total number of upper eyelid lashes touching the globe or the cornea | Count of Units | Study Eyes | Study Eyes |
|
| Mean total number of upper eyelid lashes touching the globe or the cornea | Mean | Standard Deviation | Upper lid lashes touching globe/cornea | Study Eyes |
|
| Evidence/extent of epilation in the upper eyelid | Count of Units | Study Eyes | Study Eyes |
|
| Severity of upper eyelid trichiasis | Count of Units | Study Eyes | Study Eyes |
|
| Upper Eyelid Entropion | Count of Units | Study Eyes | Study Eyes |
|
| Conjunctivalization of the lid margin grade | Count of Units | Study Eyes | Study Eyes |
|
| Trichiasis of the lower eyelid | Count of Units | Study Eyes | Study Eyes |
|
| Corneal opacity | Count of Units | Study Eyes | Study Eyes |
|
| Upper eyelid conjunctival scarring | Count of Units | Study Eyes | Study Eyes |
|
| IOP | Mean | Standard Deviation | mmHg | Study Eyes |
|
| Diagnosed with cataract: Yes | Count of Units | Study Eyes | Study Eyes |
|
| Previous eye surgery: Yes | Count of Units | Study Eyes | Study Eyes |
|
| Previous eye injury: Yes | Count of Units | Study Eyes | Study Eyes |
|
| Race/Ethnicity, Customized | Count of Participants | Participants | Participants |
|
| Fluorometholone |
Fluorometholone 0.1% eyedrops, one drop twice daily for four weeks |
|
|
|
| Secondary | Efficacy Measure 1 - Entropion | Presence and extent of entropion of the upper eyelid | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Efficacy Measure 2 - Reoperation | Number of study eyes undergoing reoperation for postoperative trichiasis | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Efficacy Measure 3 - Lashes | Number and location of trichiatic lashes from the upper eyelid touching the globe | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Mean | Standard Deviation | Lashes touching | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Efficacy Measure 4 - Health Economic Analysis | Marginal cost per case of postoperative trichiasis avoided (Cost-effectiveness in the use of Fluorometholone 0.1%) | Posted | Number | cost (2026 USD)/(PTT case avoided) | 1 year |
|
|
|
| Secondary | Safety/Adverse Outcomes 1 - Corneal Opacity | Presence and grade of corneal opacity in study eyes | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 2 - Overcorrection | Presence of overcorrection in study eyes | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 3 - Eyelid Abnormalities | Presence of eyelid notching/eyelid contour abnormalities in study eyes | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcome 4 - Lid Closure Defect | Presence of lid closure defect in study eyes | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 5 - Granuloma | Presence of granuloma in study eyes at 1 year | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 6 - Pain Level | Pain scale score ranges from 5 (least pain) to 20 (most pain) | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Mean | Standard Deviation | Point | 1 year | Study eye | Study eye |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 7 - IOP in mmHg | Intraocular pressure (IOP) elevation ≥ 10 mmHg from baseline in study eyes at week 4 | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 4 weeks | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 8 - Cataract Surgery | Occurrence of cataract surgery in study eyes | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 9 - TT in Non-study Eye | Cumulative incidence of TT in the fellow eye by one year | Consider fellow eye that doesn't have previous upper lid eyelid surgery for TT and diagnosis of upper eyelid TT at baseline, and fellow eye that cannot determine the TT status based on week 4, month 6 and month 12 visit are excluded. | Posted | Count of Units | Fellow eye | 1 year | Fellow eye | Fellow eye |
|
|
|
|
| Secondary | Safety/Adverse Outcomes 10 - Adverse Events | Adverse events attributed to study treatment by one year | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Participants | Participants | 1 year |
|
|
|
|
| Secondary | Patient-reported Outcomes 1 - Patient Satisfaction | Patient satisfaction level in regards to the trichiasis surgery outcome measured on a likert scale for satisfaction (from very dissatisfied to very satisfied) | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Patient-reported Outcomes 2 - Cosmetic Outcome | Patient satisfaction level in regards to the cosmetic outcome of the trichiasis surgery measured on a likert scale for satisfaction (from very dissatisfied to very satisfied) | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Count of Units | Study eyes | 1 year | Study eyes | Study eyes |
|
|
|
|
| Secondary | Patient-reported Outcomes 3 - Health Utility | Quality of life assessed using the tool EuroQol 5 Dimensions (EQ-5D) comprising mobility, self-care, usual activities, pain/discomfort and anxiety/depression dimensions and assessed on five levels from no problems to extreme problems | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Mean | Standard Deviation | Point | 1 year |
|
|
|
|
| Secondary | Additional Variables 1 - Visual Acuity | Visual acuity with presenting correction in study eyes | Numbers analyzed may differ due to different number of patients that completed each follow up visit due to reasons such as death or lost to follow up. | Posted | Mean | Standard Deviation | logMAR | 1 year | Study eyes | Study eyes |
|
|
|
|
| 6 |
| 1,206 |
| 83 |
| 1,206 |
| 382 |
| 1,206 |
| EG001 | Fluorometholone | Fluorometholone 0.1% eyedrops, one drop twice daily for four weeks | 8 | 1,204 | 88 | 1,204 | 287 | 1,204 |
| BLINDNESS | Eye disorders | Systematic Assessment |
|
| ECTROPION | Eye disorders | Systematic Assessment |
|
| EYE PAIN | Eye disorders | Systematic Assessment |
|
| GLAUCOMA | Eye disorders | Systematic Assessment |
|
| INTRAOCULAR PRESSURE INCREASED | Eye disorders | Systematic Assessment |
|
| TRICHIASIS | Eye disorders | Systematic Assessment |
|
| ABDOMINAL PAIN | Gastrointestinal disorders | Systematic Assessment |
|
| DYSPEPSIA | Gastrointestinal disorders | Systematic Assessment |
|
| INTESTINAL OBSTRUCTION | Gastrointestinal disorders | Systematic Assessment |
|
| HERNIA | General disorders | Systematic Assessment |
|
| DEATH | General disorders | Systematic Assessment |
|
| LOWER RESPIRATORY TRACT INFECTION | Infections and infestations | Systematic Assessment |
|
| RESPIRATORY TRACT INFECTION | Infections and infestations | Systematic Assessment |
|
| URINARY TRACT INFECTION | Infections and infestations | Systematic Assessment |
|
| FEMUR FRACTURE | Injury, poisoning and procedural complications | Systematic Assessment |
|
| THERMAL BURN | Injury, poisoning and procedural complications | Systematic Assessment |
|
| SURGERY | Investigations | Systematic Assessment |
|
| DIABETES MELLITUS | Metabolism and nutrition disorders | Systematic Assessment |
|
| URINARY TRACT PAIN | Renal and urinary disorders | Systematic Assessment |
|
| EYELID DISORDER | Eye disorders | Systematic Assessment |
|
| EYELID VASCULAR DISORDER | Eye disorders | Systematic Assessment |
|
Not provided
Not provided
| Fused-Ring Compounds |
| D011083 | Polycyclic Compounds |
| D013259 | Steroids, Fluorinated |
| D009883 | Ophthalmic Solutions |
| D019999 | Pharmaceutical Solutions |
| D012996 | Solutions |
| D004364 | Pharmaceutical Preparations |
| D045506 | Therapeutic Uses |
| D020228 | Pharmacologic Actions |
| D020164 | Chemical Actions and Uses |
| D054327 | Lubricants |
| D020313 | Specialty Uses of Chemicals |
|
|
|
|
|
| No surgery due to withdrawal after randomization |
|
| Neither satisfied nor dissatisfied |
|
| Dissatisfied |
|
| Very dissatisfied |
|
| Neither satisfied nor dissatisfied |
|
| Dissatisfied |
|
| Very dissatisfied |
|