Implementation fidelity is the degree to which an intervention is delivered as intended.  Reduced level of fidelity of trichiasis surgery program may be why there is increased unfavorable postoperative trichiasis surgery outcomes. Trachomatous trichiasis (TT) is a sign of trachoma which comes as a result of multiple rounds of Chlamydial trachomatis infection which causes recurrent chronic inflammation in the tarsal conjunctiva, which later progress to conjunctival scarring, entropion, and corneal opacification to blindness if left untreated. Trichiasis surgery is done to correct trachomatous trichiasis and prevent blindness.  However, unfavorable outcomes after surgery are frequent. This study measured the level of implementation fidelity of trichiasis surgery and the factors associated with trichiasis surgery outcomes in Northern and Eastern Uganda. We conducted a cross-sectional survey on health workers implementing trichiasis surgery programs in Eastern and Northern Uganda; from December 2019 to March 2020. Self-administered questionnaires were distributed to 408 study participants who attend the study site, and to those who failed to attend in person, the survey was emailed and others were visited and interviewed face-to-face in their offices.  The direct observation study was a participatory observation approach. The collected data was entered into Epi-info7 software and the scores from the survey were entered into computer Microsoft Excel spreadsheets 2016. STATA version 14.2 (Stata-Corp, College Station, TX) was used for analysis.  Fisher's exact test, t-test, and multi logistic regression were used to report proportions and effective measures of association.  Akaike information criterion (AIC) or Bayesian information criterion (BIC) models (nested model) were used to select the best predictors. A total of 408 participants which include; trichiasis nurse, ophthalmology clinical officers, consultant ophthalmologist, and trichiasis case finders were surveyed, and 155 direct trichiasis surgery observations were evaluated.  The level of fidelity to program content was; 46.08%, coverage 51.72%, duration 31.86%, methods of delivery 82.80%, exposure was 42.16% and participants’ responsiveness 17.16%. Factors associated with implementation fidelity for trichiasis surgery program outcomes were; quality of delivery (OR=0.439, 95% CI [0.267 .723], P<0.001), characteristics of the community (OR=70.389 95% CI [14.016 353.490], p<0.001), facilitation and sustainability strategies (OR=0.095, 95% CI [0.042 .216], p=<0.001), characteristics of patients0.105, 95% CI [0.013 .169], p<0.001), program content (OR=8.122. 95% CI [1.709 38.582], p<0.008), Participants’ responsiveness (OR= 0.048, 95% CI [0.013 .169], p<0.001), and structural/ organizational (OR=0.535, 95% CI [0.338 .846], p=<0.008). Implementation fidelity of the trichiasis surgery program was found low. To reduce unfavorable postoperative Trichiasis surgery outcomes, program implementers should adhere to the protocol, and deliver as it was prescribed by the program designer. This can be achieved if the potential associated moderating factors such; facilitation and sustainability strategies, quality of delivery, patient characteristics, and program content are improved.