Trichiasis, a very common lid abnormality, is defined as the misdirection of eyelashes toward the globe. The misdirected lashes may be diffuse across the entire lid or in a small segmental distribution.
Trichiasis has numerous causes, and the strategies to correct this problem are dictated by the anatomic abnormality causing the lash misdirection. See the image below.
View Image
Entropion (close up). Note that the lashes of the lower lid are not easily visible because they are turned in under the lower lid. The pen markings ar....
Trachoma is relatively uncommon in the United States. Exact numbers on the frequency of trichiasis are unknown. Simple trichiasis involving only a few lashes is relatively common. Diffuse trichiasis involving the entire lid margin is much less common, and it is seen primarily in countries where trachoma is endemic.[1]
Mortality/Morbidity
The primary morbidity associated with trichiasis is corneal abrasion, corneal scarring, and microbial keratitis. This condition can be vision threatening.
Race
No known racial predilection is evident.
Sex
No known sexual predilection is evident.
Age
Trichiasis can occur in all ages; however, it is seen most commonly in the adult years.
Epiblepharon, one of the common causes of trichiasis, is found primarily in children.
Prognosis is generally good. Frequent follow-up care and immediate attention to complications, recurrence, or corneal complications improve the long-term prognosis.
A single dose of oral azithromycin (1 g) after surgery can help to prevent recurrence.[14]
The history helps to direct the clinical examination and the subsequent treatment strategy.
Is the patient a child of Asian ancestry? Epiblepharon is a congenital disorder that occurs when the pretarsal orbicularis and the skin override the lid margin, causing the lashes to assume a vertical position. The lashes occasionally rub the cornea. This problem often is noted shortly after birth and most commonly is seen in children of Asian ancestry (see the image below).
View Image
Epiblepharon in an Asian child.
Has the patient ever had a severe eye infection or been to countries where trachoma commonly is seen (eg, Africa, Middle East)?[2, 3] Upper lid entropion and trichiasis commonly are seen with trachoma. Trichiasis is a leading cause of decreased vision with this trachoma and is associated with upper lid entropion (see the images below).
View Image
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
View Image
Lower lid trachoma with cicatrix.
Does the patient have a history of herpes zoster ophthalmicus (HZO)? Zoster can cause scarring of the posterior lamellae.
Is there a history of autoimmune disease involving the eyes? Ocular cicatricial pemphigoid (OCP) is a leading cause of posterior lamellar scarring and symblepharon formation (see the image below).
Is there a history of Stevens-Johnson syndrome (SJS) or a chemical burn to the eye? These conditions are common causes of posterior lamellae scarring, leading to trichiasis.
Is there any previous history of eyelid surgery?
Trauma, whether or not it is surgical, is a common cause of misdirected lashes.
A transconjunctival approach to lower lid surgery or an overaggressive repair of ectropion may lead to trichiasis.
The physical examination helps to elucidate the cause of lash misdirection and directs the surgical strategies used to repair this problem.
Examine the upper and lower lids to look for lash misdirection. This examination may require use of a slit lamp to find the offending lashes if the trichiasis is limited and focal.
Look for signs of posterior lamellar scarring. This requires flipping the upper lid, which may be very difficult in cases of trachoma (see the image below).
View Image
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
Look for symblepharon formation and fornix scars as seen in ocular cicatricial pemphigoid or Stevens-Johnson syndrome (see the image below).
Look for signs of involution entropion (see the images below) and horizontal lid laxity. Try the snap back test.
View Image
Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
View Image
Entropion (close up). Note that the lashes of the lower lid are not easily visible because they are turned in under the lower lid. The pen markings ar....
Ask the patient to look straight ahead and not to blink.
Gently pull the lower lid down and away from the globe with a finger (see the image below).
View Image
Snap back test. Retraction of the skin of the lower lid on the right.
The lid should "snap back" to its normal position against the globe without the need for the patient to blink.
If the lid simply stays away from the globe after the distraction, horizontal lid laxity is present (see the image below).
View Image
Snap back test. The lid does not reapproximate the globe after the retraction is released.
If the lid is very difficult to distract from the globe posterior lamellae, scarring may be present.
Look for lashes growing from the meibomian gland orifices. Known as distichiasis, this metaplastic change is seen in some inflammatory conditions of the lid.
Lower lid transconjunctival approach for floor fracture repair or blepharoplasty (see the image below)
View Image
Postoperative lid retraction with lower lid tissue stuck down to hardware on the orbital rim after a transconjunctival approach to a rim and floor fra....
Lubricants, such as artificial tears and ointments, may decrease the irritant effect of lash rubbing.
If a more serious disease (eg, ocular cicatricial pemphigoid, Stevens-Johnson syndrome) is the cause of the lash misdirection, medical therapy should be geared toward that disease.
According to West and colleagues, azithromycin has been shown to reduce severe postsurgical trichiasis recurrence rates to 1 year.[4]
Li et al have found that doxycycline has successfully suppressed the contractile fibroblasts in patients with trachoma and suggest that doxycycline might be useful as a treatment to prevent recurrence of trichiasis following surgery.[5]
Surgery for trichiasis can substantially improve quality of life, regardless of changes in visual acuity, as shown by Habtamu et al.[6] Many procedures for the repair of trichiasis have been described. The technique used is dependent on the cause of the problem. These procedures can be categorized as lash/follicle destroying or lash/follicle repositioning.
Lash and follicle destruction surgery
Lash and follicle destruction surgery is preferred for segmental or focal trichiasis.
Simple epilation with forceps often leaves the lash follicle and usually is only a temporizing measure. When the lash grows back, it often will be short and stiff, and even more irritating.[7, 8]
Electrolysis of lashes can be effective, but it often is painful for the patient and tedious for the surgeon.
Cryosurgery of lashes and follicles can be very effective, but it has many potential complications.
Radiofrequency ablation of lashes and follicles is extremely effective and can be performed quickly and easily at the slit lamp or with surgical loupes and local anesthesia. The smallest gauge wire (eg, Ellman TA1, A8 bendable 1/16th vari tip) is introduced alongside the lash down to the follicle, with the lowest setting that gives an easy introduction of the wire. The machine should be set on cut/coag. A small "core sample" will be missing from the lid margin and will granulate in with minimal scarring. See the image below.
View Image
Lower lid trichiasis, Ellman radiofrequency follicle ablation.
Mitomycin C injected into the hair follicle immediately after radiofrequency ablation may reduce recurrence of trichiasis.[9]
Argon laser ablation can be effective, but it can be very tedious for both the patient and the surgeon, as well as expensive.
According to Moore and colleagues, ruby laser treatment can be a viable and well-tolerated option for the relief of the symptoms of trichiasis.[10]
Wedge resection of the lid segment requires a full-thickness resection of the lid margin; in many cases, it may be excessive.
Lash and follicle repositioning surgery
Lash and follicle repositioning surgery should be directed toward the anatomical cause of the problem.
Entropion
Lower lid retractor reattachment and lateral tarsal strip can be used to repair most cases of horizontal lid laxity and entropion.
Cruz et al have described good results from autogenous tarsal graft to correct lower lid trichiasis with eyelid margin thinning.[42]
Posterior lamellar scarring
The posterior lamellae and fornix can be lengthened with grafts (eg, mucous membrane, hard palate, cadaveric dermis).
A tarsoconjunctival advancement may lengthen the posterior lamellae.
Tarsal fracture with full-thickness everting sutures repositions the lashes to point away from the globe.
Surgery of the conjunctiva may reactivate ocular cicatricial pemphigoid and should be avoided with this disease.
Repositioning of the anterior lamellae may be the method of choice when dealing with ocular cicatricial pemphigoid because it allows the conjunctiva to remain undisturbed. This technique positions the lashes away from the lid margin and further away from the globe.
Posterior lamellar tarsal rotation was found to be superior to bilamellar tarsal rotation in managing trachomatous trichiasis.[11] Barr et al reported that anterior lamellar repositioning for trachomatous trichiasis yielded results that were similar to those of bilamellar tarsal rotation, although they cautioned that the results are uncertain owing to inconsistent follow-up times.[12]
Ferraz et al concluded that lid lamellar resection was technically simpler and offered a greater chance of success compared with intermarginal split lamella with graft.[43]
Overly aggressive surgical treatment of entropion may lead to ectropion; this condition usually resolves with time. See the image below.
View Image
Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
To avoid rubbing of the conjunctiva, all sutures should be resorbable and buried; a collagen shield or a bandage contact lens can also help avoid this problem.
Although not truly a complication, if only a few lashes are being epilated/ablated, warn the patient that the lashes may grow back or that new lashes may grow. Recurrence is common.
Discuss the normal complications of bleeding, infection, recurrence, need for more surgery, scarring, and cosmesis with all patients.
Robert H Graham, MD, Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Disclosure: Partner received salary from Medscape/WebMD for employment.
Specialty Editors
Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Ron W Pelton, MD, PhD, to the development and writing of this article.
Entropion (close up). Note that the lashes of the lower lid are not easily visible because they are turned in under the lower lid. The pen markings are for lower lid retractor reinsertion and orbicularis debulking. The patient also will have a lateral tarsal strip.
Epiblepharon in an Asian child.
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
Entropion (close up). Note that the lashes of the lower lid are not easily visible because they are turned in under the lower lid. The pen markings are for lower lid retractor reinsertion and orbicularis debulking. The patient also will have a lateral tarsal strip.
Snap back test. Retraction of the skin of the lower lid on the right.
Snap back test. The lid does not reapproximate the globe after the retraction is released.
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
Postoperative lid retraction with lower lid tissue stuck down to hardware on the orbital rim after a transconjunctival approach to a rim and floor fracture on the left eye. The lashes are now turned toward the eye. The patient also has a phthisical right eye.
Lower lid trichiasis, Ellman radiofrequency follicle ablation.
Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
Epiblepharon in an Asian child.
Lower lid trichiasis, Ellman radiofrequency follicle ablation.
Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
Entropion (close up). Note that the lashes of the lower lid are not easily visible because they are turned in under the lower lid. The pen markings are for lower lid retractor reinsertion and orbicularis debulking. The patient also will have a lateral tarsal strip.
Snap back test. Retraction of the skin of the lower lid on the right.
Snap back test. The lid does not reapproximate the globe after the retraction is released.
Postoperative lid retraction with lower lid tissue stuck down to hardware on the orbital rim after a transconjunctival approach to a rim and floor fracture on the left eye. The lashes are now turned toward the eye. The patient also has a phthisical right eye.
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}