Trichiasis Treatment & Management


Background

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.

Entropion (close up). Note that the lashes of the 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.

Pathophysiology

The primary causes of trichiasis are involutional changes, posterior lamellae scarring (superior or inferior), epiblepharon, and distichiasis.

Epidemiology

Frequency

United States

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

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]

Patient Education

Instruct patients to watch for signs of new lash growth, and advise them to return for retreatment (if appropriate).



History

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).

Epiblepharon in an Asian child. 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)? [23Upper 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).

Trachoma of upper lid. The trachomatous right uppeTrachoma of upper lid. The trachomatous right upper lid was difficult to evert.
Lower lid trachoma with cicatrix. 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).

Ocular cicatricial pemphigoid, symblepharon formatOcular cicatricial pemphigoid, symblepharon formation.

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.

Physical

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).

Trachoma of upper lid. The trachomatous right uppeTrachoma 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).

Ocular cicatricial pemphigoid, symblepharon formatOcular cicatricial pemphigoid, symblepharon formation.

Look for signs of involution entropion (see the images below) and horizontal lid laxity. Try the snap back test.

Bilateral involutional entropion. Note the periocuBilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
Entropion (close up). Note that the lashes of the 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.

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).

Snap back test. Retraction of the skin of the loweSnap 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).

Snap back test. The lid does not reapproximate theSnap 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.

Causes

The causes of lash misdirection are numerous and can be categorized as follows:

  • Infectious

    • Trachoma (see the images below)

      Trachoma of upper lid. The trachomatous right uppeTrachoma of upper lid. The trachomatous right upper lid was difficult to evert.
      Lower lid trachoma with cicatrix. Lower lid trachoma with cicatrix.
    • Herpes zoster

  • Autoimmune - Ocular cicatricial pemphigoid (see the image below)

    Ocular cicatricial pemphigoid, symblepharon formatOcular cicatricial pemphigoid, symblepharon formation.
  • Inflammatory

    • Stevens-Johnson syndrome

    • Vernal keratoconjunctivitis

  • Trauma

    • Postsurgical

      • Lower lid transconjunctival approach for floor fracture repair or blepharoplasty (see the image below)

        Postoperative lid retraction with lower lid tissuePostoperative 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.
      • After enucleation

      • After ectropion repair

    • Chemical

      • Alkali burns to the eye

      • Medical drops (eg, glaucoma drops)

      • Thermal burns to face/lids.


Differential Diagnoses

Laboratory Studies

No laboratory studies are needed unless an autoimmune disease is suspected.

Procedures

In general, diagnostic procedures are not needed in the treatment of trichiasis.

If ocular cicatricial pemphigoid or trachoma is suspected, a biopsy of the conjunctiva may be helpful.


Medical Care

The primary treatment of trichiasis is surgical.

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]

Surgical Care

Surgery for trichiasis can substantially improve quality of life, regardless of changes in visual acuity, as shown by Habtamu et al. [6Many 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. [78]

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.

Lower lid trichiasis, Ellman radiofrequency follicLower 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. [11Barr 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]

Consultations

In cases of Stevens-Johnson syndrome or ocular cicatricial pemphigoid, a general medical consult may be necessary.

Cornea/external disease and/or oculoplastic services may be required in severe cases.

Complications

Overly aggressive surgical treatment of entropion may lead to ectropion; this condition usually resolves with time. See the image below.

Bilateral involutional entropion. Note the periocuBilateral 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.

Long-Term Monitoring

Patients with trichiasis should receive follow-up care as needed.