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Ophthalmology > LID
Trichiasis
Article Last Updated: Jun 26, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Robert H Graham is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society
Coauthor(s):
Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Editors: Jorge G Camara, MD, Chairman, Department of Ophthalmology and Otorhinolaryngology, Director of Fellowship Training Program, St Francis Medical Center; Associate Professor, Department of Surgery, University of Hawaii School of Medicine; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
lash inversion
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.
Pathophysiology
The primary causes of trichiasis are involutional changes, posterior lamellae scarring (superior or inferior), epiblepharon, and distichiasis.
Frequency
United States
Trachoma is relatively uncommon in the US. 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.
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, this condition most commonly is seen in the adult years. Epiblepharon, one of the common causes of trichiasis, is found primarily in children.
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 Image 2).
- Has the patient ever had a severe eye infection or been to countries where trachoma commonly is seen (eg, Africa, Middle East)?
- 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 Image 1, Image 4).
- 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 Image 5).
- 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 both the upper and the 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 Image 1).
- Look for symblepharon formation and fornix scars as seen in OCP or SJS (see Image 5).
- Look for signs of involution entropion (see Images 6-7) and horizontal lid laxity (see Images 8-9). Try the snap back test.
- 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 Image 8).
- 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 Image 9).
- 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
- Autoimmune - Ocular cicatricial pemphigoid (see Image 5)
- Inflammatory
- Stevens-Johnson syndrome
- Vernal keratoconjunctivitis
- Trauma
- Postsurgical
- Lower lid transconjunctival approach for floor fracture repair or blepharoplasty (see Image 10)
- After enucleation
- After ectropion repair
- Chemical
- Alkali burns to the eye
- Medical drops (eg, glaucoma drops)
- Thermal burns to face/lids
Blepharitis, Adult
Blepharospasm, Benign Essential
Burns, Chemical
Cicatricial Pemphigoid
Corneal Abrasion
Corneal Foreign Body
Distichiasis
Entropion
Red Eye Evaluation
Stevens-Johnson Syndrome
Trachoma
Lab Studies
- No studies are needed unless an autoimmune disease is suspected.
Procedures
- In general, diagnostic procedures are not needed in the treatment of this entity. If OCP or trachoma is suspected, a biopsy of the conjunctiva may be helpful.
Medical Care
The primary treatment for this condition is surgical.
- Lubricants, such as artificial tears and ointments, may decrease the irritant effect of lash rubbing.
- If a more serious disease (eg, OCP, SJS) is the cause of the lash misdirection, medical therapy should be geared toward that disease.
Surgical Care
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 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.
- Electrolysis of lashes can be effective, but often it 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.
- Argon laser ablation can be effective, but it can be very tedious for both the patient and the surgeon, as well as expensive.
- 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 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.
- 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 OCP and should be avoided with this disease.
- Repositioning of the anterior lamellae may be the method of choice when dealing with OCP because it allows the conjunctiva to remain undisturbed. This technique positions the lashes away from the lid margin and further away from the globe.
Consultations
In cases of SJS or OCP, a general medical consult may be necessary. Cornea/external disease and/or oculoplastic services may be required in severe cases.
Further Outpatient Care
- Patients should receive follow-up care as needed.
Complications
- Overly aggressive surgical treatment of entropion may lead to ectropion; this condition usually resolves with time.
- To avoid rubbing of the conjunctiva, all sutures should be resorbable and buried; a collagen shield or a bandage contact lens also can 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.
Prognosis
- Prognosis is generally good. Frequent follow-up care and immediate attention to complications, recurrence, or corneal complications improve the long-term prognosis.
Patient Education
- Instruct patients to watch for signs of new lash growth, and advise them to return for retreatment (if appropriate).
Medical/Legal Pitfalls
- The lashes can scratch the cornea and rarely cause a corneal ulcer.
| Media file 1:
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert. |
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| Media file 3:
Ellman radiofrequency follicle ablation of lower lid trichiasis |
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| Media file 5:
Symblepharon formation from ocular cicatricial pemphigoid |
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| Media file 6:
Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation. |
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| Media file 7:
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. |
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| Media file 8:
Snap back test. Retraction of the skin of the lower lid on the right. |
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| Media file 9:
Snap back test. The lid does not reapproximate the globe after the retraction is released. |
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| Media file 10:
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. |
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Trichiasis excerpt Article Last Updated: Jun 26, 2006
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