Trichiasis Clinical Presentation

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Mar 5, 2012
 

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)?[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). 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.
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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.
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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
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Contributor Information and Disclosures
Author

Robert H Graham, MD  Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society

Disclosure: WebMD/eMedicine Salary Employment

Specialty Editor Board

Jorge G Camara, MD  Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine

Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Ron W Pelton, MD, PhD, to the development and writing of this article.

References

  1. Rajak SN, O Collin JR, Burton MJ. Trachomatous Trichiasis and its Management in Endemic Countries. Surv Ophthalmol. Jan 27 2012;[Medline].

  2. Ngondi J, Reacher MH, Matthews FE, et al. Risk factors for trachomatous trichiasis in children: cross-sectional household surveys in Southern Sudan. Trans R Soc Trop Med Hyg. Mar 2009;103(3):305-14. [Medline].

  3. Ngondi J, Gebre T, Shargie EB, et al. Risk factors for active trachoma in children and trichiasis in adults: a household survey in Amhara Regional State, Ethiopia. Trans R Soc Trop Med Hyg. May 2008;102(5):432-8. [Medline].

  4. West ES, Munoz B, Imeru A, Alemayehu W, Melese M, West SK. The association between epilation and corneal opacity among eyes with trachomatous trichiasis. Br J Ophthalmol. Feb 2006;90(2):171-4. [Medline].

  5. Rajak SN, Habtamu E, Weiss HA, Kello AB, Gebre T, Genet A, et al. Surgery versus epilation for the treatment of minor trichiasis in Ethiopia: a randomised controlled noninferiority trial. PLoS Med. Dec 2011;8(12):e1001136. [Medline]. [Full Text].

  6. Rajak SN, Habtamu E, Weiss HA, Bedri A, Gebre T, Genet A, et al. Epilation for trachomatous trichiasis and the risk of corneal opacification. Ophthalmology. Jan 2012;119(1):84-9. [Medline].

  7. Moore J, De Silva SR, O'Hare K, Humphry RC. Ruby laser for the treatment of trichiasis. Lasers Med Sci. Mar 2009;24(2):137-9. [Medline].

  8. Woreta F, Munoz B, Gower E, Alemayehu W, West SK. Three-Year Outcomes of the Surgery for Trichiasis, Antibiotics to Prevent Recurrence Trial. Arch Ophthalmol. Dec 12 2011;[Medline].

  9. Woreta F, Munoz B, Gower E, Alemayehu W, West SK. Three-Year Outcomes of the Surgery for Trichiasis, Antibiotics to Prevent Recurrence Trial. Arch Ophthalmol. Feb 14 2012;[Medline].

  10. Bartley GB, Bullock JD, Olsen TG, Lutz PD. An experimental study to compare methods of eyelash ablation. Ophthalmology. Oct 1987;94(10):1286-9. [Medline].

  11. Bartley GB, Lowry JC. Argon laser treatment of trichiasis. Am J Ophthalmol. Jan 15 1992;113(1):71-4. [Medline].

  12. Burton MJ, Bowman RJ, Faal H, et al. The long-term natural history of trachomatous trichiasis in the Gambia. Invest Ophthalmol Vis Sci. Mar 2006;47(3):847-52. [Medline].

  13. Burton MJ, Kinteh F, Jallow O, et al. A randomised controlled trial of azithromycin following surgery for trachomatous trichiasis in the Gambia. Br J Ophthalmol. Oct 2005;89(10):1282-8. [Medline].

  14. Chi MJ, Park MS, Nam DH, Moon HS, Baek SH. Eyelid splitting with follicular extirpation using a monopolar cautery for the treatment of trichiasis and distichiasis. Graefes Arch Clin Exp Ophthalmol. May 2007;245(5):637-40. [Medline].

  15. Collin RJO. Entropion and trichiasis. In: A Manual of Systemic Eyelid Surgery. New York: Churchill-Livingstone; 1989:7-26.

  16. Dhaliwal U, Nagpal G, Bhatia MS. Health-related quality of life in patients with trachomatous trichiasis or entropion. Ophthalmic Epidemiol. Feb 2006;13(1):59-66. [Medline].

  17. Durkin SR, Casson R, Newland HS, Selva D. Prevalence of trachoma and diabetes-related eye disease among a cohort of adult Aboriginal patients screened over the period 1999-2004 in remote South Australia. Clin Experiment Ophthalmol. May-Jun 2006;34(4):329-34. [Medline].

  18. Edwards T, Cumberland P, Hailu G, Todd J. Impact of health education on active trachoma in hyperendemic rural communities in Ethiopia. Ophthalmology. Apr 2006;113(4):548-55. [Medline].

  19. El Toukhy E, Lewallen S, Courtright P. Routine bilamellar tarsal rotation surgery for trachomatous trichiasis: short-term outcome and factors associated with surgical failure. Ophthal Plast Reconstr Surg. Mar-Apr 2006;22(2):109-12. [Medline].

  20. Elder MJ, Collin R. Anterior lamellar repositioning and grey line split for upper lid entropion in ocular cicatricial pemphigoid. Eye. 1996;10 (Pt 4):439-42. [Medline].

  21. Johnson RL, Collin JR. Treatment of trichiasis with a lid cryoprobe. Br J Ophthalmol. Apr 1985;69(4):267-70. [Medline].

  22. Jordan DR, Zafar A, Brownstein S, Faraji H. Cicatricial conjunctival inflammation with trichiasis as the presenting feature of Wegener granulomatosis. Ophthal Plast Reconstr Surg. Jan-Feb 2006;22(1):69-71. [Medline].

  23. Kersten RC, Kleiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol. May 1992;110(5):714-7. [Medline].

  24. Kuckelkorn R, Schrage N, Becker J, Reim M. Tarsoconjunctival advancement: a modified surgical technique to correct cicatricial entropion and metaplasia of the marginal tarsus. Ophthalmic Surg Lasers. Feb 1997;28(2):156-61. [Medline].

  25. Nagpal G, Dhaliwal U, Bhatia MS. Barriers to acceptance of intervention among patients with trachomatous trichiasis or entropion presenting to a teaching hospital. Ophthalmic Epidemiol. Feb 2006;13(1):53-8. [Medline].

  26. Polack S, Brooker S, Kuper H, Mariotti S, Mabey D, Foster A. Mapping the global distribution of trachoma. Bull World Health Organ. Dec 2005;83(12):913-9. [Medline].

  27. Rhatigan MC, Ashworth JL, Goodall K, Leatherbarrow B. Correction of blepharoconjunctivitis-related upper eyelid entropion using the anterior lamellar reposition technique. Eye. 1997;11 (Pt 1):118-20. [Medline].

  28. Shiu M, McNab AA. Cicatricial entropion and trichiasis in an urban Australian population. Clin Experiment Ophthalmol. Dec 2005;33(6):582-5. [Medline].

  29. Tirakunwichcha S, Tinnangwattana U, Hiranwiwatkul P, Rohitopakarn S. Folliculectomy: management in segmental trichiasis and distichiasis. J Med Assoc Thai. Jan 2006;89(1):90-3. [Medline].

  30. West ES, Alemayehu W, Munoz B, Melese M, Imeru A, West SK. Surgery for Trichiasis, Antibiotics to prevent Recurrence (STAR) Clinical Trial methodology. Ophthalmic Epidemiol. Aug 2005;12(4):279-86. [Medline].

  31. West S, Alemayehu W, Munoz B, Gower EW. Azithromycin prevents recurrence of severe trichiasis following trichiasis surgery: STAR trial. Ophthalmic Epidemiol. Sep-Oct 2007;14(5):273-7. [Medline].

  32. West SK, West ES, Alemayehu W, et al. Single-dose azithromycin prevents trichiasis recurrence following surgery: randomized trial in Ethiopia. Arch Ophthalmol. Mar 2006;124(3):309-14. [Medline].

  33. Wojono TH. Lid splitting with lash resection for cicatricial entropion. Ophthalmic Plast Reconst Surg. 1992;8:287-289.

  34. Wood JR, Anderson RL. Complications of cryosurgery. Arch Ophthalmol. Mar 1981;99(3):460-3. [Medline].

  35. Yeung YM, Hon CY, Ho CK. A simple surgical treatment for upper lid trichiasis. Ophthalmic Surg Lasers. Jan 1997;28(1):74-6. [Medline].

  36. Zhang H, Kandel RP, Atakari HK, Dean D. Impact of oral azithromycin on recurrence of trachomatous trichiasis in Nepal over 1 year. Br J Ophthalmol. Aug 2006;90(8):943-8. [Medline].

 
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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.
Lower lid trachoma with cicatrix.
Ocular cicatricial pemphigoid, symblepharon formation.
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.
 
 
 
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