Introduction
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.
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.
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.
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.
Clinical
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 Media file 2).
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)?1,2
- 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 Media file 1, Media file 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 Media file 5).
Ocular 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 Media file 1).
- Look for symblepharon formation and fornix scars as seen in ocular cicatricial pemphigoid or Stevens-Johnson syndrome (see Media file 5).
- Look for signs of involution entropion (see Media files 6-7) and horizontal lid laxity (see Media files 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 Media file 8).
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 Media file 9).
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.
Causes
The causes of lash misdirection are numerous and can be categorized as follows:
- Infectious
- Trachoma (see Media file 1, Media file 4)
Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
- Herpes zoster
- Trachoma (see Media file 1, Media file 4)
- Autoimmune - Ocular cicatricial pemphigoid (see Media file 5)
- Inflammatory
- Stevens-Johnson syndrome
- Vernal keratoconjunctivitis
- Trauma
- Postsurgical
- Lower lid transconjunctival approach for floor fracture repair or blepharoplasty (see 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.
- After enucleation
- After ectropion repair
- Lower lid transconjunctival approach for floor fracture repair or blepharoplasty (see Media file 10)
- Chemical
- Alkali burns to the eye
- Medical drops (eg, glaucoma drops)
- Thermal burns to face/lids
- Postsurgical
More on Trichiasis |
 Overview: Trichiasis |
| Differential Diagnoses & Workup: Trichiasis |
| Treatment & Medication: Trichiasis |
| Follow-up: Trichiasis |
| Multimedia: Trichiasis |
| References |
| Next Page » |
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Further Reading
Keywords
trichiasis, ingrown eyelashes, lash inversion, lid abnormality, eyelid abnormality, eyelash misdirection, lash misdirection, misdirected lashes, misdirected eyelashes
