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).
Has the patient ever had a severe eye infection or been to countries where trachoma commonly is seen (eg, Africa, Middle East)? [3, 4] 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).
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.
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).
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.
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.
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).
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 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:
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Infectious
Trachoma (see the images below)
Herpes zoster
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Autoimmune - Ocular cicatricial pemphigoid (see the image below)
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Inflammatory
Stevens-Johnson syndrome
Vernal keratoconjunctivitis
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Trauma
Postsurgical
Lower lid transconjunctival approach for floor fracture repair or blepharoplasty (see the image below)
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
Chemical
Alkali burns to the eye
Medical drops (eg, glaucoma drops)
Thermal burns to face/lids
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Trachoma of upper lid. The trachomatous right upper lid was difficult to evert.
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Epiblepharon in an Asian child.
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Lower lid trichiasis, Ellman radiofrequency follicle ablation.
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Lower lid trachoma with cicatrix.
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Ocular cicatricial pemphigoid, symblepharon formation.
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Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.
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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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Snap back test. Retraction of the skin of the lower lid on the right.
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Snap back test. The lid does not reapproximate the globe after the retraction is released.
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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.
