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 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.

View Media Gallery

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.^[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).

Clinical Presentation

Rajak SN, O Collin JR, Burton MJ. Trachomatous Trichiasis and its Management in Endemic Countries. Surv Ophthalmol. 2012 Jan 27. [QxMD MEDLINE Link].
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. 2009 Mar. 103(3):305-14. [QxMD MEDLINE Link].
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. 2008 May. 102(5):432-8. [QxMD MEDLINE Link].
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. 2006 Feb. 90(2):171-4. [QxMD MEDLINE Link].
Li H, Ezra DG, Burton MJ, Bailly M. Doxycycline prevents matrix remodeling and contraction by trichiasis-derived conjunctival fibroblasts. Invest Ophthalmol Vis Sci. 2013 Jul 12. 54(7):4675-82. [QxMD MEDLINE Link]. [Full Text].
Habtamu E, Wondie T, Aweke S, Tadesse Z, Zerihun M, Mohammed A, et al. Impact of Trichiasis Surgery on Quality of Life: A Longitudinal Study in Ethiopia. PLoS Negl Trop Dis. 2016 Apr. 10 (4):e0004627. [QxMD MEDLINE Link].
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. 2011 Dec. 8(12):e1001136. [QxMD MEDLINE Link]. [Full Text].
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. 2012 Jan. 119(1):84-9. [QxMD MEDLINE Link].
Kim GN, Yoo WS, Kim SJ, Han YS, Chung IY, Park JM, et al. The effect of 0.02% mitomycin C injection into the hair follicle with radiofrequency ablation in trichiasis patients. Korean J Ophthalmol. 2014 Feb. 28 (1):12-8. [QxMD MEDLINE Link].
Moore J, De Silva SR, O'Hare K, Humphry RC. Ruby laser for the treatment of trichiasis. Lasers Med Sci. 2009 Mar. 24(2):137-9. [QxMD MEDLINE Link].
Habtamu E, Wondie T, Aweke S, Tadesse Z, Zerihun M, Zewudie Z, et al. Posterior lamellar versus bilamellar tarsal rotation surgery for trachomatous trichiasis in Ethiopia: a randomised controlled trial. Lancet Glob Health. 2016 Mar. 4 (3):e175-84. [QxMD MEDLINE Link].
Barr K, Essex RW, Liu S, Henderson T. Comparison of trichiasis recurrence after primary bilamellar tarsal rotation or anterior lamellar repositioning surgery performed for trachoma. Clin Experiment Ophthalmol. 2014 May-Jun. 42 (4):311-6. [QxMD MEDLINE Link].
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. 2011 Dec 12. [QxMD MEDLINE Link].
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. 2012 Feb 14. [QxMD MEDLINE Link].
Bartley GB, Bullock JD, Olsen TG, Lutz PD. An experimental study to compare methods of eyelash ablation. Ophthalmology. 1987 Oct. 94(10):1286-9. [QxMD MEDLINE Link].
Bartley GB, Lowry JC. Argon laser treatment of trichiasis. Am J Ophthalmol. 1992 Jan 15. 113(1):71-4. [QxMD MEDLINE Link].
Burton MJ, Bowman RJ, Faal H, et al. The long-term natural history of trachomatous trichiasis in the Gambia. Invest Ophthalmol Vis Sci. 2006 Mar. 47(3):847-52. [QxMD MEDLINE Link].
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. 2005 Oct. 89(10):1282-8. [QxMD MEDLINE Link].
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. 2007 May. 245(5):637-40. [QxMD MEDLINE Link].
Collin RJO. Entropion and trichiasis. A Manual of Systemic Eyelid Surgery. New York: Churchill-Livingstone; 1989. 7-26.
Dhaliwal U, Nagpal G, Bhatia MS. Health-related quality of life in patients with trachomatous trichiasis or entropion. Ophthalmic Epidemiol. 2006 Feb. 13(1):59-66. [QxMD MEDLINE Link].
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. 2006 May-Jun. 34(4):329-34. [QxMD MEDLINE Link].
Edwards T, Cumberland P, Hailu G, Todd J. Impact of health education on active trachoma in hyperendemic rural communities in Ethiopia. Ophthalmology. 2006 Apr. 113(4):548-55. [QxMD MEDLINE Link].
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. 2006 Mar-Apr. 22(2):109-12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Johnson RL, Collin JR. Treatment of trichiasis with a lid cryoprobe. Br J Ophthalmol. 1985 Apr. 69(4):267-70. [QxMD MEDLINE Link].
Jordan DR, Zafar A, Brownstein S, Faraji H. Cicatricial conjunctival inflammation with trichiasis as the presenting feature of Wegener granulomatosis. Ophthal Plast Reconstr Surg. 2006 Jan-Feb. 22(1):69-71. [QxMD MEDLINE Link].
Kersten RC, Kleiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol. 1992 May. 110(5):714-7. [QxMD MEDLINE Link].
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. 1997 Feb. 28(2):156-61. [QxMD MEDLINE Link].
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. 2006 Feb. 13(1):53-8. [QxMD MEDLINE Link].
Polack S, Brooker S, Kuper H, Mariotti S, Mabey D, Foster A. Mapping the global distribution of trachoma. Bull World Health Organ. 2005 Dec. 83(12):913-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Shiu M, McNab AA. Cicatricial entropion and trichiasis in an urban Australian population. Clin Experiment Ophthalmol. 2005 Dec. 33(6):582-5. [QxMD MEDLINE Link].
Tirakunwichcha S, Tinnangwattana U, Hiranwiwatkul P, Rohitopakarn S. Folliculectomy: management in segmental trichiasis and distichiasis. J Med Assoc Thai. 2006 Jan. 89(1):90-3. [QxMD MEDLINE Link].
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. 2005 Aug. 12(4):279-86. [QxMD MEDLINE Link].
West S, Alemayehu W, Munoz B, Gower EW. Azithromycin prevents recurrence of severe trichiasis following trichiasis surgery: STAR trial. Ophthalmic Epidemiol. 2007 Sep-Oct. 14(5):273-7. [QxMD MEDLINE Link].
West SK, West ES, Alemayehu W, et al. Single-dose azithromycin prevents trichiasis recurrence following surgery: randomized trial in Ethiopia. Arch Ophthalmol. 2006 Mar. 124(3):309-14. [QxMD MEDLINE Link].
Wojono TH. Lid splitting with lash resection for cicatricial entropion. Ophthalmic Plast Reconst Surg. 1992. 8:287-289.
Wood JR, Anderson RL. Complications of cryosurgery. Arch Ophthalmol. 1981 Mar. 99(3):460-3. [QxMD MEDLINE Link].
Yeung YM, Hon CY, Ho CK. A simple surgical treatment for upper lid trichiasis. Ophthalmic Surg Lasers. 1997 Jan. 28(1):74-6. [QxMD MEDLINE Link].
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. 2006 Aug. 90(8):943-8. [QxMD MEDLINE Link].
Cruz AAV, Garcez C, Duarte A, Akaishi PMS. Interlamellar Autogenous Tarsal Graft for the Correction of Lower Eyelid Trichiasis Associated With Eyelid Margin Thinning. Ophthalmic Plast Reconstr Surg. 2018 Jan 25. [QxMD MEDLINE Link].
Ferraz LC, Meneghim RL, Galindo-Ferreiro A, Wanzeler AC, Saruwatari MM, Satto LH, et al. Outcomes of two surgical techniques for major trichiasis treatment. Orbit. 2018 Feb. 37 (1):36-40. [QxMD MEDLINE Link].

Media Gallery

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.