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.

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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

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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. [Medline].
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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. [Medline].
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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. [Medline].
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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.