Trichiasis Treatment & Management

Updated: Sep 20, 2018
  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

The primary treatment of trichiasis is surgical.

Lubricants, such as artificial tears and ointments, may decrease the irritant effect of lash rubbing.

If a more serious disease (eg, ocular cicatricial pemphigoid, Stevens-Johnson syndrome) is the cause of the lash misdirection, medical therapy should be geared toward that disease.

According to West and colleagues, azithromycin has been shown to reduce severe postsurgical trichiasis recurrence rates to 1 year. [4]

Li et al have found that doxycycline has successfully suppressed the contractile fibroblasts in patients with trachoma and suggest that doxycycline might be useful as a treatment to prevent recurrence of trichiasis following surgery. [5]

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Surgical Care

Surgery for trichiasis can substantially improve quality of life, regardless of changes in visual acuity, as shown by Habtamu et al. [6] Many procedures for the repair of trichiasis have been described. The technique used is dependent on the cause of the problem. These procedures can be categorized as lash/follicle destroying or lash/follicle repositioning.

Lash and follicle destruction surgery

Lash and follicle destruction surgery is preferred for segmental or focal trichiasis.

Simple epilation with forceps often leaves the lash follicle and usually is only a temporizing measure. When the lash grows back, it often will be short and stiff, and even more irritating. [7, 8]

Electrolysis of lashes can be effective, but it often is painful for the patient and tedious for the surgeon.

Cryosurgery of lashes and follicles can be very effective, but it has many potential complications.

Radiofrequency ablation of lashes and follicles is extremely effective and can be performed quickly and easily at the slit lamp or with surgical loupes and local anesthesia. The smallest gauge wire (eg, Ellman TA1, A8 bendable 1/16th vari tip) is introduced alongside the lash down to the follicle, with the lowest setting that gives an easy introduction of the wire. The machine should be set on cut/coag. A small "core sample" will be missing from the lid margin and will granulate in with minimal scarring. See the image below.

Lower lid trichiasis, Ellman radiofrequency follic Lower lid trichiasis, Ellman radiofrequency follicle ablation.

Mitomycin C injected into the hair follicle immediately after radiofrequency ablation may reduce recurrence of trichiasis. [9]

Argon laser ablation can be effective, but it can be very tedious for both the patient and the surgeon, as well as expensive.

According to Moore and colleagues, ruby laser treatment can be a viable and well-tolerated option for the relief of the symptoms of trichiasis. [10]

Wedge resection of the lid segment requires a full-thickness resection of the lid margin; in many cases, it may be excessive.

Lash and follicle repositioning surgery

Lash and follicle repositioning surgery should be directed toward the anatomical cause of the problem.

Entropion

Lower lid retractor reattachment and lateral tarsal strip can be used to repair most cases of horizontal lid laxity and entropion.

Cruz et al have described good results from autogenous tarsal graft to correct lower lid trichiasis with eyelid margin thinning. [42]

Posterior lamellar scarring

The posterior lamellae and fornix can be lengthened with grafts (eg, mucous membrane, hard palate, cadaveric dermis).

A tarsoconjunctival advancement may lengthen the posterior lamellae.

Tarsal fracture with full-thickness everting sutures repositions the lashes to point away from the globe.

Surgery of the conjunctiva may reactivate ocular cicatricial pemphigoid and should be avoided with this disease.

Repositioning of the anterior lamellae may be the method of choice when dealing with ocular cicatricial pemphigoid because it allows the conjunctiva to remain undisturbed. This technique positions the lashes away from the lid margin and further away from the globe.

Posterior lamellar tarsal rotation was found to be superior to bilamellar tarsal rotation in managing trachomatous trichiasis. [11] Barr et al reported that anterior lamellar repositioning for trachomatous trichiasis yielded results that were similar to those of bilamellar tarsal rotation, although they cautioned that the results are uncertain owing to inconsistent follow-up times. [12]

Ferraz et al concluded that lid lamellar resection was technically simpler and offered a greater chance of success compared with intermarginal split lamella with graft. [43]

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Consultations

In cases of Stevens-Johnson syndrome or ocular cicatricial pemphigoid, a general medical consult may be necessary.

Cornea/external disease and/or oculoplastic services may be required in severe cases.

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Complications

Overly aggressive surgical treatment of entropion may lead to ectropion; this condition usually resolves with time. See the image below.

Bilateral involutional entropion. Note the periocu Bilateral involutional entropion. Note the periocular redness from constant lid rubbing due to irritation.

To avoid rubbing of the conjunctiva, all sutures should be resorbable and buried; a collagen shield or a bandage contact lens can also help avoid this problem.

Although not truly a complication, if only a few lashes are being epilated/ablated, warn the patient that the lashes may grow back or that new lashes may grow. Recurrence is common.

Discuss the normal complications of bleeding, infection, recurrence, need for more surgery, scarring, and cosmesis with all patients.

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Long-Term Monitoring

Patients with trichiasis should receive follow-up care as needed. [13]

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