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Seminars in Ophthalmology, 25(3), 66–71, 2010
Copyright © 2010 Informa UK Ltd.
ISSN: 0882-0538 print/ 1744-5205 online
DOI: 10.3109/08820538.2010.488580
Trichiasis
Isabela Soares Ferreira,1 Taliana Freitas Bernardes,2 and Adriana Alvim Bonfioli2
Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
2
Oftalmoclínica Rui Marinho, Belo Horizonte, Minas Gerais, Brazil
1
ABSTRACT
Trichiasis is a lid margin disorder in which the eyelashes are misdirected toward the ocular surface.
It is a major cause of ocular morbidity. Trichiasis is secondary to inflammation and scarring of the
eyelash follicles. There is a frequent association between trichiasis and cicatricial entropion and
the correct diagnosis is mandatory for a successful treatment. There are several options for the
management of trichiasis and the main purpose is to eliminate the anomalous cilia and improve
the patient’s comfort. Temporary measures include eye lubricants, contact lenses, and mechanical
epilation. Surgical treatments have initial success but long-term results are poor and recurrences
are frequent. Definitive trichiasis treatments include bipolar electrolysis, radiofrequency ablation,
cryotherapy and laser ablation, and surgical procedures. The techniques are described in detail
along with possible complications and outcome.
KEYWORDS: trichiasis; diagnosis; treatment; review
INTRODUCTION
and Latin America.7 Trachoma is currently estimated
to affect around 10 million people.9
Trichiasis is bilateral in 70% of the cases and affects
mainly the central portion of the lower eyelid. If associated with trachoma it is more common in the upper
eyelid.3,7 It is rarely seen before the third decade and
its incidence significantly increases with age. The
prevalence of trichiasis varies widely among countries but in areas endemic for trachoma it is 2 to 4
times more frequent in women.
Trichiasis is a lid margin disorder in which the
eyelashes lose their normal direction (away from
the globe) and are misdirected toward the ocular
­surface.
It is a frequent acquired condition and a major
cause of ocular morbidity. Trichiasis is usually secondary to inflammation and scarring of the eyelash
follicles. The main causes are: (a) chronic inflamation
of the eyelid margin (blepharitis, meibomitis); (b) skin
diseases (actinic elastosis, eczema, atopic diseases,
leprosy, herpes zoster); (c) conjunctival diseases (cicatricial trachoma, Stevens-Johnson syndrome, ocular
pemphigoid, vernal keratoconjunctivitis, chemical
and physical burns); and (d) eyelid margin scars
related to surgery or trauma.
Trachoma is a chronic ocular infection caused by
Chlamydia trachomatis and for a long time was considered the main cause of trichiasis. Once endemic
in many parts of the world, including United States
and Europe, the disease is now concentrated in
­sub-Saharan Africa, the Middle East, pockets of Asia
CLASSIFICATION
Trichiasis may be classified according to the amount
of misdirected eyelashes: major trichiasis affects 5 or
more cilia (Figure 1) and in minor trichiasis less than
5 cilia are affected (Figure 2). The severity of the disease can also be assessed by identifing the extension
of eyelid involvement: segmental (nasal, central or
temporal portions) or diffuse trichiasis.
CLINICAL FEATURES
Correspondence: Isabela Soares Ferreira, MD, Rua Bernardo
Guimarães 2523 apto 1200, Lourdes, Belo Horizonte, Minas Gerais,
Brazil 30140-082. E-mail: [email protected]
The majority of the patients are symptomatic
(91.5%) and present with foreign body sensation.
66
Trichiasis
67
FIGURE 3 Entropion (courtesy of Alfredo Bonfioli, MD).
FIGURE 1 Major trichiasis.
affect all of the eyelid structures causing tarsal deformities, disrupting the hair follicles and changing the
direction of the cilia. In more complex cases anomalous
cilia can be found behind the orifices of the meibomian
glands, a condition caused by metaplasia of the tarsal
glands and called acquired distichiasis.2
EVALUATION
FIGURE 2 Minor trichiasis (courtesy of Alfredo Bonfioli, MD).
Other ­frequent complaints are photophobia, tearing,
­discharge, dry eye sensation, burning, pain, blepharospasm, and conjunctival congestion.3,5
Ocular examination can show one or more misdirected lashes, superficial keratopathy, corneal abrasion,
infection, vascularization, opacities, and loss of vision.
DIFFERENTIAL DIAGNOSIS
There is some confusion among trichiasis, distichiasis
and entropion. Distichiasis is a congenital condition
characterized by an accessory row of cilia arising from
behind the meibomian gland orifices. It may be inherited in an autosomal dominant pattern. The eyelid is in
a normal position and the eyelashes are directed posteriorly toward the ocular surface. The condition may
be assymptomatic until about 5 years of age. Entropion
occurs when the eyelid margin is turned inward causing the eyelashes to touch the eye. The implantation,
direction, and number of cilia are normal (Figure 3).
There is a common association between trichiasis
and cicatricial entropion. Chronic inflammation can
© 2010 Informa UK Ltd.
Trichiasis diagnosis does not present a great challenge
but it is essential to detect associated conditions that
may change the treatment strategy. Upper and lower
eyelids should be examined looking for eyelash misdirection or misplacement, changes in margin position,
and horizontal laxity. The conjunctiva must be assessed
by flipping the upper lid and pulling the lower lid away
from the globe. Any signs of symblepharon formation
and fornix scars should be noted. All anomalous cilia
must be detected and mapped. If the patient had any
eyelashes removed recently the exam must be repeated
in 2 to 3 weeks.
Surgical procedures should not be performed if
there is active inflammation. The ethiology must be
detected and the condition treated prior to surgery to
avoid recurrences and worsening of the inflammatory
process.
TREATMENT
There are several options for the treatment of trichiasis
and the main purpose is to eliminate the anomalous
cilia and improve the patient’s comfort. Non-surgical
measures are short-term and may be useful during
the treatment of acute inflammatory processes like
Stevens-Johnson syndrome and chemical burns prior
to surgery.2 They include eye lubricants, contact
lenses, and mechanical epilation. Eyelash removal
with forceps is a simple method, inexpensive and free
68
I. Soares Ferreira et al.
of complications; however, recurrence is common after
2 to 6 weeks.5,6,12 In addition, the hair often breaks during removal leaving a sharp stub that is even more
irritating.7
Surgical treatments have initial success but longterm results are poor and recurrences are frequent.
Patients with C. Trachomatis infection present the
highest recurrence rates. Research has demonstrated
that using a single dose of azythromycin (1g) at the
time of the surgery may reduce trichiasis recurrence
in 47%.7,9,14
Differentiating true trichiasis from entropion and
associated entropion-trichiasis is the base for selecting
the most appropriate treatment. Symptomatic patients
with true trichiasis should be treated with lash ablation
procedures. Patients with entropion without trichiasis or with minor trichiasis will require a lid margin
rotation technique. If there is entropion and trichiasis
the surgery should address both. Definitive trichiasis
treatments include bipolar electrolysis, radiofrequency
ablation, cryotherapy and laser ablation and surgical
procedures.
Bipolar Electrolysis
Bipolar electrolysis is used to treat segmental and
minor trichiasis. Removing multiple eyelashes may
produce scarring of the lid and secondary deformities.
This technique has high recurrence rates (60%).5,6,12
After anesthetic infiltration the electrolysis needle
tip is introduced inside the hair follicle. The eyelid
should be pulled away from the globe to avoid damage to the cornea. The eletric current is applied for 1
or 2 seconds, just enough to burn the eyelash. When
the bulb has been completely destroyed the hair can
be easily removed by plucking. Antibiotic ointment is
applied to the lid for a week.
mately 0.5mm of adjacent tissue.6 When the bulb is
completely destroyed the hair can be easily removed
using forceps. Antibiotic ointment is applied to the lid
for a week. Kormann et al. reported 100% success rate
after 2 or 3 sessions. More than 60% of the patients
were cured with only one procedure. The complications included short-lived edema, erythema or hematoma, and thickening of the lid margin.6
Cryotherapy
Cryotherapy is effective for segmental and diffuse trichiasis. It is based on the principle that the hair follicles
are more sensitive to the destructive effects of freezing
than the skin and conjunctiva. The success rates are 34
to 56% after one application and 70 to 90% after two
sessions.1,4,12
The technique uses a special equipment to freeze the
tissues to between -20°C and -30°C. The temperature
of the tissue is monitored by a thermocouple inserted
through the skin and orbicularis at the pretarsal region
and placed close to the anomalous lashes (Figure 5).
The globe should be protected using corneoscleral
shell. The lid anesthetized using lidocaine and epinephrine. After placing a drop of gel or artificial tear
on the lid, the tip of the nitrous oxide-loaded probe is
applied to the lashes or to the conjunctiva 2 to 3 mm
from the margin. The tissues are frozen for 20 to 30
seconds until the adequate temperature is achieved
and the ice ball is allowed to thaw spontaneously. The
cycle is repeated in a double freeze-thaw method.1,2
Repeated applications are made along the length of
the affected lid margin. The lashes can be removed or
allowed to shed spontaneously. ­Antibiotic ointment is
applied to the lid for a week.
Radiofrequency Ablation
Radiofrequency ablation of lash follicles is a very effective treatment with few complications. It is performed
similarly to bipolar electrolysis but has better success
rates and causes less lid scarring.
The authors use the Wavetronic 5000 LLP Master set
to cut/coag, 1mV. The lid is anesthetized using lidocaine and epinephrine. Under operating microscope
­magnification the electrolysis tip is inserted alongside
the lash 3 to 4 mm down to the bulb and the current
is applied for 1 to 2 seconds (Figure 4). The electrical
charge can be reapplied until bubbling or frothing is
seen at the base of the eyelash. The radiofrequency
waves selectively destroy the follicles and approxi-
FIGURE 4 Radiofrequency
ablation.
Seminars in Ophthalmology
Trichiasis
FIGURE 5 Cryotherapy.
Possible complications of this procedure are: trichiasis recurrence, skin despigmentation, madarosis,
dry eye syndrome, lid notching, palpebral necrosis,
corneal ulcer, herpes zoster reactivation, exacerbation of inflammatory diseases, symblepharon, and
­entropion.
In patients with distichiasis splitting of the eyelid
into anterior and posterior lamellas and cryotherapy
to the posterior lamella is effective in removing the
anomalous cilia and preserving the anterior lamella
lashes.1
Laser Ablation
The use of laser for the treatment of trichiasis offers
some advantages when compared to electrolysis
and cryotherapy. It can be performed under topical
­anesthesia, produces less inflammation and has fewer
complications. Laser ablation is used to treat minor trichiasis. In the presence of many affected lashes surgical
procedures have better results and the laser can be use
as an adjunctive therapy.2
Argon laser was the first used for trichiasis treatment
(Berry, 1979).15 Success rates vary from 37% to 59% with
one session and 100% with two or more procedures.4,10
Many authors perform the technique under topical
anesthesia but subcutaneous infiltration brings more
comfort to the patient.2,5 The patient is positioned at
the slit lamp and the globe is protected using corneoscleral shell. The patient’s gaze should be directed to
the opposite side to protect the eye. The lid is everted
so that the eyelash root is coaxial to the laser beam.
It is suggested a 50 to 200 µm spot, an output of 0.2
to 1.5W for heavily pigmented lids and 0.8 to 1.5W
for less pigmented lids during 0.2 seconds. Sequential
shots are directed to each bulb and the output can be
increased until there has been total destruction of the
© 2010 Informa UK Ltd.
69
follicle. Usually 20 to 30 shots are necessary.2 Recent
studies showed that a burn depth of at least 1.4 mm for
the lower lid and 2.4 mm for the upper lid are needed
to completely destroy the eyelash bulbs.2,4,5 Complications are uncommon with argon laser ablation but
lid notching and hypopigmentation may occur. Some
disadvantages of the procedure are technical difficulties with uncooperative patients and the high cost
of the device. If the eyelashes are not pigmented the
photocoagulation is not effective. It was demonstrated
that the use of black mascara successfully solves this
problem.4
Other types of laser can be used for trichiasis treatment. Carbon dioxide laser has the same success rates
as cryotherapy and argon laser ablation, but causes
greatest soft tissue swelling and more pronounced
tarsal thinning.4 YAG, alexandrite, diode, and ruby
lasers are now considered the best choice for hair
control, providing better penetration and more specific absorption than argon laser.11 Diode laser can be
applied by using a direct contact tip that can be oriented in different angles to efficiently transmit laser
energy and achieve adequate tissue penetration.10 The
810nm wavelength of the diode laser can penetrate
deeper than the 514 nm wavelength of argon laser.
The disadvantages of diode laser are high cost and
limited availability. However, compared to the argon
laser it is less expensive, requires no maintenance,
and has a longer lifetime. Ruby laser (694 nm) treatment is well tolerated and effective, with no reported
­complications.11
TRICHIASIS SURGERY
Surgical treatment is indicated for diffuse trichiasis,
segmental trichiasis with a large number of anomalous
lashes, and relapsing cases. It should also be considered in patients with scarring diseases6 and even in
mild cases where other treatment modalities are not
available.9
Excision of Trichiatic Eyelash Bulbs
Eyelash trephination is a quick, inexpensive, and
effective procedure with low morbidity. The success
rate is comparable to electrolysis and argon laser ablation.12 Several different trephines have been used but
the removal of less normal tissue is achieved with
the 21-gauge (0.81mm) Sisler Ophthalmic Microtrephine (Visitec, Sarasota, FL, USA). After local anesthesia using 2% lidocaine with epinephrine, the lid
is stabilized and the microtrephine is used to extract
the follicle of the abnormal lash. The lash is used
70
I. Soares Ferreira et al.
as a guide inside the lumen of the trephine and it
penetrates 2mm into the lid margin. The bored-out
follicle is removed within the trephine or it can be
pulled away with forceps and excised at the base of
the trephination.12
Full Thickness Block Resection
If the trichiasis is localized and affects less than a
third of the eyelid, a full thickness block resection will
efficiently eliminate the anomalous eyelashes with an
excellent aesthetic result. The area should be excised,
forming a pentagon, and the sutures placed in three
planes. A 6-0 silk suture is placed at the grey line and
light traction is applied to align the margin. The tarsoconjunctival plane is closed using a continuous 6-0
absorbable suture. The orbicularis plane is closed the
same way. The marginal suture is knotted and two
more stitches are placed anteriorly and posteriorly to
obtain a perfect alignment. The skin is closed with 6-0
non-absorbable sutures. If necessary, lateral cantholysis
can reduce the tension and facilitate the approximation
of the borders.
Partial Excision of the Anterior Lamella
If there is more extensive involvement of the lid margin, a strip of the anterior lamella including the eyelashes may be removed. The bare tarsal plate can be
left to granulate spontaneously.13 This is a very simple
technique suitable for older patients with severe trichiasis, recurrences after other treatments, and in whom
comfort is more important than an esthetic result.
Anterior Lamella Repositioning
Anterior lamella repositioning techniques are used
when there is extensive trichiasis. Initially, skin and
orbicularis are removed in a blepharoplasty fashion.
Pretarsal skin and muscle are dissected toward the lid
margin and fixated superiorly to the tarsus and levator aponeurosis. The margin is incised along the grey
line and left to granulate. If additional lash rotation is
needed mattress sutures may be placed through skin,
orbicularis, and tarsal plate above the lash line.1
Mucocutaneous Graft
This procedure is a modification of the technique
described by Van Millingen in 1888, consisting of eyelid splitting into anterior and posterior lamellas and
FIGURE 6 Mucocutaneous graft (courtesy of Ana Rosa
Pimentel de Figueiredo, PhD).
interposition of a mucocutaneous graft, which forms
a barrier between the anomalous eyelashes and the
globe.
The graft may be obtained from the contour of the
lip or from the superior margin of the tarsus on the
upper lid. The lip incision should be closed with 6-0
nylon. There is no need for sutures at the tarsoconjunctival area. The grey line incision is extended 2 mm
beyond the trichiatic area on each side. The anterior
and posterior lamellas are dissected approximately
4 mm deep. The graft is placed at the receptor area
and a continuous suture is made using 8-0 or 9-0 nylon
(Figure 6). Antibiotic ointment should be used for 7 to
10 days until the sutures are removed.2
Tarsal Rotation
If there is entropion associated with trichiasis the surgical procedure of choice involves horizontal fracture
of the tarsal plate and eyelid marginal rotation. In the
lamellar tarsal rotation (Trabut procedure) a horizontal
lid split is made of approximately 3 mm of the margin through tarsal conjunctiva and tarsal plate. The
margin is rotated outward with everting sutures. The
bilamellar tarsal rotation additionally involves the
orbicularis muscle and the skin. This is the procedure
recommended by the World Health Organization
since a randomized controlled trial showed its high
effectiveness with success rates of 77%.7,8 Besides the
excellent initial results obtained by the tarsal rotation
techniques, the long-term trichiasis recurrence rates are
high, varying from 16 to 62%.7,9,14
Seminars in Ophthalmology
Trichiasis
REFERENCES
[1] Levine M, El-Toukhy E, Schaefer A. Entropion. In: Smith’s
Ophthalmic Plastic and Reconstructive Surgery. Mosby, 1998;
271–289.
[2] Figueiredo A, Soares E, Dantas R. Triquíase. In: Soares E,
Moura E, Gonçalves J. Cirurgia e Plástica Ocular. Rocca, 1997;
185–192.
[3] Araújo F, Cruz A. Alterações de cílios no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto –USP. Arq
Bras Oftalmol 2002; 65(3): 343–349.
[4] Hata M, Monteiro E, Schellini S, Aragon F, Padovani C.
Laser de argônio no tratamento da triquíase e da distiquíase.
Arq Bras Oftalmol 1999;62(3): 285–295.
[5] Fonseca Junior N, Lucci L, Paulino L, Rehder R. O uso do
laser de argônio no tratamento da triquíase. Arq Bras Oftalmol 2004; 67(2): 277–281.
[6] Kormann R, Moreira H. Eletrólise com radiofreqüência
no tratamento da triquíase. Arq Bras Oftalmol 2007; 70(2):
276–280.
[7] Gower E. Trichiasis: Making progress toward elimination.
Int Ophthalmol Clin 2007; 47(3): 77–86.
[8] Bowman R. Trichiasis surgery. Community Eye Health 1999;
12(32): 53–54.
© 2010 Informa UK Ltd.
71
[9] Burton M, Solomon A. What’s new in trichiasis surgery?
Community Eye Health Journal 2004; 17(52): 52–53.
[10] Pham R, Biesman B, Silkiss R. Treatment of trichiasis using
an 810-nm diode laser: an efficacy study. Ophthal Plast Reconstr Surg 2006; 22(6): 445–447.
[11] Moore J, De Silva S, O’Hare K, Humphry R. Ruby laser for
the treatment of trichiasis. Lasers Med Sci 2009; 24: 137–139.
[12] McCracken M, Kikkawa D, Vasani S. Treatment of trichiasis
and distichiasis by eyelash trephination. Ophthal Plast Reconstr Surg 2006; 22(5): 349–351.
[13] Moosavi A et al. Simple surgery for severe trichiasis. Ophthal
Plast Reconstr Surg 2007; 23(4): 296–297.
[14] West S, Alemayehu W, Munoz B, Gower E. Azithromycin
prevents recurrence of severe trichiasis following trichiasis surgery: STAR trial. Ophthalmic Epidemiology 2007; 14:
273–277.
[15] Berry J. Recurrent trichiasis treatment with laser and photocoagulation. Ophthalmic Surg 1979; 10:36–38.
[16] Majekodunmi S. Cryosurgery in treatment of trichiasis. British J Ophthalmol 1982; 66: 337–339.
[17] Owji N, Bagheri A, Aslani A. Combined Wies procedure and
direct internal eyelash bulb extirpation – an effective procedure for treatment of cicatricial entropion and trichiasis.
Asian J Ophthalmol 2006; 8(1): 28–30.
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