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. 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