Trichiasis

Overview

Trichiasis is an eye condition in which the eyelashes grow abnormally and turn inward toward the eye surface instead of growing outward. These misdirected lashes rub against the cornea (the clear front surface of the eye), the conjunctiva (the membrane covering the white part of the eye), and the inner surface of the eyelids. This constant friction can cause significant discomfort, irritation, and potentially serious damage to the eye if left untreated.

The condition can affect one or both eyes and may involve just a few lashes or entire sections of the eyelid. Trichiasis is different from entropion, where the entire eyelid margin turns inward, though the two conditions can occur together. While trichiasis can develop at any age, it is more common in older adults and in populations where trachoma, a bacterial eye infection, is endemic.

The severity of trichiasis ranges from mild cases with occasional discomfort to severe cases that can lead to corneal scarring, vision loss, and secondary infections. Early detection and treatment are crucial to prevent complications and preserve vision. The condition affects millions of people worldwide, with higher prevalence in developing countries where access to eye care may be limited.

Symptoms

The symptoms of trichiasis result from the constant irritation caused by eyelashes rubbing against the eye surface. These symptoms can range from mild discomfort to severe pain and vision problems, depending on the number of affected lashes and the duration of the condition.

Primary Eye Symptoms

Additional Symptoms

Complications and Advanced Symptoms

• Corneal abrasions or ulcers from repeated scratching
• Chronic eye discharge or crusting
• Frequent eye infections
• Corneal scarring leading to permanent vision changes
• Increased blinking or eye spasms (blepharospasm)
• Difficulty keeping eyes open due to discomfort
• Secondary bacterial infections from corneal damage

The severity of symptoms often correlates with the number of misdirected lashes and how long the condition has been present. Some patients may experience periods of relief followed by flare-ups, while others have constant symptoms that progressively worsen without treatment.

Causes

Trichiasis can result from various conditions that affect the eyelid structure, eyelash follicles, or surrounding tissues. Understanding the underlying cause is essential for determining the most appropriate treatment approach and preventing recurrence.

Infectious Causes

• Trachoma: The leading infectious cause worldwide, caused by Chlamydia trachomatis bacteria. Repeated infections lead to scarring that pulls lashes inward
• Chronic blepharitis: Long-term inflammation of the eyelid margins affecting lash follicles
• Herpes zoster ophthalmicus: Shingles affecting the eye area can cause eyelid scarring
• Bacterial infections: Severe conjunctivitis or other eye infections causing lid scarring

Inflammatory and Autoimmune Conditions

• Ocular cicatricial pemphigoid: Autoimmune condition causing progressive conjunctival scarring
• Stevens-Johnson syndrome: Severe drug reaction affecting mucous membranes including eyes
• Chemical burns: Alkali or acid exposure causing eyelid scarring and distortion
• Atopic keratoconjunctivitis: Severe allergic eye disease with chronic inflammation
• Graft-versus-host disease: Complication of bone marrow transplant affecting eyes

Traumatic and Mechanical Causes

• Eyelid trauma: Injuries, burns, or surgical complications affecting lid structure
• Previous eye surgery: Scarring from procedures on the eyelids or surrounding areas
• Radiation therapy: Treatment near the eye area causing tissue changes
• Chronic eye rubbing: Mechanical trauma altering lash direction

Age-Related and Degenerative Causes

• Aging changes: Loss of elasticity and structural changes in eyelid tissues
• Distichiasis: Congenital condition with extra row of lashes growing from oil gland openings
• Epiblepharon: Congenital redundant skin fold pushing lashes against eye
• Idiopathic trichiasis: No identifiable cause, possibly related to aging

Risk Factors

Several factors increase the likelihood of developing trichiasis. Understanding these risk factors helps identify individuals who may need closer monitoring or preventive measures:

Demographic Risk Factors

• Age: More common in older adults due to eyelid changes and accumulated damage
• Gender: Women have higher rates in trachoma-endemic areas due to childcare exposure
• Geographic location: Higher risk in areas with endemic trachoma (parts of Africa, Asia, Middle East)
• Ethnicity: Some Asian populations have higher rates of epiblepharon

Medical and Environmental Factors

• History of eye infections: Repeated conjunctivitis or blepharitis
• Chronic eye inflammation: From allergies, autoimmune conditions, or irritants
• Previous eye surgery or trauma: Scarring from procedures or injuries
• Immunosuppression: HIV/AIDS, chemotherapy, or immunosuppressive medications
• Poor hygiene: Limited access to clean water and sanitation
• Crowded living conditions: Increased exposure to infectious agents
• Contact lens wear: Chronic irritation potentially affecting lid margins

Occupational and Lifestyle Factors

• Exposure to chemicals or irritants at work
• Outdoor occupations with dust and wind exposure
• Limited access to healthcare and eye care services
• Poor nutrition affecting immune function and healing

Diagnosis

Diagnosing trichiasis typically involves a comprehensive eye examination by an ophthalmologist or optometrist. The diagnosis is primarily clinical, based on direct observation of misdirected eyelashes and associated symptoms.

Clinical Examination

• Visual inspection: Examining eyelids and lash position with proper lighting
• Slit lamp examination: Detailed microscopic evaluation of:
  • Number and location of misdirected lashes
  • Eyelid margin abnormalities
  • Corneal damage or scarring
  • Conjunctival changes
• Fluorescein staining: Special dye to reveal corneal abrasions or ulcers
• Eversion of eyelids: Checking for follicles, scarring, or foreign bodies

Diagnostic Tests

• Visual acuity testing: Assessing impact on vision
• Photography: Documenting baseline condition and treatment progress
• Corneal topography: Mapping corneal surface in severe cases
• Schirmer test: Measuring tear production if dry eye suspected
• Culture and sensitivity: If secondary infection suspected

Identifying Underlying Causes

• Medical history: Previous infections, surgeries, trauma, medications
• Trachoma grading: Using WHO simplified grading system if suspected
• Biopsy: Rarely needed, for suspected pemphigoid or malignancy
• Blood tests: For autoimmune markers if indicated
• Allergy testing: If allergic component suspected

Differential Diagnosis

Conditions that may be confused with or coexist with trichiasis:

• Entropion (inward-turning eyelid)
• Ectropion (outward-turning eyelid)
• Distichiasis (extra row of lashes)
• Foreign body in eye
• Corneal abrasion from other causes
• Dry eye syndrome

Treatment Options

Treatment for trichiasis aims to redirect or remove the offending eyelashes, relieve symptoms, and prevent corneal damage. The choice of treatment depends on the number of affected lashes, underlying cause, severity of symptoms, and patient factors. Multiple treatment sessions are often required.

Temporary Measures

• Manual epilation: Plucking misdirected lashes with forceps
  • Provides immediate relief but temporary (lashes regrow in 4-6 weeks)
  • Can be taught to patients or caregivers
  • Risk of broken lashes and follicle damage
• Lubricating drops: Artificial tears to reduce friction and discomfort
• Antibiotic ointments: Prevent secondary infection and provide lubrication
• Bandage contact lenses: Protect cornea while awaiting definitive treatment

Ablative Procedures

• Electrolysis:
  • Electric current destroys lash follicles
  • Success rate: 50-90% after multiple sessions
  • Can cause lid notching or scarring if not done carefully
• Radiofrequency ablation:
  • Similar to electrolysis but with less collateral damage
  • Good for multiple adjacent lashes
• Laser ablation:
  • Argon or diode laser destroys follicles
  • Precise but requires specialized equipment
  • May need protective corneal shields
• Cryotherapy:
  • Freezing destroys lash follicles
  • Double freeze-thaw technique most effective
  • Risk of skin depigmentation and lid notching

Surgical Options

• Anterior lamellar repositioning: For multiple lashes, rotates lash-bearing tissue
• Posterior lamellar tarsal rotation: For severe cases with lid scarring
• Lid splitting with cryotherapy: Combines surgical and ablative approaches
• Mucous membrane grafting: For recurrent cases, replaces lash-bearing tissue
• Entropion repair: If concurrent lid malposition present

Medical Management

• Treat underlying conditions: Blepharitis, infections, or inflammatory diseases
• Corticosteroid drops: Reduce inflammation in active disease
• Immunosuppressive therapy: For autoimmune causes like pemphigoid
• Oral doxycycline: Anti-inflammatory effects for certain conditions

Post-Treatment Care

• Regular follow-up to detect recurrence early
• Continued use of lubricating drops
• Sun protection for treated areas
• Monitoring for complications like infection or scarring

Prevention

While not all cases of trichiasis can be prevented, several strategies can reduce the risk of developing the condition or prevent its progression:

Primary Prevention

• Trachoma control: In endemic areas, the WHO SAFE strategy:
  • Surgery for advanced disease
  • Antibiotics to treat infection
  • Facial cleanliness promotion
  • Environmental improvements (water, sanitation)
• Eye protection: Safety glasses for chemical exposure or trauma risk
• Prompt treatment: Early care for eye infections and inflammation
• Good hygiene: Regular face washing and avoiding eye rubbing

Secondary Prevention

• Regular eye exams: Early detection of lash abnormalities
• Manage chronic conditions: Control of blepharitis and allergies
• Avoid irritants: Minimize exposure to smoke, dust, and chemicals
• Proper contact lens care: Reduce risk of infections and inflammation
• Post-surgical care: Follow instructions after eye procedures

Community-Level Prevention

• Improved access to clean water and sanitation
• Health education about eye hygiene
• Mass antibiotic distribution in trachoma-endemic areas
• Training of community health workers for early detection
• Access to affordable eye care services

When to See a Doctor

Early medical attention for trichiasis can prevent serious complications and preserve vision. Certain symptoms require immediate evaluation:

Seek Immediate Care If:

• Sudden severe eye pain or vision loss
• Signs of corneal ulcer (white spot on eye, severe pain)
• Pus or thick discharge from the eye
• Eye injury or chemical exposure
• Inability to open eye due to pain or swelling

Schedule an Appointment If:

• Persistent foreign body sensation lasting more than a few days
• Recurrent eye redness or irritation
• Visible eyelashes touching the eye
• Chronic tearing or discharge
• Light sensitivity affecting daily activities
• Blurred vision or visual changes
• Previous trichiasis treatment with symptom recurrence

Related Conditions

References

1. World Health Organization. Trachoma and Trichiasis. WHO Technical Report Series. 2022.
2. American Academy of Ophthalmology. External Disease and Cornea. Basic and Clinical Science Course. 2023.
3. Ferraz LC, et al. Trichiasis: diagnosis and management. International Ophthalmology Clinics. 2023.
4. Rajak SN, et al. Trichiasis surgery in trachoma. British Journal of Ophthalmology. 2022.
5. Gower EW, et al. Trachomatous trichiasis and its management in endemic countries. Survey of Ophthalmology. 2023.