What is the diagnosis and recommended management for trichiasis (inward‑growing eyelashes)?

Trichiasis: Diagnosis and Management

Diagnosis

Trichiasis is diagnosed clinically when eyelashes arising from their normal position are misdirected toward the ocular surface, causing irritation and potential corneal damage. 1, 2

Key Diagnostic Features

• Slit-lamp examination reveals: Misdirected eyelashes contacting the cornea or conjunctiva, often with associated corneal punctate epithelial erosions, marginal infiltrates, or epithelial defects 3, 1
• Eyelid margin assessment shows: Inflammation, vascularization, scarring, collarette formation at lash bases, or loss of normal eyelid margin anatomy 3
• Fluorescein staining demonstrates: Corneal epithelial defects where aberrant lashes contact the ocular surface 3

Critical Differential Diagnosis

In elderly patients with chronic, unilateral, unresponsive trichiasis—especially with focal lash loss (ciliary madarosis), nodular mass, ulceration, or extensive scarring—sebaceous carcinoma must be excluded by eyelid biopsy before initiating treatment. 3, 4, 5 This is particularly important with recurrent chalazia in the same location or marked asymmetry resistant to therapy 3, 4

Underlying Causes to Identify

• Cicatricial conditions: Ocular mucous membrane pemphigoid, Stevens-Johnson syndrome/toxic epidermal necrolysis, graft-versus-host disease, trachoma 3
• Inflammatory eyelid disease: Chronic blepharitis (staphylococcal, seborrheic, or meibomian gland dysfunction), ocular rosacea 3
• Previous trauma or surgery: Including eyelid surgery, chemical/thermal injury 3

Management Algorithm

Step 1: Address Underlying Inflammation (If Present)

For trichiasis secondary to blepharitis, initiate eyelid hygiene first: Daily warm compresses for several minutes followed by gentle cleansing of lash bases with diluted baby shampoo or hypochlorous acid 0.01% cleaners 4

• If inadequate response after 2-4 weeks, add topical antibiotic ointment (bacitracin or erythromycin) to eyelid margins once daily or at bedtime 4
• For meibomian gland dysfunction with persistent symptoms, escalate to oral doxycycline or minocycline 4

Step 2: Definitive Trichiasis Treatment Based on Severity

Treatment selection depends on the number of affected lashes and presence of eyelid malposition:

For ≤7 Misdirected Lashes WITHOUT Entropion

Argon laser photoablation is the preferred definitive treatment 6, 2

• Technique: Under local anesthesia, apply argon laser (532 nm) directly to the lash follicle root through the eyelid margin 7, 6
• Success rate: 82% achieve permanent lash removal after one session; 9% require a second session; only 6% need 3-4 sessions 6
• Advantages: Outpatient procedure, rapid, well-tolerated, precise control, minimal complications compared to cryotherapy 7, 6
• Key technical point: Limit to ≤7 lashes per eyelid for optimal results 6

Alternative Ablative Methods (When Laser Unavailable)

• Radiofrequency ablation or bipolar electrolysis: Effective for focal trichiasis 1, 2
• Cryotherapy: More effective than electrolysis but carries significant risks including visual loss, lid notching, corneal ulcer, skin depigmentation, and severe soft tissue reaction 7, 2

For >7 Lashes OR Associated Entropion

Surgical correction is mandatory 6, 2

• Laser or ablative techniques alone will fail when eyelid malposition (entropion) is present 6
• Surgical options include follicle excision, lid margin split procedures, or full-thickness eyelid rotation procedures depending on severity 1, 2

Step 3: Temporary Measures During Treatment

• Mechanical epilation: Provides 4-6 weeks of relief but lashes regrow, often more misdirected 1, 2
• Ocular lubrication: Preservative-free artificial tears and ointments to protect corneal surface 2
• Therapeutic contact lenses: For corneal protection in severe cases 2

Critical Management Pitfalls

Never treat trichiasis with ablative methods when cicatricial conjunctival disease is present without first establishing the underlying diagnosis (e.g., ocular mucous membrane pemphigoid), as treatment may accelerate scarring and symblepharon formation 3

Do not use cryotherapy as first-line treatment given the high complication rate including visual loss, corneal ulceration, and acceleration of symblepharon formation in cicatricial disease 7

Recognize that recurrence is common with all treatment modalities—patients require long-term follow-up and may need repeated treatments 1, 6, 2

Monitoring for Complications

Untreated or inadequately treated trichiasis can cause:

• Corneal scarring, neovascularization, and permanent vision loss 3, 5
• Corneal ulceration and perforation (especially in children) 3, 5
• Neurotrophic keratopathy leading to blindness 6
• Secondary bacterial keratitis from chronic epithelial defects 3