Deanne Nakamoto, MD, and C. Robert Bernardino, MD, FACS, New Haven, Conn.
Trichiasis can be a chronic and debilitating condition for patients, and its treatment course can be just as exasperating. Patients suffer from irritation, tearing and pain when aberrant eyelashes become misdirected and grow toward the eye. This sometimes results in serious ocular sequelae such as corneal ulcers, punctate keratopathy, abrasions and scarring.1
Globally, trachoma is the primary cause of trichiasis and is the leading infectious cause of blindness in the world.2 Lash misdirection in trachoma occurs secondary to involution of a normal lash line after posterior lamella scarring. In the
Whatever the cause, if trichiasis is associated with entropion, management is directed at treating the lid malposition first, using tarsal rotation procedures and spacer grafts. The treatment of entropion is not addressed in this article. Rather, we will discuss the treatment of trichiasis in well-positioned eyelid margins, or in lids after entropion correction.
The treatment of trichiasis includes mechanical epilation, electrolysis, cryotherapy and argon lasers, as well as various surgical approaches that can employ combinations of the above.3 Therapy is based on the cause, extent and location of the cilia as well as the patient's tolerance for side effects and soft tissue damage.
Mechanical epilation is usually the first-line treatment, especially for a few isolated lashes. Lashes tend to grow back in a few weeks, however, and additional therapy is usually needed if the lashes return. Michael McCracken, MD, and colleagues described eyelash trephination, a slight variation in which lash follicles are bored out with a hollow, 21-ga. stainless-steel tube.4 They report a 62 percent success rate with no complications.
Electrolysis or electroepilation involves inserting a probe into each individual follicle under slit lamp or operating microscope magnification. After local anesthetic is infiltrated into the eyelid, the probe is inserted along a hair shaft (See Figure 2). Electrical charge is applied until bubbling is seen at the root of the hair shaft. If the hair shaft and bulb pull freely, the treatment is successful (See Figure 3). This method has also proven fairly effective for isolated follicles, but is a cumbersome solution for more than a handful of lashes and also can result in regrowth and scarring of the eyelid. Radiofrequency epilation is performed in much the same way and has been found to have high single-treatment success rates (56 to 90 percent) and cause less scarring than electrolysis.3,5
Argon laser has achieved similar success rates with limited side effects because of precise tissue destruction. It is an appropriate choice when troublesome eyelashes are few and scattered, and when they are not secondary to an inflammatory condition.6 The argon beam is generally titrated based on the pigmentation of the cilia, with suggested laser settings varying between 300 mW/0.5 s/50 µm and 1,200 mW/0.2 to 0.5 s/50 to 100 µm.6 The beam is directed 2 to 3 mm below the lash base, coaxial to the lash.7 Repetitive burns are required for follicle destruction. Reported success rates range from 45 to 62 percent after a first treatment, and 68 to 70 percent after two treatments.6-9 Side effects—primarily short-lived edema and erythema—are minimal as compared to more destructive modalities.7
A few recent studies have used a 810-nm diode laser instead of argon, which uses a contact probe to direct the laser energy along the shaft. Randall Pham, MD, and colleagues reported a reduction of eyelashes from 3.58 per patient to 0.73 after three months, without any reported complications.10
Cryotherapy is effective for large, confluent areas of trichiasis. After local anesthetic is injected, the probe is applied to the treatment area using a coupling gel such as Surgilube. The cold treatment is then initiated, with the thermocouple set to -20 to -30 degrees Celsius. A frost-ball will propagate, and slight traction on the probe will cause eyelid distraction, thus confirming thermocoupling. The coupling is held for 5 seconds and then allowed to thaw. This process is repeated, thus completing the double-freeze thaw technique. Clinical whitening indicates adequate follicle destruction.11 Success rates as high as 90 to 91 percent have been reported.12-14 However, the surrounding soft tissues are often affected, leading to eyelid notching, entropion, eyelid edema, canalicular scarring, herpes zoster reactivation, symblepharon and eyelid pigmentary changes.13
Very extensive trichiasis may also be treated surgically. Surgical techniques include eyelid wedge resection, horizontal blepharotomy, tarsal fracturing and eyelid splitting.15 Surgical or radiosurgical splitting of the lid margin allows for direct access to the lash follicles, which can then be efficiently destroyed and/or extirpated internally using some of the aforementioned techniques.
The pattern and cause of the trichiasis, as well as patient and surgeon comfort, should guide treatment decisions. Until a randomized, controlled trial directly compares these treatments in their current state of practice, making evidence-based management decisions will remain challenging. Ultimately, two or more of these methods may be used on many refractory patients. It may be prudent to remind patients, especially in cases of numerous offending eyelashes, that the goal of therapy is reducing signs and symptoms, and that the potential regrowth of a few lashes is not a treatment failure.
Drs. Nakamoto and Bernardino are in the Department of Ophthalmic Plastics and Orbital Surgery at Yale Eye Center/Yale University School of Medicine. Contact them at
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