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Trichiasis

Misdirected eyelashes that turn inward and rub against the cornea. A common cause of chronic eye irritation, redness, and tearing.

4 min read

Trichiasis is the misdirection of eyelashes - lashes that grow toward and brush against the cornea instead of growing outward. The result is chronic mechanical irritation, tearing, red eye, and sometimes corneal abrasion. Trichiasis is distinct from entropion (in which the entire eyelid turns inward, taking the lashes with it), from distichiasis (an extra row of lashes emerging from the meibomian gland orifices, which can be congenital - sometimes part of the FOXC2-related lymphedema-distichiasis syndrome - or acquired from chronic inflammation), and from epiblepharon (a congenital horizontal fold of skin and orbicularis pushing otherwise normally-oriented lashes against the eye, common in young children and often resolving spontaneously).

Key Takeaways

  • Trichiasis is misdirection of individual lashes that rub the cornea - not a turning-in of the entire eyelid
  • Symptoms include foreign-body sensation, tearing, redness, and intermittent eye pain
  • Causes include chronic blepharitis, trachoma, ocular cicatricial pemphigoid, prior trauma or surgery, and idiopathic
  • Treatment options include epilation (plucking), electrolysis, cryotherapy, radiofrequency ablation, and laser ablation; recurrence is common with simple plucking
  • Lubricants, and occasionally clinician-fitted bandage contact lenses, can provide short-term relief while definitive treatment is planned

Symptoms

  • Foreign-body sensation in the affected eye
  • Chronic tearing
  • Photophobia
  • Redness, particularly at the lid margin
  • Sometimes a visible misdirected lash on close inspection
  • Recurrent corneal abrasions in severe cases
  • Reduced vision if corneal scarring develops

Causes

  • Trachoma - globally the leading cause of trichiasis and trichiasis-related blindness; chronic chlamydial infection produces tarsal scarring
  • Chronic blepharitis - the most common cause in high-income, non-tropical settings; chronic inflammation distorts the lash follicle
  • Ocular cicatricial pemphigoid (OCP) - autoimmune scarring of the conjunctiva and lid margin
  • Stevens-Johnson syndrome / toxic epidermal necrolysis
  • Prior surgery or trauma
  • Idiopathic - particularly in older adults

Diagnosis

A careful slit lamp examination confirms misdirected lashes, identifies any associated lid disease, and assesses corneal damage with fluorescein staining. The doctor distinguishes trichiasis from entropion (whole lid in-turning, with lashes following), distichiasis (extra lash row from meibomian gland openings), and epiblepharon (a skin/muscle fold pushing normally-oriented lashes against the cornea, common in young children).

Treatment

Mechanical Epilation

Plucking with forceps. Quick, sometimes with a brief sting, but the lash regrows in 4-8 weeks. Useful as a temporary measure.

Electrolysis

A small probe delivers an electrical current to the lash follicle, aiming to destroy it permanently. Takes more than one session in some cases.

Cryotherapy

Freezing of the lid margin destroys lash follicles. Effective for clusters of misdirected lashes; risk includes lid notching and pigmentary changes.

Radiofrequency Ablation

Modern alternative to cryotherapy or electrolysis. Targets individual follicles with less collateral damage.

Laser Ablation

Argon laser ablation of individual lash follicles - historically used and effective for isolated misdirected lashes, though now less commonly first-line where radiofrequency or surgical options are available.

Lid Surgery

For trichiasis caused by underlying lid distortion (cicatricial entropion, severe OCP), formal lid reconstruction is required. For trachomatous trichiasis, the WHO-recommended definitive procedure is bilamellar tarsal rotation (BLTR) or posterior lamellar tarsal rotation, which rotates the lash-bearing margin away from the cornea.

Bandage Contact Lens

Can provide short-term symptomatic relief and protect the cornea while definitive treatment is planned. It should be fitted and monitored by an eye clinician because contact lenses can increase infection risk.

Treatment of Underlying Cause

  • Lid hygiene and antibiotic or anti-inflammatory drops for blepharitis when indicated
  • Systemic immunosuppression for ocular cicatricial pemphigoid / ocular mucous membrane pemphigoid
  • Treatment of trachoma in endemic regions

Frequently Asked Questions

Why does plucking not solve the problem?

Plucking removes the visible lash but leaves the follicle intact. The lash usually regrows in the same misdirected orientation in 4-8 weeks. Longer-lasting treatment requires destruction of the follicle by electrolysis, cryotherapy, radiofrequency, or laser.

Are misdirected lashes the same as entropion?

No. Trichiasis is misdirection of individual lashes from a properly positioned lid. Entropion is the whole lid turning inward, which secondarily turns the lashes inward. The two often coexist but the treatments differ.

Can trichiasis cause permanent vision loss?

Severe untreated trichiasis can produce corneal scarring and vision loss. With timely treatment this is uncommon, but in regions where trachoma-related trichiasis is untreated, it remains a leading cause of preventable blindness worldwide.

References

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