Eyelid misdirection and its management

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Leonid Skorin Jr, OD, DO, FAAO, FAOCO
Eyelid misdirection and its management
Misdirected eyelashes may result
from various causes, but it is
important to identify the exact
mechanism or anatomical deviation
for the misdirection to adequately
address treatment. The goal of
treatment is to remove or redirect
the offending eyelashes.
Mucocutaneous Junction
Meibomian glands
Grey line
Patients with misdirected lashes will present
with discomfort, irritation and a foreign body
sensation, excessive tearing and conjunctival
injection with chemosis. The abrasive effects
of the eyelashes on the cornea can lead to
corneal erosion, scarring, vascularisation and
corneal ulceration. Untreated, this ulceration
may result in perforation and its subsequent
blindness and loss of the globe 1,2 .
This article reviews the various causes
of eyelid misdirection and addresses its
treatment, both in practice and
surgically.
Anatomy
The eyelids consist of superficial and deep
layers 3 . The superficial layer consists of the
overlying skin, sweat glands, sebaceous
glands and the striated muscle fibres of the
orbicularis oculi muscle, which actually closes
the eye. The deep layer consists of the tarsal
plate, which gives the eyelid its firmness and
shape. Also included in the deep layer is the
tarsal muscle – smooth musculature of the
levator palpebrae which inserts into
the tarsal plate and the palpebral
conjunctiva.
The surgical anatomy of the eyelid is
divided into posterior and anterior lamellae 1 .
The anterior lamellae consists of the skin and
orbicularis oculi muscle, whereas the tarsus
and conjunctiva make up the posterior
lamellae. The two lamellae are divided along
the eyelid margin by the grey line, which
structurally consists of the muscle of Riolan
(pretarsal orbicularis muscle). Just posterior
to the grey line are the meibomian gland
orifices. The mucocutaneous border is located
posterior to the openings of the meibomian
glands (Figure 1). The mucocutaneous
junction is where the non-keratinised
palpebral conjunctiva meets the keratinised
skin of the eyelid margin. The normal lid
margin should have a well-defined anterior
and posterior edge, which is nearly square
when viewed in cross-section 4 .
The eyelashes help to protect the globe
from dust, dirt and other foreign bodies. To
some extent, they shade the eye from the
sun and glare. The eyelashes project from the
anterior aspect of the margin of the eyelid.
On the upper eyelid, approximately 150
eyelashes are arranged in three or four rows;
on the lower eyelid there are about 75 in two
rows 2 .
Figure 1
Simple schematic diagram showing the anatomy of the normal lid margin
Trichiasis
In trichiasis, the eyelashes grow abnormally,
characterised by the presence of one or more
in-turning lashes of the upper or lower
eyelid 5 . These eyelashes may be extremely
fine, thin and non-pigmented (lanugo hairs)
and may only be visualised under
biomicroscopy. In some races, however,
particularly Asians, physiologic trichiasis of
the lower lids often occurs near the
punctum 5 .
The lashes are misdirected toward the
globe after emerging from follicles at bizarre
angles, from meibomian gland orifices, or
from other areas of the eyelids or conjunctiva
which are normally free of eyelash growth 6 .
In trichiasis, the eyelid margin is normally
positioned, whereas in entropion, the eyelids
are inverted, causing the lashes to rub
against the eye 4 .
In most cases, trichiasis is the result of
ageing changes of the lid, and no underlying
disease process is present 5 . Trichiasis can be
further divided into congenital causes such
as epiblepharon and distichiasis, and
acquired causes such as marginal entropion,
trauma, and metaplasia.
Epiblepharon
In epiblepharon, the pretarsal skin and
muscle rides above the lid margin and pushes
the lashes against the globe (Figure 2). The
eyelid and the margin are in normal
position 4 . It might be considered both a
mechanical and congenital abnormality. The
condition is most commonly seen in Asian
children and involves only the lower eyelids 1 .
Patients usually present by the age of four or
five 4 .
If the child is asymptomatic, no treatment
is indicated. If the child has symptoms or
signs of corneal involvement, then
conservative therapy with non-preserved
artificial tears during the day, and bland
lubricating ointment at bedtime, is all that
may be required to make the child
asymptomatic. This conservative approach
may be tried initially since some children
may outgrow the condition as their facial
features mature 4 .
If the conservative approach fails, then
surgical correction with excision of a strip of
skin and muscle, and fixation of the skin
crease to the tarsal plate, can be done. This
is known as the tarsal fixation of Hotz 7 .
Distichiasis
In congenital distichiasis, which is a
relatively rare condition, an accessory row of
lashes lies posterior to the normal lashes,
arising from the meibomian gland orifices 3,4,5 .
Figure 2
Epiblepharon
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September 20, 2002 OT www.optometry.co.uk

Figure 3
Involutional entropion with preseptal
muscle override causing in-turning of lid
margin and eyelashes rubbing the globe
Figure 4
Involutional entropion causing untoward
corneal and conjunctival changes
The meibomian glands themselves may be
rudimentary, atrophic or normal 8 . Often this
extra row of lashes is incomplete. Although
the lashes in trichiasis are typically of normal
calibre, the aberrant hairs in distichiasis are
often softer, shorter, less pigmented and
finer 9 . It has been associated with
strabismus, ptosis, cleft palate, congenital
ear defects, trisomy 18, and mandibulofacial
dystosis 4,5 .
Acquired distichiasis happens when
normal, non-hair producing meibomian
glands (sebaceous) of the tarsal plate are
transformed into hair follicles (pilosebaceous
units) by mechanical or chemical stimuli 10 .
These stimuli include chronic inflammation
such as blepharitis and meibomitis,
cicatricial conditions of the mucosa such as
Stevens-Johnson syndrome, ocular
pemphigoid and severe chemical burns, and
metaplastic triggering process such as
mechanical or surgical trauma to the
meibomian glands 5 .
The goal of treatment is to destroy the
distichiatic lashes while retaining the normal
ones. This is best accomplished by
performing a lid-splitting procedure
combined with cryotherapy. This is done by
splitting the lid into the anterior and
posterior lamellae along the grey line.
Cryotherapy is then applied to the posterior
lamellae using a double freeze-thaw
technique. This procedure avoids the risk of
damage to the normal lashes and
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depigmentation of the skin. To prevent postoperative
cicatricial entropion, the anterior
lamellae is recessed during reconstruction 11 .
If there are only one or two distichiatic
lashes, then direct surgical excision
performed with the aid of an operating
microscope can be done. Each abnormal cilia
is located and excised through the
conjunctival surface of the lid 12 .
The application of lubricants or a soft
bandage contact lens or, in severe cases,
topical antibiotics may be indicated before
surgical intervention 5,13 .
Marginal entropion
Marginal entropion occurs when only the
posterior eyelid margin becomes rounded,
physically causing inversion through the
posterior pulling of the posterior lamellae
structures. This causes the lashes to become
misdirected as the mucocutaneous junction
migrates anteriorly and the keratinised
portion of the lid is pulled posteriorly 4 .
Marginal entropion can be considered a mild
form of cicatricial entropion 1 . Marginal
entropion is the most common cause of
trichiasis in adults 1,14 .
Entropion
Entropion is a condition in which the eyelid
margin turns inward against the globe 14 . It
can be classified as congenital, spastic,
involutional (senile) or cicatricial 15 .
Involutional entropion is the most
common cause of entropion in elderly
patients. It affects mainly the lower eyelid
because the upper lid has a wider tarsal
plate and is more stable. Ageing changes
create a relative excess of skin and anterior
lamellae of the eyelid. This causes overriding
of the preseptal orbicularis muscle over the
pretarsal muscle during lid closure, which
tends to move the lower border of the tarsal
plate away from the globe and the upper
border towards the globe 14 (Figure 3).
Persistent rubbing by in-turned eyelashes
against the conjunctiva and cornea leads to
conjunctival chemosis and injection,
superficial punctate keratopathy and
eventual corneal ulceration (Figure 4).
Continued stretching of the orbicularis
muscle, as well as both medial and lateral
canthal tendons, causes a horizontal lid
laxity. This lid laxity is aggravated by any
orbital fat atrophy or enophthalmos 14
(Figure 5). All these factors help contribute
to the destabilisation of the eyelid.
Management of entropion requires
surgical reconstruction. If there is no or
minimal horizontal lid laxity, a base-down
triangle tarsal resection may be indicated
(Figure 6). If there is horizontal lid laxity,
then a combination of lateral canthal
strengthening and tightening of the lower
lid retractors increases the pull of the lower
lid retractors, and also creates a barrier
between the preseptal and pretarsal
orbicularis muscles (Figure 7).
Figure 5
Insufficient support for prosthesis resulting
in enophthalmic appearance and in-turning
of superior and inferior eyelids. This
simulates severe trichiasis
Figure 6
Base-down triangle resection. Sutures are
in place prior to tightening
Figure 7
Forceps are holding the inferior lid
retractors. Tightening them and
strengthening the lateral canthus corrects
entropion
Metaplasia
Cicatricial lash problems result from acute or
chronic inflammation. Subtle scarring of the
posterior lamellae pulls the eyelashes
toward the eye. This same inflammation can
result in metaplasia of the meibomian
glands resulting in the production of hair
follicles and the consequent aberrant
lashes 4 .
The most common acute inflammatory
causes include viral infection (herpes zoster,
herpes simplex, vaccinia); chemical burns,
especially alkali; trauma; radiation; and
surgery or cryotherapy. The most common
chronic inflammatory causes include
blepharitis (Staphylococcus, seborrhea,
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Figure 8
ProLectro ophthalmic epilator
Figure 9
Eyelid with trichiasis being anaesthetised
with a subcutaneous injection
Figure 10
Electrolysis microstylet wire inserted
adjacent to aberrant eyelash
rosacea); trachoma; chronic viral infection;
conjunctival shrinkage (ocular cicatricial
pemphigoid, Stevens-Johnson syndrome) or
use of topical medication (drug-related
pseudopemphigoid) 16 .
Many ocular medications, including
topical ophthalmic idoxuridine, demecarium,
epinephrine, timolol, pilocarpine,
echothiophate and dipivefrin, are associated
with a pemphigoid-like syndrome 17-19 . When a
patient who is taking a glaucoma medication
topically develops pemphigoid-like changes,
a conjunctival biopsy should be done and
the medication discontinued. In many cases,
the cicatricial changes will arrest 2 . A
different class of glaucoma agent or
glaucoma surgery should be tried.
Treatment of trichiasis
The treatment approach depends on the
extent of lid involvement. Epilation of
multiple lashes can be inappropriate because
often, lashes grow back rapidly in a more
aberrant fashion and thicker in diameter 10 .
Very fine, thin eyelashes (lanugo hairs) may
be difficult to see and grasp with forceps.
If mechanical removal is indicated (there
are only one or two misdirected lashes),
then simple epilation with jewellers’ forceps
or epilating forceps can be attempted. A
drop of topical anesthetic improves patient
comfort and compliance. To avoid breakage,
the lash should be grasped securely at its
base. A firm tug outward will remove the
lash by its root 5 . Unfortunately, the
eyelashes typically recur within three to six
weeks 1 .
Areas of recurrent trichiasis require more
definitive treatment. These treatment
modalities include electrolysis, laser
photoablation, cryotherapy and surgical
repair and reconstruction.
Electrolysis
This procedure is efficient when removing
individual misdirected eyelashes. An easy
and inexpensive method is with the use of
the ProLectro electrolysis unit 5 . This is a
small, hand-held unit which uses the basic
principle of electrolysis. A mild, galvanic
current is transmitted from the power source
(a battery). The amount of current is
regulated by a rheostat and gauge. The
current passes through a connecting wire to
the operator-held handpiece which contains
the microstylet wire (Figure 8).
The patient’s eyelid should first be
anaesthetised with a subcutaneous injection
of lidocaine 1% with 1:100,000 epinephrine
(Figure 9). The patient is then seated behind
the biomicroscope and instructed to hold
the electrode (power source, rheostat,
gauge) in their hand to complete the circuit.
The clinician everts the lid and inserts the
microstylet wire to a depth of 2mm
immediately adjacent to the eyelash shaft
into the hair follicle 1,5,10 . The wire must be
positioned in the same direction in which
the hair is growing 5 . When the wire is
properly positioned, the switch which is
located on the operator’s hand-piece is
pressed and this starts the flow of current.
The power is increased slowly until the tissue
around the follicle coagulates 4 . This appears
as frothy bubbling and can take anywhere
from five to 10 seconds to be seen at the
follicular orifice 10 (Figure 10).
The eyelash usually slides out as the
microstylet wire is removed. This indicates
successful treatment. The lash can also be
either wiped away with a cotton-tipped
applicator or removed with epilating forceps.
Any resistance to its removal indicates
incomplete treatment and a second
application should be done.
Electrolysis can cause mild swelling or
irritation in the immediate area of
treatment 5 . Treatment of many lashes close
together, or over-zealous use of electrolysis,
can create scarring, notching and tendency
toward cicatricial entropion 10,16 . Other
disadvantages include the difficulty of
making an accurate ‘blind’ insertion of the
wire into the follicle, creating a false
passage or not going deep enough, and
difficulty in treating small or lanugo
lashes 16 .
The failure rate by some authors has
been stated to be as high as 50-70%,
indicating recurrence of lashes 1,4 . Other
sources state that only a low incidence of
regrowth is seen, mostly with coarse or
previously tweezed lashes 5 . Success rates can
be increased by applying meticulous
technique.
Electrical current can be converted into
controlled energy in the radiowave portion
of the electromagnetic spectrum using a
radiosurgical unit as an alternative method
of treating localised trichiasis 1 . This
radiosurgical epilating method uses an
insulated electrocautery needle. Otherwise,
the procedure is identical to the standard
electrolysis surgical regimen. First treatment
success rate has been reported to be as high
as 67% 20 .
Laser photoablation
Argon laser photoablation can be used for
treating focal, localised areas of trichiasis 21 .
It is hoped that the pinpoint accuracy of the
argon laser would allow destruction of the
abnormal lash follicle with the least amount
of damage to the surrounding structures,
compared to other techniques such as
cryotherapy or electrolysis 1 .
Laser energy is delivered with a standard
slit lamp. The eyelid is infiltrated with a
local anaesthetic as used in electrolysis. A
cotton-tipped applicator is used to orient
the eyelid so that the lash follicle is parallel
to the laser beam. Laser settings of 1.0
watts to 2.5 watts, 0.2 seconds to 0.5
seconds duration, 50 micron or 100 micron
spot size, and blue-green colour are directed
co-axially along the lash to a depth of 2mm
giving the best results 1,2,4,10,16 . It usually
takes from 15-30 burns per eyelash 1 .
Non-pigmented lashes can be dyed with
gentian violet for more efficient laser
uptake 4 . The success rate ranges from
50-90% 21 .
Complications are typically rare but
include eyelash recurrence, notching,
scarring, depigmentation, and erythema 1 . As
with electrolysis, only one lash follicle can
be treated at a time 2 .
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Cryotherapy
There is a graded sensitivity of tissues to the
effects of freezing. Eyelash and hair follicles
are more sensitive than epithelial cells and
connective tissue, but are less sensitive than
pigment cells. Abnormal eyelashes can be
destroyed by freezing the lash follicles to a
temperature of -20˚C, whereas the
surrounding eyelid tissue can withstand
temperatures of -40˚C 4,14 . Freezing to -20˚C
will cause depigmentation which may or may
not improve with time, therefore non-white
patients may be better treated with a
combination of electrolysis and surgery
rather than cryotherapy 14 .
Cryotherapy causes intracellular ice
crystal formation, which results in cell
membrane rupture. A change in the pH
value of intracellular fluid results in protein
desaturation. The cold injury to blood
vessels causes thrombosis with secondary
ischemia and infarction 10 .
Cryotherapy uses an instrument called a
cryoprobe and nitrous oxide as a heat sink.
The eye should be protected with a plastic
corneo-scleral guard. The eyelid is
anaesthetised with lidocaine 1% with
1:100,000 epinephrine injection. The
vasoconstrictive effective of the epinephrine
speeds freezing and slows thawing. The
cryoprobe is placed on the lid skin adjacent
to the misdirected lashes. The probe is
placed for 30 seconds along the upper lid
and for 25 seconds along the lower lid 4 .
During the freezing portion of the
procedure, ice crystals known as an ‘ice ball’
will form on the skin and should be allowed
to expand for 2mm or 3mm beyond the edge
of the probe 4 . For larger areas of
involvement, applications are made in an
overlapping manner. The cryoprobe tip must
be in firm contact with the tissue at the
time of freezing without fluid between the
two surfaces 16 .
The thaw portion of the procedure
typically takes 30 seconds and is considered
complete when there is no evidence of ice
crystals on the skin or conjunctiva 1 .
Irrigation should not be used during the
thaw. The maximum effect is achieved if the
freeze is rapid, the thaw is slow, and the
freeze-thaw cycle is repeated 14 . The
lashes are then removed after the second
cryo-treatment using forceps, and a
steroid-antibiotic ointment is applied to the
treated area three times a day for four days 1 .
Significant inflammation, swelling, burning
and pain occurs within the first 48 to 72
hours post-operatively 10 . Systemic analgesics
or narcotics can be prescribed.
The double freeze-thaw technique using a
cryoprobe has a success rate as high as
84% 22 . This is because relatively large areas
can be treated quickly and easily, small
lashes which are difficult to epilate often
respond well, and the procedure can be
repeated as necessary 16 . Approximately 20%
of patients do experience complications such
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as scarring, eyelid margin disruption, eyelid
thinning, eyelash recurrence, loss of normal
eyelashes, pigmentary skin changes,
exacerbations of ocular cicatricial
pemphigoid, and damage to the globe 1 .
Although cryotherapy can be used to treat
trichiasis in ocular cicatricial pemphigoid, it
can cause further damage to the tear film
and sometimes exacerbate the inflammatory
response 2 . Cicatricial pemphigoid is a
systemic autoimmune disorder characterised
by inflammatory lesions of the mucous
membranes which scar and, when the
conjunctiva is involved, forms symblepharon
and fornix shallowing and shortening.
Surgery
There are several surgical approaches used in
the treatment of trichiasis. A simple
pentagonal wedge resection can be used to
treat localised trichiasis. When trichiasis is
more diffuse, more elaborate techniques are
necessary. These can include the tarsal
fracture operation, terminal tarsal rotation
operation or anterior lamellae recession if
the upper eyelid is involved.
About the author
Leonid Skorin Jr is a licensed optometrist
and board-certificated ophthalmologist. He is
fellowship-trained in neuro-ophthalmology.
He has written numerous publications and
has lectured internationally.
Please note that this article is written in the
context of optometry in the US.
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