45.1 Goals

The goal of managing aberrant lashes, or trichiasis, is to prevent lashes from touching the cornea which can lead to corneal irritation and/or damage. Trichiasis is defined as lashes that are in the normal position, yet are pointing in an abnormal direction (Fig. 45‑1). This is distinct from distichiasis, which refers to lashes growing in an abnormal position, usually posterior to the normal lash line in the area of the Meibomian gland orifices.

45.2 Advantages

Aberrant lashes can be extremely uncomfortable for patients as well as potentially harmful to the ocular surface. Any technique to manage aberrant eyelashes has the advantage of removing lashes that touch the ocular surface.

45.3 Expectations

Management of aberrant lashes is fraught with difficulty. It is important to tell patients that it will likely take more than one procedure to eradicate the lashes, and even any intervention may not be completely successful.

45.4 Key Principles

One of the most important things to consider when managing aberrant lashes is to establish what is causing the lashes to turn inward. The most common causes for aberrant lashes are cicatricial processes from acute inflammation (viral, chemical burns, trauma, radiation, surgery, or cryotherapy) and chronic inflammation (blepharitis, trachoma, ocular cicatricial pemphigoid [OCP], Stevens-Johnson syndrome [SJS], topical medications, and tumor). Entropion can also lead to aberrant lashes; yet, this is often simply addressed by fixing the malposition of the eyelid. Failure to establish the etiology of aberrant lashes can undermine any intervention. For example, undiagnosed OCP can lead to blindness if the patient is not initiated on immunosuppressants as well as worsen the surgical result.

45.5 Indications

Significant ocular surface discomfort and/or evidence of corneal damage from aberrant lashes are indications for intervention.

45.6 Contraindications

Management for aberrant lashes should not be undertaken until the etiology has been determined. Ocular lubrication and bandage contact lenses can be used in the interim to prevent corneal damage and help ease discomfort. Current infections or inflammations should be treated prior to surgical intervention, if possible, as surgery may exacerbate the eyelash problem.

45.7 Preoperative Preparation

Preoperative preparation includes a careful history to elicit previous eyelid trauma, surgery, foreign travel, history of oral or skin lesions suggestive of herpetic infection, history of prior radiation in the periocular area, use of glaucoma medication, or the use of any cosmetic eyelash preparations. A complete ophthalmic examination should also be performed focusing on the location and type of abnormal eyelash growth. Attention should be paid to the inferior fornix for evidence of active conjunctival inflammation, cicatrized conjunctiva, or tarsal fibrosis. It should be noted whether there are any eyelid lesions causing lash distortion which could suggest a cutaneous neoplasm. The cornea should be evaluated for any superficial punctate keratopathy, thinning, cellular infiltrates, or scarring. If an infectious process is suspected, appropriate culture should be performed. Suspicious eyelid lesions should be biopsied. A conjunctival biopsy should be performed if OCP is suspected. If a patient has a diagnosis of OCP or other severe ocular surface inflammation, perioperative immunosuppression (e.g., oral steroids) should be considered after consultation with the treating subspecialist (cornea or uveitis). ¹

45.8 Operative Technique

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  There are many different techniques that can be considered in the management of aberrant eyelashes. The choice of technique often depends on the etiology, the extent of the aberrant lashes on the eyelid, the location of the misdirected lashes, and the patient’s preference. No technique is 100% effective.

  
  
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  Manual epilation: This can be performed at the slit lamp with just topical anesthesia. This is minimally invasive, but does necessitate frequent office visits as it only takes 1 to 2 months for the lashes to grow back. Some also feel that this can accelerate lash growth.

  
  
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  Radiofrequency or electrolysis: Radiofrequency or electrolysis is useful when there are few aberrant lashes on a single lid or multiple lids. In both instances, energy is delivered to the hair follicle on a fine-tip probe. Electrolysis delivers electrical energy to an individual hair follicle. A radiofrequency device, such as the Ellman Surgitron (Ellman International Manufacturing, Hewlett, NY; Fig. 45‑2), can be used to selectively deliver energy at 3.8 MHz (radio wave) to the hair follicle. Radiofrequency devices deliver more focused energy with less collateral tissue damage than electrolysis units (such as a Bovie electrosurgical unit). After local anesthesia is infiltrated into the eyelid, a fine wire-tip electrode is inserted into the hair shaft parallel to the direction of the abnormal eye lash, approximately 2 to 3 mm in depth. The Ellman is set on “cut” or “coag” (i.e., coagulation) starting at level 4 and can be adjusted upward to a maximum of 8. The electrical current is applied until bubbles are noted at the hair follicle opening. At that point, the aberrant lash should either come out on its own (i.e., with withdrawal of the probe) or be easily removed with forceps. Each lash must be treated separately. It is often useful to use a slit lamp or an operating microscope to adequately visualize the lashes. If necessary, treatment can be repeated after several weeks. Recurrences are common, and often a few retreatments are needed. ²

  
  
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  Argon laser ablation: Argon laser is used to apply focal tissue coagulation within the follicle with minimal surrounding tissue damage. After local anesthetic is injected, the patient is positioned in an argon laser headrest. A laser-safe corneal protective shield is placed over the eye. The eyelid is everted and the argon laser beam is directed parallel to the direction of the aberrant eyelash. The spot size is set to 100 to 200 μm with a pulse duration of 0.5 seconds with a low power setting of 1 watt. Repeated pulses are applied to a depth of 2 to 3 mm. As with hyfrecation, recurrences are common and often at least three treatments are required. Hypopigmentation and dimpling of the lid margin can occur. ³

  
  
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  Cryoepilation: Cryosurgery has the ability to treat multiple eyelash follicles at once. The eyelid can be manually distracted from the globe or a corneal protector can be placed. After injection of local anesthesia, the cryotherapy probe is applied at the base of the affected eyelashes, either on the eyelid skin or the palpebral conjunctiva. Various cryotherapy devices have been described, with application times ranging from 20 to 25 seconds to 30 to 45 seconds, allowing the tissue to reach –20°C. A microthermocouple needle probe can be used to monitor the tissue temperature. It is placed within the orbicularis oculi muscle 3 mm away from the cilia base. During application, ice crystals allow the probe to adhere to the tissue surface and will disengage as the probe temperature rises. A second application is then completed. Hypopigmentation, eyelid notching, and prolonged pain and edema may occur. Eyelid necrosis is associated with treatment below –30°C.

  
  
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  Trephination: The eyelash follicle can be removed in its entirety with a microtrephine. Various microtrephines have been described, including a diameter as small as 0.81 mm. The eyelid is injected with local anesthesia and is manually stabilized with forceps. The affected eyelash is introduced into the lumen of the microtrephine, and the instrument is then used to core out the base of the eyelash, including its follicle and a minimal cuff of surrounding tissue, to a depth about 2 mm. Success rates have been described similar to electrolysis. As with electrolysis, a slit lamp or operating microscope is recommended for improved visualization. Eyelid scarring is a potential complication. ⁴

  
  
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  Full-thickness wedge resection: For focal areas of trichiasis or distichiasis, a full-thickness wedge resection can be considered. After local anesthetic is infiltrated, the area can be incised in a pentagonal fashion. Partial-thickness tarsal sutures are placed with 6–0 polyglactin or silk suture. The tarsus at the margin is closed in a similar manner or with vertical mattress suture placement to more effectively evert the edges (Fig. 45‑3). The eyelash line and skin are closed with the surgeon’s choice of external suture. Eyelid scarring or notching are potential complications, although rare.

  
  
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  Lid splitting with anterior lamella recession: When the entire horizontal extent of the eyelid is affected, recession of the lash line with lid splitting is considered. After injection of local anesthesia, the gray line of the eyelid margin is incised along the horizontal extent of the affected eyelid. Sharp-tip Westcott scissors are used to dissect off the anterior lamella, exposing the anterior tarsus. Recession of the anterior lamella is facilitated by full-thickness incisions of the anterior lamella at the medial and lateral aspects of the dissection. The eyelash line can be treated with destructive procedures as previously described, or removed entirely. The anterior lamella is sutured in place, 2 mm from the posterior margin, with multiple horizontal mattress sutures that are placed in a partial-thickness fashion through the tarsus and full-thickness through the anterior lamella (Fig. 45‑4). The patient should be informed of the permanent change in appearance of the eyelid margin, so this procedure should therefore be reserved for refractory cases.

  
  
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  Tarsal fracture (Weis procedure): Another consideration for trichiasis affecting the entire eyelid is a horizontal blepharotomy with rotation of the eyelid margin. The eyelid is anesthetized and an eyelid plate is placed behind the eyelid. A full-thickness incision is made 3 to 4 mm from the eyelid margin, along the full horizontal width of the tarsus. Double-armed absorbable 5–0 suture is used to rotate the margin outward by approximating the proximal marginal skin edge, to the distal posterior tarsal edge. This is repeated across the horizontal extent of the incision, and the skin is closed with the surgeon’s choice of external suture (Fig. 45‑5). A permanent change in eyelid appearance is possible. Overcorrection can occur and be treated with massage or cautery to the palpebral conjunctiva.

  
  
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  Modified tarsotomy: This procedure is similar to the Weis procedure, yet is less destructive with excellent cosmetic and functional results. The eyelid is anesthetized and a 4–0 silk traction suture is placed through the margin. This lid is then everted over a cotton-tipped applicator. A Supersharp blade is used to make a full-thickness tarsal incision 2 mm proximal to the lid margin. The length of the incision should extend 2 mm beyond the area of cicatrization. Relaxing incisions are made medially and laterally toward the lid margin. Dissection is performed between the tarsal place and the orbicularis oculi muscle to the lid margin. As in the Weis procedure, rotational horizontal mattress sutures are then placed with double-armed 6–0 Vicryl sutures from the proximal tarsus through the skin just above the lash line. This is repeated across the horizontal extent of the incision. ⁵

  
  
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  Eyelash extirpation with mucous membrane grafting: Lid splitting with eyelash extirpation and mucous membrane grafting is an option for recurrent or severe cicatricial entropion from SJS or OCP. In this technique, the anterior and posterior lamellae are divided, and the eyelash line is excised at a depth sufficient to remove the eyelash follicles. Mucous membrane can be obtained from either the lower lip mucosa, buccal mucosa, or hard palate. The mucous membrane is then sewn into position onto the raw anterior surface of the posterior lamella along the eyelid margin (Fig. 45‑6). The advantage of the hard palate is that it is more durable with little shrinkage, compared to that of the lower lip mucosa. Another advantage of this procedure is that recurrence is rare and other eyelid pathology, such as conjunctival keratinization, is addressed. The disadvantages are postoperative discomfort of the donor site until re-epithelialization and change of eyelid appearance. Thus, this procedure should be reserved for severe cases. ⁶