Eyelash abnormalities


Although ingrowing lashes are usually only a minor irritant they may cause permanent scarring of the cornea and threaten sight, especially if the cornea is insensitive or the eye is dry.


    • Trichiasis

    • Distichiasis

Trichiasis is a common, acquired, misdirection of eyelashes arising from their normal site of origin. Distichiasis is a rare, congenital growth of an extra row of eyelashes arising from the meibomian gland orifices in the posterior lid lamella. In both, the position of the lid margin is normal. If there is entropion of the lid margin this must be treated first (see Chapter 6 ) before treatment of the abnormal lashes.


Choice of operation

Electrolysis is preferred for the treatment of a small number of isolated lashes. Cryotherapy is more effective for many abnormal lashes. If there is a concentration of abnormal lashes in only one site along the lid margin the area may be excised (see 14.1 , 14.2 ).


A nitrous oxide probe is preferred to a liquid nitrogen spray for the treatment of lashes because of better control of the temperature and of the area treated. The use of a thermocouple may be helpful to determine the temperature in the target tissue although precise placement of the probe can be difficult. With experience the time taken to reach the required temperature with a particular cryoprobe can be predicted accurately and the use of a thermocouple becomes less important. A double freeze–thaw cycle to −20°C is used.

Fig. 8.1 post

Trichiasis lashes cleared.


Anaesthetise the lid with 2% lignocaine with 1 : 200 000 adrenaline.

Fig. 8.1a

Trichiasis of the lower lid.


With a corneal guard in place apply the cryoprobe for the appropriate duration (usually 20–30 seconds, depending on the probe used), allow the ice ball to thaw and reapply the cryoprobe for the same duration. Remove the lashes from the area of the cryotherapy.

Fig. 8.1b

Cryotherapy with the ‘Collin’ probe. Cornea protected with a plastic spatula or spoon.

Complications and management

Melanocytes are destroyed at −10°C so depigmented patches will appear if this treatment is used on pigmented skin. The conjunctiva may occasionally migrate over the treated area of the lid margin causing a red line along the margin which is difficult to reverse. Shallow notches and skin sloughing will follow excessive treatment. Recurrent lashes may be retreated.


Lamellar division and cryotherapy to the posterior lamella ( Fig. 8.2 is Fig. 8.2 in 3e)

This technique protects the normal lashes in the anterior lamella from the effects of the cryotherapy to the posterior lamella and most of them will survive. In the lower lid preservation of the normal lashes is less important and cryotherapy without splitting the lamellae may be used. In dark-skinned people, however, pigment loss will be avoided if the lamellae are split.


Evert the upper lid and incise along the length of the grey line with a fine pointed scalpel, trying to avoid damage to the lashes.

Fig. 8.2a

Distichiasis. Incision in the grey line.


Deepen the grey line incision, carefully dissecting between the tarsal plate and orbicularis muscle, to expose the whole anterior surface of the tarsal plate, thus splitting the lid into its anterior and posterior lamellae (see 1.4 ).

Fig. 8.2b

Lid lamellae separated. Distichiasis lashes arise from the posterior lamella.

Key diag. 8.2b


Disinsert Muller’s muscle from the superior tarsal border and dissect superiorly between Muller’s muscle and the conjunctiva for 5 to 10 mm to allow the tarsal plate to advance by about 3 to 4 mm.

Fig. 8.2c

Separation of Muller’s muscle from the superior tarsal border.


Protect the cornea. Freeze the lower few millimetres of the tarsal plate with a double freeze–thaw cycle to –20°C.

Fig. 8.2d

Cryoprobe applied to the posterior lamella.


Pass three double-armed 4/0 catgut sutures from the conjunctiva just superior to the tarsus, through the full thickness of the lid to the skin at the site of the skin crease to hold the anterior lamella recessed on the posterior lamella by about 2 to 4 mm.

Fig. 8.2e

Full-thickness double-armed sutures hold the anterior lamella recessed on the posterior lamella.


Suture the anterior lamellar margin to the tarsal plate.

Fig. 8.2f

Fine sutures placed between the margin of the anterior lamella and the tarsal plate.

Fig. 8.2 post

Two months after upper lid lamellar division and cryotherapy. Note the few persistent distichiasis lashes which have resisted cryotherapy. A few normal lashes have been lost.

Alternative procedure

8.3 Eyelid split and direct excision of distichiasis lash roots

This can be used as the primary procedure for distichiasis or as a secondary procedure for persistent distichiasis lashes following the technique described in 8.2 .

Place a large chalazion clamp, with the ring located posteriorly, on the eyelid margin and evert the lid. Using an operating microscope or surgical loupes incise the grey line immediately anterior to the lashes to be excised. Deepen the incision to about 3 to 4 mm to expose the roots of the lashes. Using a fine pointed scalpel carefully excise each lash follicle and remove the lash. Reposition the chalazion clamp as required until all the aberrant lashes have been removed. It is not essential to suture the lid closed but if the lamellae do not fall together naturally use an 8/0 continuous absorbable suture.

An alternative approach is to incise the tarsal conjunctiva and underlying tarsal plate directly over each distichiasis eyelash, follow the lash to the root and treat it directly with cautery. No sutures are required.

Sep 8, 2018 | Posted by in OPHTHALMOLOGY | Comments Off on Eyelash abnormalities

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