BASICS

DESCRIPTION

• Acquired misdirection or inturning of eyelashes in an otherwise normal eyelid margin position

• Distichiasis—abnormal hair growing from meibomian gland openings

EPIDEMIOLOGY

Incidence

• Cicatricial—ocular cicatricial pemphigoid (OCP)—females >males

• Average age 60–70 years

Prevalence

Cicatricial—OCP—1 in 15,000–20,000 (1)

RISK FACTORS

Genetics

OCP—associated with HLA—DQB7^∗301

PATHOPHYSIOLOGY

• Distichiasis—hair grows from poorly differentiated pilosebaceous units

• Trachoma–-Chlamydial infection

• Ocular pemphigoid—autoimmune

ETIOLOGY

• Usually unknown

• Scarring of eyelid margin

• Prostaglandin analog eyedrops

• OCP–-a systemic autoimmune pemphigoid disorder that has ocular and nonocular manifestations

– OCP thought to be a type 2 hypersensitivity reaction, genetically predisposed

COMMONLY ASSOCIATED CONDITIONS

• Uncommon:

– Ocular pemphigoid

– Trachoma

DIAGNOSIS

HISTORY

• Foreign body sensation

• Tearing

• Redness

• Previous chemical or physical trauma

PHYSICAL EXAM

• Inturned eyelashes abrading globe with normal position of eyelid margin

• Superficial punctuate keratopathy or corneal abrasions

• Chronic blepharitis

• Eyelid or conjunctival scarring

• Symblepharon—cicatricial—linear scar/fold of palpebral conjunctiva to bulbar conjunctiva, shortening of fornix

– Scarring of upper eyelid tarsal conjunctiva on eyelid eversion (trachoma)

DIAGNOSTIC TESTS & INTERPRETATION

Imaging

Initial approach

• None

• OCP—ANA

Follow-up & special considerations

OCP—elevated soluble CD 8 glycoprotein, elevated tumor necrosis factor

Diagnostic Procedures/Other

Cicatricial—conjunctival biopsy

Pathological Findings

OCP—biopsy of conjunctiva for direct immunofluorescence studies or indirect immunofluorescence for presence of antibodies—positive in >80%

DIFFERENTIAL DIAGNOSIS

• Entropion

• Epiblepharon

• Epicanthus

TREATMENT

MEDICATION

First Line

• Ocular lubrication

– Frequent artificial tears, ophthalmic ointment

• Treat underlying blepharitis

Second Line

Single-dose oral azithromycin (1 g) for trachoma—household member treatment does not improve prognosis (2)

ADDITIONAL TREATMENT

General Measures

Epilation of lashes—recurrence very common every 2–6 weeks

Issues for Referral

Ophthalmologist 1 week

Additional Therapies

• Bandage contact lens

• OCP—prednisone, dapsone, methotrexate, cyclophosphamide, CellCept, or doxycycline

SURGERY/OTHER PROCEDURES

• Procedures to destroy eyelash follicle

– Electrolysis or cautery

– Cryotherapy

– Laser

– Radiofrequency

• Surgical cutting procedures

– Trephination, excision of follicles

– Eyelid splitting and cryo

– Eyelid resection

– Eyelid margin rotation

– Anterior lamellar resection

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Eyelashes regrow in few weeks

Patient Monitoring

Ophthalmologist – outpatient

PATIENT EDUCATION

• Warning signs of ocular irritation

• Trachoma is one of the most important and prevalent eye diseases in the world

PROGNOSIS

• Lashes will almost always regrow; follicles are not damaged by epilation

• Trachoma—cycles of infection, inflammation, scarring, and increased trichiasis and entropion

• Ocular pemphigoid—stabilize if possible with

COMPLICATIONS

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