Overview

Trichiasis is an eye condition where the eyelashes grow inwards toward the eye, rather than outwards. The misdirected eyelashes rub against the cornea, conjunctiva, and inside the eyelids, causing irritation, discomfort, and redness, sometimes leading to corneal damage. The condition typically affects the lower eyelid and can occur even when the eyelash follicles are healthy.^1,2,3

As per global statistics from 2016, 2.8 million people are affected by trichiasis. Although the exact cause of trichiasis is unknown, certain risk factors such as infection, inflammation, ageing, or trauma contribute to its development. In severe cases, the condition may lead to corneal damage and can even progress to blindness if left untreated.^1,2,3

There are several non-surgical treatment options, such as lubricants, contact lenses, and simple epilation. More advanced non-surgical treatment options, such as cryoablation, radiofrequency ablation (RFA), electrolysis, and laser ablation, are effective in mild to moderate cases.^4,5

Understanding radiofrequency ablation (RFA)

Definition and principles of RFA

RFA is a minimally invasive procedure that uses radiofrequency energy to generate heat and selectively destroy target tissue. In treating trichiasis, RFA effectively removes the misdirected eyelashes by coagulating and destroying the affected hair follicle, thereby preventing regrowth.^6,7 

Mechanism of action

RFA uses a catheter and a probe with a distal electrode to deliver controlled heat energy to the affected hair follicle. An alternating current of 400–500 kHz is passed through the electrodes to heat the affected hair follicle to at least 50°C for 4–6 minutes, selectively destroying the follicles with approximately 0.5 mm of adjacent tissue. The current through the electrode generates heat production, which irreversibly damages the hair follicle's ability to regenerate. High temperatures (>100°C) are usually avoided as the heat may vaporise water inside the cells and completely burn the tissue.⁸

Advantages of RFA over traditional methods

When compared to traditional methods, RFA offers several advantages:

• Higher precision: Selectively target and destroy the individual hair follicles without affecting surrounding tissues
• Minimal discomfort: Simple and effective in-office surgical procedure that causes less pain than electrolysis or cryoablation
• Long-lasting benefits: Other than eyelash epilation or other non-surgical procedures, it provides long-lasting benefits
• Fewer complications: There is a lower chance of eyelid complications, such as notching and scarring, than with electrocautery or surgical excision
• Low recurrence rate: Although recurrence of eyelash growth is possible, repeating the procedure every 2-3 months after initial treatment improves the success rate compared to electrolysis or cryoablation
• Faster recovery: Being a minimally invasive procedure, healing or recovery time is faster^{6, 9}

Indications and patient selection

Ideal candidates for RFA

The procedure is ideal for:

• Individuals with limited areas of misdirected eyelashes¹⁰
• Those who prefer simple, cost-effective, well-tolerated, and minimally disruptive procedures^10,11

Contraindications and limitations

Although RFA is generally a safe procedure, it is not recommended for everyone. Your doctor will assess your overall health, medical history, and any other specific condition being treated to determine if RFA is the appropriate choice. 

• Patients with cardiac pacemakers, defibrillators, or those receiving oxygen therapy are contraindicated for RFA. If there are no other options, a grounding plate is placed away from the heart, and the lowest power setting will be used
• Patients with active herpetic infection should have the infection treated before undergoing the procedure^9,12

Procedure of RFA for trichiasis

Pre-procedure preparation

A thorough ophthalmologic examination is performed to assess the severity of trichiasis.

The patient is advised to lie on their back, placing a passive electrode of the radiofrequency unit under the patient’s back or shoulder area.

Step-by-step technique

Anesthesia application

• A local anaesthetic is injected into the eyelid to numb the affected area
• A topical anaesthetic is then applied to the misdirected eyelashes and eyelid margin with a sponge for additional numbing
• The doctor ensures the patient is fully anaesthetised before the procedure to avoid discomfort to the patient

Use of a radiofrequency probe

• A micro-insulated needle, electrode, or fine wire electrode is aligned along the shaft of the misdirected eyelash
• The electrode is then inserted adjacent to the eyelash till it reaches the base of the follicle

Targeting and removal of misdirected eyelashes

• Once the electrode reaches the hair follicle, the foot pedal is pressed for 1-2 seconds at a low power setting to apply heat, allowing the eyelash to stick to the electrode and be removed easily
• Multiple attempts are often required to stick eyelashes to the electrode. If it is unsuccessful even after 5-10 attempts, forceps can be used to pull the follicle. The procedure is repeated until all misdirected eyelashes are removed

Post-procedure cleaning

• Apply removal, an ointment is applied to the eyelid margin to prevent infection and promote healing.
• Blood pressure and pulse are measured after the procedure to measure the effects of the anaesthetic injection
• An antibiotic ointment is prescribed for use three times daily for seven days to prevent infection and aid healing

Post-procedure care and recovery

• Patients may experience redness and bruising, which are temporary and should resolve within 1-2 weeks
• In rare cases, patients may develop an infection, treatable with topical or oral antibiotics
• Patients are advised to return sooner if signs and symptoms of any infection do not improve
• Patients are instructed to book follow-up appointments to assess the treatment's success and to determine re-treatment (if needed)⁹

Effectiveness and outcomes

Success rates and recurrence rates

Kormann et al. reported a 100% success rate after 2 or 3 sessions. More than 60% of the patients were cured with only one procedure.¹³

Comparison with other treatment modalities

• Cryoablation: Cryoablation destroys the misdirected eyelashes and their roots using extremely cold gas with a success rate of 34-56% in one session, and 70-90% after two sessions. Although effective, cryoablation can cause complications like eyelid scarring or changes in skin colour
• Electrolysis: Electrolysis destroys the misdirected eyelashes and their roots permanently using electric current, but has a high recurrence rate of 60%
• Laser ablation: Laser ablation is used to treat minor trichiasis. Surgeons usually use laser ablation as an adjunctive therapy to surgical procedures in severe cases for improved outcomes. Argon laser has high success rates ranging from 37% to 59% with one session and 100% with two or more sessions. It produces less inflammation and a lower complication rate compared to electrolysis or cryoablation
• Surgical excision: A permanent solution for severe cases, but with a longer recovery time^{2, 7, 14}

Potential complications and risks

Although RFA is a safe procedure, a few side effects need to be considered:

Common side effects

• Skin redness
• Swelling and bruising
• Discomfort or pain
• Thickening of the eyelid margin

Rare but serious complications

• Infection
• Bleeding
• Damage to the surrounding tissues¹²

Summary

Trichiasis is an eye condition where the eyelashes grow inward toward the eye, rubbing against the cornea and conjunctiva, causing irritation, discomfort, redness, and in some cases, corneal damage. Mild to moderate trichiasis can be effectively managed with traditional and advanced non-surgical treatments, including lubricants, contact lenses, cryoablation, and electrolysis. RFA is a minimally invasive procedure that uses radiofrequency energy to generate heat and destroy the targeted tissue. A fine, needle-like probe is inserted into the targeted area to deliver the heat and destroy the affected hair follicle. In treating trichiasis, RFA effectively removes the misdirected eyelashes by coagulating and destroying the hair follicle and preventing regrowth. The procedure offers the advantages of higher precision, minimal discomfort, fewer complications, a lower recurrence rate, faster recovery, and long-lasting benefits.

Although generally safe, RFA is contraindicated in patients with cardiac pacemakers, defibrillators, active herpetic infection, or those receiving oxygen therapy. Compared to other treatment options, RFA has a high success rate, with over 60% of patients achieving complete resolution after a single session and 100% success after 2-3 sessions. It is ideal for individuals with limited areas of misdirected who prefer simple, cost-effective, and minimally invasive procedures.