Overview

Trichiasis is an eye condition where the eyelashes grow inward toward the eye rather than outwards. The misdirected eyelashes rub against the cornea, conjunctiva, and inside the eyelids and cause irritation, discomfort, and redness. The condition typically affects the lower eyelid and occurs even though the eyelash follicles are healthy.^1,2,3

As per statistics from 2016, 2.8 million people worldwide live with trichiasis. Although the exact cause of trichiasis is unknown, certain risk factors such as infection, inflammation, aging, 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 The resulting irritation and corneal damage can potentially impact the individual’s ocular health and quality of life. Hence, timely treatment is necessary not only to prevent visual loss but also to improve physical and psychological health.⁴ For mild to moderate cases, non-surgical treatment options such as lubricants, contact lenses, and simple epilation can improve patient symptoms and provide temporary relief.^5,6

What are the symptoms of trichiasis?

Individuals with trichiasis may experience:

• Eye redness
• Eye irritation (feeling like a foreign object in the eye)
• Eye watering or tearing
• Photophobia (light sensitivity)
• Eye discomfort or pain²

How do we diagnose trichiasis?

A slit-lamp examination and upper eyelid eversion help in accurately diagnosing trichiasis and its severity.

Slit-lamp examination

A slit-lamp biomicroscope is a high-magnification device that allows ophthalmologists to identify misdirected eyelashes that may not be visible to the naked eye, corneal damage (such as erosions, abrasions, scarring) caused by eyelash friction, and other eyelid abnormalities such as entropion or distichiasis.⁷

Eyelid eversion

Eyelid eversion is a simple technique used in a primary care setting to examine the inner eyelid and conjunctiva. The procedure involves flipping the upper eyelid over a cotton-tipped applicator to detect inflammatory lesions, such as styes, conjunctival changes from chronic infections or allergic conditions, and small foreign objects stuck in the conjunctival fornix.⁸

How do we differentiate trichiasis from other eyelash disorders?

Trichiasis is often confused with other eyelash-related conditions like distichiasis and entropion, but key differences exist:

Distichiasis

Distichiasis is a genetic congenital condition where extra lashes grow from the meibomian gland orifices. The condition is mostly asymptomatic until 5 years of age. Unlike trichiasis, the eyelashes grow from an abnormal location rather than a normal eyelid margin.⁹

Entropion

Entropion occurs when the eyelid margin turns inward, causing the eyelashes to rub against the eye, but the implantation, direction, and eyelashes remain normal. In contrast, in trichiasis, the eyelid is normal, but the lashes grow in the wrong direction, causing irritation and discomfort.⁹

Sometimes trichiasis occurs along with entropion when there is chronic inflammation of the eyelids. In more complex cases, it can lead to ‘acquired distichiasis’ where eyelashes grow from meibomian gland orifices.⁹

How do we assess the severity of trichiasis?

Trichiasis severity is graded based on the number of misdirected eyelashes, the extent of corneal involvement, and associated ocular complications such as corneal abrasions or scarring. It is classified as minor when fewer than five eyelashes are involved and major when five or more eyelashes are involved or misdirected. This grading helps ophthalmologists to choose between non-surgical management options and surgical procedures.¹⁰

What are the non-surgical treatment options for treating trichiasis?

Several easy home remedies are available to ease the discomfort, such as warm compresses for swollen eyelids, cool compresses for itching or cucumber slices for anti-inflammatory and antioxidant properties. However, these remedies provide temporary relief and do not guarantee a permanent cure. There are several non-surgical options available in the management of trichiasis. The treatment choice depends on the number of lashes involved, the cause, and the preference.¹¹

Eyelash epilation

Epilation is the manual removal of misdirected eyelashes causing ocular discomfort and irritation performed under topical anesthesia using forceps. The misaligned eyelashes are gripped at the base and gently plucked out without damaging the surrounding eyelashes. The procedure is a simple and cost-effective treatment option and improves patient symptoms in the short term.

However, the epilated lashes typically regrow within 4–6 weeks. Furthermore, epilated lashes often fall off during removal, resulting in sharp eyelash stubs that can cause corneal damage.  Repeated epilation may eventually weaken the hair follicles and does not offer a permanent correction for trichiasis.^5,11

Lubrication therapy

Lubrication therapy is used to manage mild cases of trichiasis by reducing the irritation and protecting the ocular surface from further damage. Medium to high viscosity ophthalmic lubricants provide adequate retention time and effective relief. Several options are available in the market, such as Refresh Liquigel, Systane Ultra and Genteal Gel. Ointments can also help in protecting the ocular surface but often cause excessive blurring during daytime hours.¹²

Eyelid taping

A medical tape is used to correct in-turning eyelashes on a patient's upper eyelid. The tape is cut into specific dimensions and applied over the excess upper eyelid skin to prevent eyelashes from rubbing against the eye. The technique relieves the symptoms of foreign body sensation, itchiness, and tearing; however, the symptoms return once we remove the tape. This is a temporary realignment to keep lashes away from the cornea, which is typically used in acute or emergency settings.¹³

Advanced non-surgical approaches

Cryoablation

Cryoablation, called cryosurgery, destroys the misdirected eyelashes and its roots using extremely cold gas. In some cases, it is paired with eyelid splitting, where the provider cuts eyelids to expose the hair follicles and then uses cryoablation. The success rates of the procedure range from 34 to 56% with one session and from 70 to 90% after two sessions. Although effective, cryoablation can cause complications like eyelid scarring or changes in skin color.^{5, 9,14}

Electrolysis

Electrolysis destroys the misdirected eyelashes and their roots using an electric current. The procedure involves inserting a fine needle into the eyelash root and passing an electrical or radiofrequency current through it to destroy the follicle. Although effective, removing multiple eyelashes causes complications like eyelid scarring and secondary deformities. This technique has high recurrence rates of 60%.^{5, 9,14}

A study found that 16 out of 24 patients who underwent electrolysis treatment using 55-μm ultrafine needles had a satisfactory outcome within one session, 5 patients responded well after two sessions, and 3 responded well after 3 sessions. All eyelids healed within 2 weeks after treatment without any scarring but with faint hypopigmentation and mild notching of the eyelid in a few cases.¹⁵

Radiofrequency ablation

Radiofrequency ablation is a very effective treatment with fewer complications. It is performed similarly to bipolar electrolysis but has better success rates and causes less eyelid scarring. The radiofrequency waves selectively destroy the follicles and approximately 0.5mm of adjacent tissue. When the bulb is destroyed, the hair can be easily removed using forceps.^{5, 9,14}

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. The complications included short-lived oedema, erythema or hematoma, and thickening of the lid margin.¹⁶

Laser ablation

Laser ablation is used to treat minor trichiasis. In cases of severe trichiasis with numerous affected lashes, surgeons use laser ablation as an adjunctive therapy to surgical procedures for improved outcomes. Argon laser was the first type of laser used in treating trichiasis, with success rates ranging from 37% to 59% with one session and 100% with two or more sessions. Other types of lasers used include carbon dioxide lasers, infrared diode lasers, ruby lasers, and Nd: YAG lasers (neodymium-doped yttrium aluminum garnet lasers). It produces less inflammation and a lower complication rate compared to electrolysis and cryotherapy.^{5, 9,14}

Preventive strategies and long-term management

Genetic factors contributing to trichiasis cannot be prevented, but the following preventive strategies might help to minimise the risk of trichiasis:

• Regularly cleaning the eyelids reduces the risk of infections and irritation contributing to trichiasis.
• Promptly undergoing treatment for underlying eye conditions such as blepharitis, conjunctivitis, and other eyelid inflammations to avoid further complications
• Protecting the eye from physical, chemical, or thermal injuries during activities that have the risk of injury
• Regular eye checkups can help to detect early signs of eyelash misdirection before complications arise
• Promptly seek medical attention or an eye care professional when suspecting the symptoms of eye irritation or discomfort
• Educating individuals about self-care techniques, symptom recognition, and early intervention strategies to improve long-term outcomes and reduce complications¹⁷

Summary

Trichiasis is an eye condition where eyelashes grow toward the eye, causing irritation and discomfort. If left untreated, trichiasis can cause complications such as corneal damage, vision loss, or permanent blindness. Slit-lamp examination and eyelid eversion help in diagnosing trichiasis and its severity. Several non-surgical treatment options are available, providing symptom relief and preventing complications. Non-surgical treatments like eyelash removal, lubricating eye drops, and eyelid taping provide temporary relief. Advanced treatments such as cryoablation, electrolysis, radiofrequency ablation, and laser therapy are effective and provide longer-lasting results by destroying the eyelash follicles. However, the best treatment plan depends on the severity of the condition, the recurrence rate, and the long-term benefits. Individuals with severe trichiasis or who are at risk of developing corneal damage may need other options, such as the surgical procedure to prevent vision loss. Regular eye checkups, early treatment, and patient education are important for effectively managing trichiasis.