Definition

Trichiasis is an abnormal condition of the eyelids wherein the eyelashes grow inward towards the eyes. These misdirected eyelashes can occur across the entire eyelid or be confined to specific areas. Trichiasis affects individuals across all age groups, races, and genders, though it is more prevalent among adults than children. This condition is relatively rare but commonly observed in regions where trachoma, an eye infection caused by the bacterium Chlamydia trachomatis, is endemic.

Cause

Trichiasis can result from changes in eyelid shapes due to recurrent inflammation. Blepharitis, the inflammation of the eyelids, can be caused by various factors such as blockage of the eyelids' oil glands, bacterial infection with Staphylococcus aureus, and infestation by Demodex mites. Additionally, recurrent infections such as trachoma, characterized by redness and pus-like discharge in the eyes, can lead to scar tissue formation on the eyelids, causing them to fold inward.

Other causes of trichiasis include conditions that alter the eyelash growth line, such as trauma, surgical procedures, chemical burns, infections, and autoimmune disorders like pemphigoid or dermatological conditions such as Stevens-Johnson Syndrome. Moreover, trichiasis can stem from distichiasis, where eyelashes grow from really deep locations or in aberrant locations.

In pediatric cases, trichiasis may be preceded by epiblepharon, a congenital condition where the eyelid muscles and skin fold inward. This condition is inherited and predominantly seen in Asian and Hispanic populations.

Risk Factors

Risk factors for trichiasis are categorized into four primary groups: inflammation, infection, trauma, and anatomical anomalies.

• Inflammatory Risk Factors: These include conditions causing eyelid inflammation, such as:
• Blepharitis
• Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS-TEN)
• Ophthalmic herpes zoster
• Acne rosacea
• Atopic keratoconjunctivitis
• Infection Risk Factors: Primarily related to trachoma.
• Trauma Factors: These encompass eyelid injuries and surgical interventions.
• Anatomical Factors: These involve inward-folding eyelids due to chronic or congenital inflammation and misdirected eyelash growth.

Symptoms

Common symptoms of trichiasis include:

• Eye pain
• Foreign body sensation in the eye
• Eye redness and watery eyes
• Visual loss in severe cases

These symptoms arise because the misdirected eyelashes can contact the cornea, the transparent front part of the eye, which is richly innervated. Continuous rubbing of the cornea by the eyelashes can lead to corneal injury, resulting in blurred vision and increased sensitivity to light. In extreme cases, trichiasis can cause blindness.

Diagnosis

The diagnosis of trichiasis is typically made by a doctor through an examination of the eyelids. The primary diagnostic indicator is the presence of inward-growing eyelashes. Additionally, the eyelids may appear inverted, posing a risk factor for trichiasis. During the examination, the doctor will also inspect for scar tissue or eyelashes emerging at the tips of the oil glands.

A direct eye examination may reveal redness, and if the eyelashes have reached the cornea, corneal abrasions may be observed. Visual acuity tests may show decreased vision or even blindness.

In cases where trachoma is suspected, a biopsy of the conjunctival tissue (the transparent membrane covering the sclera and inner eyelid) may be conducted for further analysis. If an autoimmune disease is suspected, laboratory tests might be necessary.

Management

The management of trichiasis is contingent on its underlying causes. If the condition is preceded by inflammation, addressing the inflammation is crucial. For instance, treating trachoma with antibiotics can reduce the incidence of trichiasis. If the cause is an autoimmune disease such as pemphigoid or dermatological conditions like Stevens-Johnson Syndrome (SJS-TEN), managing the primary disease is essential to reduce the cases of trichiasis.

Lubricants, such as artificial tears, can alleviate eye discomfort. Epilation, or the removal of ingrown eyelashes, may also be considered.

Surgical intervention is the primary treatment for trichiasis, with various treatment goals depending on the individual cases. One approach is to destroy the hair follicles of the misdirected eyelashes, which can be achieved through electrolysis or cryosurgery (freezing the tissues). Cryosurgery is often preferred due to its reduced pain compared to electrolysis. Radiofrequency ablation, which minimizes scar tissue formation, and laser surgery are other surgical options.

If the eyelids are inverted or scar tissue is present, surgery aims to reposition the eyelashes and hair follicles. In cases of recurrent trichiasis, surgical intervention might involve a graft (skin transplant) from the oral mucosa to prevent scar tissue formation. These treatment options should be discussed with doctors to determine the most appropriate approach based on the patient's condition.

Complications

Complications of trichiasis are primarily related to visual function. Inward-growing eyelashes can cause corneal abrasions and infections. Repeated corneal abrasions can lead to scar tissue formation on the cornea, resulting in diminished visual acuity or blindness.

Prevention

Trichiasis can be prevented by addressing risk factors, particularly trachoma infection. Trachoma is transmitted through direct contact, shared towels, and flies that come into contact with the eyes or nose of an infected person. Thus, maintaining facial and ocular hygiene is crucial in preventing trachoma. It is also advisable to use personal towels and facial care items to prevent transmission.

Preventing blepharitis, another risk factor, involves keeping the face, eyebrows, eyelashes, and eyelids clean. This can be achieved by gently cleaning the eyelashes with clean fingers or a cotton bud moistened with warm water and rubbing it for approximately 15 seconds.

While many trauma and anatomical risk factors cannot be prevented, early detection is vital to prevent complications, especially in cases involving inward-folding eyelids. In infants and children, trichiasis often results from inward-folding eyelids, necessitating medical evaluation if this condition is observed.

When to See a Doctor?

If you experience ocular discomfort or a sensation of foreign objects in the eye, coupled with inward-growing eyelashes, it is advisable to seek medical attention. Untreated trichiasis can lead to complications affecting vision. Prompt treatment generally results in quick improvement. Individuals with a history of trichiasis should undergo regular check-ups to detect any recurrence early, thereby reducing the risk of vision-related complications.

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