Trichiasis: Symptoms, Types, Causes and Treatment

Trichiasis is a common yet potentially sight-threatening eyelid condition, where eyelashes grow inward toward the eye rather than outward. This misdirection can cause discomfort, chronic irritation, and even blindness if left untreated. In this article, we’ll explore trichiasis in detail—its symptoms, various types, underlying causes, and current treatment options—drawing on the latest clinical research and expert consensus.

Symptoms of Trichiasis

Trichiasis can often begin subtly, but its symptoms quickly become hard to ignore. Recognizing these early signs is crucial for timely intervention and prevention of further complications. Here, we’ll summarize the most common symptoms and their clinical significance.

Symptom	Description	Complications	Source(s)
Eye Irritation	Persistent discomfort, foreign body sensation	Corneal damage	1, 6
Redness	Inflammation of conjunctiva and eyelids	Chronic inflammation	1, 6
Tearing	Excessive watering due to ocular irritation	Dry eye symptoms	1
Photophobia	Sensitivity to light	Vision impairment	6
Pain	Especially when blinking or with lash contact	Corneal ulceration	6

Table 1: Key Symptoms

Eye Discomfort and Foreign Body Sensation

The hallmark of trichiasis is a constant feeling that something is in the eye. This sensation is caused by lashes rubbing against the sensitive corneal and conjunctival surfaces with each blink, leading to persistent irritation and pain 6.

Redness and Inflammation

Chronic inflammation is common due to repeated trauma from misdirected lashes. Over time, the conjunctiva and eyelids may appear red and swollen. This can also lead to more serious complications if untreated, such as conjunctival scarring and secondary infections 1, 6.

Tearing and Dry Eye

Though excessive tearing is a classic symptom, paradoxically, patients may also report dry eye sensations. This is often due to the disrupted tear film and ocular surface damage, sometimes detected using lissamine green staining in clinical exams 1.

Photophobia and Pain

Light sensitivity develops as the cornea becomes more inflamed or ulcerated. Pain can range from mild to severe, especially if the cornea is scratched repeatedly or if secondary infection occurs 6.

Types of Trichiasis

Trichiasis isn’t a one-size-fits-all disorder. Understanding its different types is critical for accurate diagnosis and effective management. Here we outline the main clinical variants encountered in practice.

Type	Description	Eyelid Involvement	Source(s)
Acquired	Secondary to inflammation or scarring	Upper/lower lids	2, 6
Congenital	Rare, present from birth	Usually lower lid	6
Misdirected	Lashes grow abnormally, not due to entropion	Any lid	2
Entropic	Associated with inward-turning eyelid (entropion)	Typically upper lid	2, 6
Metaplastic	Lashes transformed due to scarring/chronic disease	Often upper lid	2

Table 2: Types of Trichiasis

Acquired Trichiasis

Most cases are acquired and develop after chronic eyelid inflammation, trauma, or following repeated infections such as trachoma. Acquired trichiasis can affect both upper and lower lids and is commonly seen in adults 6.

Congenital Trichiasis

This rare type is present from birth and typically involves only a few lashes, usually on the lower lid. Unlike acquired forms, congenital trichiasis is not due to scarring or inflammation 6.

Misdirected and Metaplastic Lashes

• Misdirected trichiasis occurs when lashes grow in the wrong direction, but the eyelid margin itself remains in a normal position. This is often seen in trachomatous trichiasis, where not all cases are due to entropion (inward turning of the lid) 2.
• Metaplastic lashes are abnormal, coarse lashes that develop after chronic scarring, often in response to repeated inflammation from trachoma or other cicatrizing diseases 2.

Entropic Trichiasis

This type is associated with entropion, where the eyelid turns inward, causing the lashes to rub against the eye. While common in trachomatous disease, not all trichiasis cases involve clinically evident entropion 2.

Causes of Trichiasis

Trichiasis arises from a variety of underlying processes, most commonly involving chronic inflammation and scarring. Here we break down the key causative factors, both global and local.

Cause	Mechanism	Key Features	Source(s)
Trachoma	Repeated Chlamydia trachomatis infection	Cicatricial scarring	3, 4, 5
Chronic Blepharitis	Lid margin inflammation	Follicle damage	6
Autoimmune Disorders	Inflammation/scarring (e.g., cicatrizing conjunctivitis)	Ocular surface damage	10
Trauma	Physical or chemical injury	Scar formation	10
Other Infections	Bacterial/viral infection leading to scarring	Inflammation	10, 6
Idiopathic	Unknown origin	No clear cause	6

Table 3: Causes of Trichiasis

Trachoma: The Leading Cause Worldwide

Trachomatous trichiasis is the most common cause globally, especially in low-resource settings. It results from repeated infection with Chlamydia trachomatis, leading to chronic conjunctival inflammation, scarring, entropion, and eventually trichiasis and corneal blindness 3, 4, 5. Scarring disrupts the normal alignment of the eyelid and lashes, causing them to turn inward.

• Over eight million people are affected by trachomatous trichiasis worldwide, mainly in rural communities 3.
• The condition progresses from conjunctival scarring to entropion and trichiasis, and, if untreated, to blinding corneal opacification 3, 5.

Chronic Blepharitis and Local Inflammation

Non-trachomatous trichiasis often arises from chronic blepharitis—an inflammation of the eyelid margins. Persistent inflammation damages the hair follicles, resulting in misdirected growth 6.

Autoimmune and Cicatrizing Disorders

Diseases such as mucous membrane pemphigoid or Stevens-Johnson syndrome can cause significant conjunctival scarring, leading to trichiasis, eyelid malposition, and dry eye 10. These cases often require a multidisciplinary approach due to the systemic nature of the disease.

Trauma and Other Infections

Physical injuries (burns, lacerations) or chemical exposure can scar the eyelid margin, causing abnormal lash growth. Similarly, other infectious agents can induce chronic inflammation and subsequent scarring 10.

Idiopathic Cases

In some instances, no clear cause can be identified, and trichiasis is deemed idiopathic. Such cases may be isolated or part of broader eyelid margin pathology 6.

Treatment of Trichiasis

Managing trichiasis aims to relieve symptoms, prevent corneal damage, and preserve vision. A variety of medical and surgical treatments are available, each suited for different clinical scenarios.

Treatment	Main Approach	Effectiveness/Outcomes	Source(s)
Epilation	Mechanical removal of lashes	Temporary, recurrences common	6, 8
Lubricants/Contact Lenses	Symptomatic relief	Adjunctive, not curative	6
Electrolysis/Cryotherapy	Destruction of lash follicles	Higher success, some recurrence	6, 7
Laser Ablation	Precise removal of follicles	Good results, needs equipment	6
Surgical Correction	Rotation/realignment of eyelid margin	Most effective, prevents blindness	8, 9
Antibiotics (e.g., azithromycin)	Adjunct post-surgery	May reduce recurrence	8
Oral Doxycycline	Post-surgical anti-inflammatory	No added benefit	11

Table 4: Treatment Options

Conservative Management

Epilation—removal of misdirected lashes with forceps—is a common first-line approach, especially for mild cases. However, lashes usually regrow within weeks, necessitating repeated procedures 6, 8.

Lubricating eye drops and bandage contact lenses can provide symptomatic relief by reducing friction between lashes and the ocular surface but do not address the underlying problem 6.

Destructive Procedures

• Electrolysis and radiofrequency ablation involve destroying the lash follicles, offering longer-term relief but with some risk of recurrence or scarring 6.
• Cryotherapy uses freezing to ablate follicles and has proven effective, especially for recurrent or multiple aberrant lashes. Complications are generally rare when performed properly 6, 7.

Laser Treatments

Laser ablation offers a precise way to eliminate problematic follicles with minimal tissue damage. This option may be limited by availability and cost 6.

Surgical Management

Surgical intervention is the definitive treatment, especially for moderate to severe or recurrent trichiasis. The primary goal is to realign the eyelid margin and prevent lashes from contacting the globe.

• Tarsal rotation procedures (e.g., bilamellar or posterior lamellar tarsal rotation) are the gold standard for trachomatous trichiasis 8, 9. These surgeries rotate the lash-bearing portion of the eyelid outward, away from the eye.
• Bilamellar rotation and posterior lamellar rotation have both been widely used. Recent studies show posterior lamellar tarsal rotation (PLTR) is more effective and has lower recurrence rates than bilamellar rotation (BLTR) 9.

Other surgical approaches, such as conjunctival grafting or mucous membrane transplantation, are reserved for severe cases with significant scarring or surface disease 10.

Adjunctive and Preventive Strategies

• Antibiotics like azithromycin are recommended post-operatively, especially in trachoma-endemic areas, to reduce the risk of recurrence and secondary infection 8.
• Oral doxycycline was investigated for its anti-inflammatory properties but showed no benefit in reducing post-surgical recurrence 11.
• Comprehensive management often includes treating underlying inflammation with steroids or immunosuppressive agents in cases secondary to autoimmune disease 10.

Community and Programmatic Considerations

Surgery can be delivered effectively by ophthalmologists or trained eye care assistants in both clinical and community settings. Community-based surgical programs increase access and uptake without compromising outcomes 8.

Conclusion

Trichiasis is a significant cause of ocular morbidity and blindness worldwide, particularly in areas affected by trachoma. Early recognition and tailored treatment are essential to prevent sight-threatening complications.

Key Takeaways:

• Symptoms: Persistent eye irritation, redness, tearing, pain, and photophobia are classic signs.
• Types: Trichiasis can be acquired, congenital, misdirected, entropic, or metaplastic—each with unique clinical features.
• Causes: Chronic infection (especially trachoma), inflammation, autoimmune disease, trauma, and sometimes unknown reasons can lead to trichiasis.
• Treatment: While epilation and conservative measures offer temporary relief, definitive management often requires destructive procedures or surgery. Surgical correction (especially tarsal rotation) is the most effective option for preventing recurrence and blindness.

By understanding the varied presentations and best-practice interventions for trichiasis, healthcare providers and patients alike can work together to preserve sight and improve quality of life—even in resource-limited settings.