hapter 73

Eyelid Abnormalities: Ectropion, Entropion,

Trichiasis
KENNETH V. CAHILL and MARCOS T. DOXANAS
Main Menu Table Of Contents
ECTROPION
ENTROPION
TRICHIASIS
REFERENCES

Numerous procedures have been described for the correction of lower

eyelid abnormalities. These procedures are a reflection of the gradual
evolution of operative approaches to the alleviation of underlying
anatomic abnormalities. No longer are scarring procedures advocated.
Specific anatomic defects are identified and rectified.
Thorough knowledge of eyelid anatomy is essential for the
appreciation of the etiology and surgical intervention of lower eyelid
abnormalities. The eyelid can be conceptionalized to consist of an
anterior and posterior lamella. The anterior lamella consists of the
skin and orbicularis muscle. The thin delicate skin of the eyelid lacks
the connective tissue, fat, and pilosebaceous apparatus of the dermis
that would reduce eyelid mobility. The orbicularis muscle is
categorized as either orbital or palpebral portions based on its
association with adjacent anatomic structures. The orbital orbicularis
muscle overlies the orbital rim. The palpebral orbicularis muscle is
further classified as preseptal or pretarsal based on the proximity of
orbital septum or tarsus, respectively. At the eyelid margin a strip of
orbicularis muscle, the muscle of Riolan, is directly associated with the
eyelashes. This is responsible for the darker coloration of the slightly
depressed midsection of the lid margin commonly referred to as the
gray line.1
The posterior lamella consists of the eyelid retractor, the tarsus, and
the conjunctiva. Hawes and Dortzbach2 reviewed and highlighted
lower eyelid anatomy, specifically the lower eyelid retractor (Fig. 1).
The lower eyelid is analogous to the upper eyelid; the main variation
is the eyelid retractor system. The upper eyelid has a distinct eyelid
retractor, the levator muscle, to enhance upper eyelid mobility. The
lower eyelid does not have a specialized eyelid retractor. The lower
eyelid retractor system originates as a fascial extension of the inferior
rectus muscle (capsulopalpebral head). This fascial system splits to
encapsulate the inferior oblique muscle and then reunites to form a
dense fibrous sheet (capsulopalpebral fascia) to insert onto the
inferior tarsal border. The inferior tarsal muscle is a smooth muscle
analogous to the superior tarsal muscle (Mller's muscle) of the upper
eyelid. This muscle originates in the inferior fornical area and extends
toward the inferior tarsal border but does not insert on the tarsal
border as its counterpart in the upper eyelid does. The inferior tarsal
muscle receives sympathetic innervation, and interruption of its
innervation will result in a slightly elevated position of the lower eyelid

Search

margin as observed in Horner's syndrome. Otherwise, the inferior

tarsal muscle has little pathologic significance.

Fig. 1. Sagittal section of the lower eyelid. The anterior lamella

consists of the skin and orbicularis muscle (o). The posterior lamella
consists of the conjunctiva, capsulopalpebral fascia (CPF), inferior
tarsal muscle (ITM), and tarsus (T). F, fornix; Te, Tenon's capsule;
SO, septum orbitale; l, Lockwood's ligament; IO, inferior oblique
muscle; CPH, capsulopalpebral head; IR, inferior rectus; OF, orbital
fat.(From Hawes JJ, Dortzbach RK: The microscopic anatomy of the
eyelid retractors. Arch Ophthalmol 100:1313,
1982.)

The tarsus provides the primary support or foundation for the eyelids.
Although degeneration of the tarsus may promote eyelid laxity,3 the
principle focus of weakness of the eyelids is at the lateral and medial
canthal tendons.4 Jones and Wobig5 described the medial canthal
tendon with a prominent anterior component firmly connecting the
medial canthal angle to the maxillary process of the frontal bone. The
posterior limb of the medial canthal tendon provides deep support to
the posterior lacrimal crest. Anderson6 also emphasized the role of a
superior branch of the medial canthal tendon to support the canthal
angle. Gioia and coworkers7 have provided a clear description of
lateral canthal anatomy. The lateral canthal tendon has contributions
from the lateral aspects of the tarsus and the preseptal and pretarsal
orbicularis muscle; these insert on the inner aspect of the lateral
orbital rim at Whitnall's (lateral orbital) tubercle. The posterior deep
insertion of the lateral canthal tendon allows the lateral aspect of the
eyelids to approximate the globe.
Ectropion and entropion share similar anatomic features. The most
common predisposing anatomic factors for lower lid malpositions are
horizontal eyelid laxity and weakness or defects of the lower lid
retractors. The general weakness of the eyelid is caused by a
weakness of the medial and lateral canthal tendons, permitting
horizontal eyelid laxity.4 As such, it is best to consider lower eyelid
laxity as resulting from laxity of the tarsoligamentous sling or support
for the eyelid. The anatomic weakness can be demonstrated by the
snap test. Downward retraction is exerted on the lower lid, pulling it
away from the globe. On relapse, the lower lid should snap back
against the globe spontaneously. Failure of the eyelid to snap back
against the globe with a single blink indicates excessive laxity of the
tarsoligamentous sling.
The lower eyelid retractors may be weakened or may actually become
disinserted from the inferior tarsal border. Weakness or defect of the
lower eyelid retractors creates in an instability of the inferior tarsal
border that is manifested clinically as ectropion or entropion.
In addition, enophthalmos is associated with both ectropion and

entropion. However, the role of enophthalmos as a pathophysiologic

feature of lower eyelid malpositions has been grossly
overstated.8,9 Enophthalmos may secondarily reduce tarsal stability by
exaggerating horizontal lid laxity. It reduces the tension exerted on
the eyelids by retraction of the globe and soft tissues. The normal arc
or outward bowing of the eyelids is minimized with the enophthalmic
globe, and eyelid tension is reduced. Retrobulbar injections stabilize
eyelid malpositions by reducing horizontal eyelid laxity. Volume
introduced in the retrobulbar area re-establishes the normal outward
arch, or bowing, of the eyelid.
The development of ectropion and entropion is a reflection of the
relationship between the anterior and the posterior lamellae. The
eyelid position is maintained by an appropriate balance of the anterior
and posterior lamellae. If tractional forces are unbalanced, eyelid
malpositions may manifest as ectropion, entropion, or eyelid
retraction. If traction is produced by the anterior lamella, either by
chronic cicatricial changes or mechanical aberrations, the eyelid
margin is everted away from the globe. This most commonly results
from mild solar-induced changes or following surgical procedures or
trauma of the eyelid, which produce a shortening or scarring of the
skin and underlying orbicularis muscle.
Involutional entropion is more complex because of the multitude of
factors producing this abnormality. The tarsal instability of entropic
lids is due to horizontal eyelid laxity and loss of support of the lower
eyelid retractors.10 The orbicularis muscle dynamics also assume a
prominent pathophysiologic role in the production of entropion. In
entropic eyelids, the preseptal orbicularis muscle overrides the
pretarsal orbicularis muscle, which rolls the superior border of the
tarsus internally. This is differentiated from spastic entropion, which is
theoretically due to a spasm of Riolan's muscle. However, the primary
differentiating feature of spastic entropion is a specific precipitating
etiologic factor, such as recent eye surgery, eyelid edema, or ocular
inflammation with secondary eyelid edema. An appreciation of the
multiple etiologic causes of entropion has resulted in the evolution of
combined approaches to correcting the various anatomic
abnormalities and stabilizing the tarsus and orbicularis muscle.1114
This chapter is divided into three sections that discuss eyelid
abnormalities. These include ectropion, entropion, and trichiasis.
Sections on ectropion and entropion are further divided according to
the underlying etiology of the eyelid malposition. Specific surgical
approaches are highlighted in each section.
Back to Top

ECTROPION

Ectropion is an eversion of the eyelid away from the globe. It is

classified according to its anatomic features as involutional, cicatricial,
tarsal, congenital, or paralytic (Fig. 2). Surgical approaches can be
directed toward the underlying etiologic factors.
Fig. 2. Clinical presentation of ectropion. A. Medial
ectropion. B. Generalized ectropion with retraction of eyelid. C. Tarsal
ectropion, with total eversion of tarsus. D. Cicatricial ectropion
developing following orbital floor
exploration.

INVOLUTIONAL ECTROPION
Involutional ectropion evolves slowly secondary to eyelid laxity and
tractional forces of the anterior lamella. This may result from mild
cicatricial changes of the skin or orbicularis muscle or a mechanical or
gravitational eversion of the eyelid margin. There is generally a
progression from eyelid laxity to punctal ectropion, medial ectropion,
and then generalized ectropion. If the punctum is slightly everted
from the lacus lacrimalis, tears cannot effectively drain into the
canalicular system. In addition, the siphoning effect of the lacrimal
excretory system, as demonstrated by Doane,15 is not generated if the
lacrimal puncta do not occlude on lid closure and do not approximate
the lacus lacrimalis. With the puncta approximated, attempted eyelid
opening creates negative pressure within the lacrimal excretory
system. When the puncta initially separate, the negative pressure
siphons tears from the lacus lacrimalis. Also, horizontal eyelid laxity
may produce a flaccid canalicular syndrome or poor lacrimal pump, so
that tears are not siphoned from the lacus lacrimalis.16 This tearing
malfunction is aggravated by the chronic ectropion and eyelid
retraction that produce lagophthalmos and secondary exposure
keratopathy. With time, the exposed conjunctive thickens and
keratinizes, producing further ocular irritation.
Mild medial ectropion is manifested by rotation of the punctum away
from the ocular surface causing mild tearing. This can be treated with
a one- or two-snip punctal plasty, establishing anatomic continuity
between the canalicular system and lacus lacrimalis in the medial
canthal angle. This procedure is performed by opening the punctum
and vertical canaliculus with a single snip of a sharp iris or Westcott
scissors or by excising a very thin V wedge (two snips). This
procedure may also be helpful after ectropion repairs if a mild
eversion of the puncta remains. This can be performed as an office
procedure. A cotton-tipped applicator saturated with 4% lidocaine
solution held over the punctum and adjacent palpebral conjunctiva
usually provides adequate anesthesia. If it does not, a 30-gauge
hypodermic needle can be passed through the punctum and vertical
canaliculus so that 1% or 2% lidocaine can be infiltrated into the
pericanalicular tissue. Medial ectropion, when more severe, may
require surgical intervention. Surgery directed at the lateral canthal
angle, as discussed later in this chapter, does not fully alleviate medial
lid malpositions, and this approach is not universally successful in
restoring eyelid position. Removal of a conjunctival and lower lid
retractor spindle may be necessary. The spindle is directly beneath
the tarsus with its long axis directly parallel to the eyelid margin (Fig.
3). The conjunctival retractor spindle should measure no more than 5

Back to Top

ENTROPION
Entropion is the inward turning of the eyelid. It is most commonly
seen as an aging phenomenon produced by attenuation or
detachment of the lower eyelid retractor and associated with
horizontal eyelid laxity. Forceful eyelid closure causes the preseptal
orbicularis muscle to override the tarsus, resulting in the inward
turning of the eyelid. Entropion may be classified as involutional
(spastic), cicatricial, and congenital (Fig. 13).
Fig. 13. Entropion. A. Involution entropion. B. Cicatricial entropion.
Note the obliteration of the inferior fornix.

INVOLUTIONAL ENTROPION
A multitude of surgical procedures have been advocated for the
correction of entropion, reflecting the various pathophysiologic
features of the disorder (Table 1). Combination procedures are now
used to specifically attack each anatomic aberration.811 The correction
of a single anatomic feature of entropion results in a less than
predictable surgical outcome. Combination procedures are now used
to specifically attack each of the anatomic aberrations in an individual
patient.1114

TABLE 1. Previously Advocated Procedures for Involutional Entropion

Corrective Measure
Vertical skin-muscle shortening

Procedure
Ziegler cautery

Horizontal tightening of lid at lower tarsal border Fox procedure

Schimek suture
Bick procedure
Barricading of orbicularis fibers

Wies procedure
Jones procedure

Tightening of orbicularis fibers

Wheeler procedure

Repair or tightening of inferior retractors (CPF)

Jones procedure

CPF, capsulopalpebral fascia.

Internal scarring procedures to stabilize the eyelids have been very

helpful in minimizing ocular irritations. Quickert and
Rathbun48 advocated suture repair for entropion (Fig. 14A, suture a),

and Iliff49 later modified this procedure (see Fig. 14A, suture b). The
placement of horizontal mattress sutures from the inferior fornix to
exit the skin directly beneath the eyelashes (as in the Iliff
modification) enhances the everting forces of the eyelid. This
procedure is easy to perform and serves as an excellent temporizing
procedure until a more definitive procedure is possible. In eyelids with
a minimal degree of horizontal lid laxity, such treatment may suffice
indefinitely. In eyelids with a greater degree of horizontal laxity, care
must be taken not to use too much eversion effect with the Iliff
modification, or an immediate ectropion can be created. Also, in
eyelids with spastic entropion, such as following ocular surgery or
ocular irritations, this procedure may stabilize the lid until the
irritating focus has resolved.

Fig. 14. Entropion suture repair. A. Quickert-Rathbun suture placed

directly beneath the tarsus (a); Iliff modification in which the doublearmed suture is placed from the inferior fornix to the skin in the
infralash location (b). B. Location of the three
everting sutures.

The type of suture material used for Quickert-Rathbun sutures is not

as important as the tension with which the sutures are tied. The
suture tension can lead to focal tissue necrosis and scarring, giving
Quickert-Rathbun sutures the potential for some permanent
correction. Double-armed sutures provide the safety of making all
suture passes away from the globe. 4-0 chromic gut sutures generally
remain in place for 2 weeks, which is long enough to provide the
necessary effect without the need for scheduled suture removal. Silk
and polyglactin sutures will last longer but can lead to tissue
infections resulting from the duration and their polyfilament structure.
Nylon sutures are less likely to cause infection but are sometimes
uncomfortable for the patient because of their stiffness.
Patients with entropion usually require a combined procedure to
eliminate horizontal lid laxity and repair the lower lid retractors.50 No
procedure addressing an isolated anatomic feature has been
universally successful in alleviating entropion. Isolated repair of lower
lid retractor defects (analogous to repair of the levator aponeurosis in
ptosis procedures) often results in lower lid retraction or actual
ectropion.5153 This is due to the preexisting significant horizontal
eyelid laxity, which again promotes an unstable eyelid margin. The
tendency is further exacerbated if the lower eyelid retractor is
inadvertently advanced onto the tarsus. If horizontal eyelid laxity is
evident, a tarsal strip procedure should be performed, as discussed
for the treatment of ectropion (see Fig. 6). Various suture placements
through the lateral tarsal strip as in the correction of ectropion or
entropion described by McCord and coworkers54 are not relevant. The
goal of the tarsal strip procedure is to firmly affix the tarsus to the
inner aspect of the lateral orbital rim. This is best accomplished by
using two interrupted 5-0 nonabsorbable monofilament sutures,
although some surgeons prefer 4-0 or 5-0 polyglactin. The sutures

should be tied on the anterior tarsal surface; attempts to bury the

knots beneath the tarsus will prevent adequate tarsal approximation
to the inner aspect of the lateral orbital rim.
The preferred procedure for involutional entropion thus consists of a
lateral tarsal strip and repair of the lower eyelid retractors. Isolated
lower lid retractor repairs are inappropriatean invitation for
additional procedures. A lateral canthal incision is created and
extended in an infralash position, and a skin muscle flap is elevated to
expose the orbital septum (Fig. 15B and C). The orbital septum is
penetrated and orbital fat identified and retracted inferiorly. Directly
beneath the orbital fat is the white fibrous appearing lower eyelid
retractor. This is directly analogous to the location of the levator
aponeurosis in the upper eyelid. The lower eyelid retractor is normally
attached to the inferior tarsal border; however, in entropion, a defect
is generally apparent between the lower eyelid retractor and the
tarsus. The superior edge of lower eyelid retractor system is identified
and carefully reapproximated to the inferior tarsal border (see Fig.
15D and E). Care should be taken not to advance the lower eyelid
retractor to prevent lower eyelid retraction or actual ectropion. A
lateral tarsal strip procedure as described in the section on ectropion
should then be performed to tighten the eyelid horizontally (see Fig.
6). Herniated orbital fat is an important etiologic factor in promoting
orbicularis muscle overriding and creating tarsal instability. Redundant
orbital fat is carefully removed. To finalize the procedure, redundant
skin is draped over the lid margin and is excised as in a lower lid
blepharoplasty. Skin removal should be minimal to prevent ectropion.
It is this combination type of procedure that produces minimal
recurrences and has been extremely successful in managing
entropion.

Fig. 15. Lower lid retractor repair for entropion. A. Lower lid retractor
defect contributes to tarsal instability. Note the failure of attachment
of the lower eyelid retractor to the inferior tarsal border. B to C. A
skin-muscle flap is elevated and the orbital septum penetrated to
identify the lower eyelid retractor. D to E. The lower eyelid retractor
is attached to the inferior tarsal border with interrupted
nonabsorbable sutures. F. Final skin closure.

The Weis (transverse tarsotomy) procedure has also been advocated

for the correction of entropion. This procedure everts the lid margin
and produces an anatomic barrier that prevents preseptal orbicularis
muscle override and secondary tarsal rotation (Fig. 16). It has been
advocated for involutional entropion but is best suited for patients
with varying degrees of cicatricial entropion. The Weis procedure has

been called the two-snip procedure and is relatively easy to perform.

A stab incision is created through the full thickness of the lid at the
inferior aspect of the tarsus approximately 3 mm from the eyelid
margin (Fig. 16A). A sharp iris scissors is used to extend the fullthickness lid incision nasally and temporally (hence the two-snip
procedure) (see Fig. 16B). The short vertical height of the tarsus of
the lower eyelid,55 especially in patients with cicatricial entropion,
makes the incision of the tarsus challenging. An alternative method of
creating this full-thickness horizontal eyelid incision is to make partial
thickness lid incisions with a number 15 blade through skin and
orbicularis muscle externally and conjunctiva and tarsal plate
internally. Each of these incisions is placed 3 mm below the lid
margin. Any remaining tissue can be cut with scissors. Ideally, the
incision is through the inferior portion of the tarsus; however, this
may be difficult and the incision may occur just below the inferior
border of the tarsus. As such, the procedure may be better described
as a transverse blepharotomy. Rotation of the tarsus is accomplished
by placing horizontal mattress sutures (5-0 chromic) originating from
the conjunctiva and lower eyelid retractor, then extending to an infralash position (seeFig. 16C). Tying these sutures will evert the eyelid
margin and also stabilize the orbicularis muscle. Lance and
Wilkins14 evaluated patients treated with a Weis procedure alone and
found the recurrence rate to be 11%. However, when a lateral canthal
tightening procedure was added, no recurrences were encountered.
Thus, if the Weis procedure is used to treat involutional or cicatricial
entropion with horizontal laxity, it is best coupled with a tarsal strip
procedure to further stabilize the eyelid margin.

Fig. 16. Transverse tarsotomy (Weis) procedure. A. A lower eyelid

crease incision is made and (B) extended to full thickness of the
lower eyelid. C. Double-armed mattress sutures approximate the
conjunctiva and lower lid retractor to the orbicularis muscle and skin,
effectively everting the eyelid margin. (Soll DB: Entropion and
ectropion. In Soll DB [ed]: Management of Complications in
Ophthalmic Plastic Surgery. Birmingham, AL: Aesculapius Press,
1976.)

CICATRICIAL ENTROPION
Cicatricial entropion presents a surgical challenge because of
underlying pathologic changes of the eyelid and the associated
features of trichiasis, distichiasis, and epidermalization of the eyelid
margin. This condition results when contraction of the posterior
lamella of the eyelid draws the eyelid margin to the globe. It may
result from chemical or thermal injury, trachoma, chronic allergies, or
ocular medications. In addition, conjunctival cicatricial changes may

result in mucous membrane disorders such as Stevens-Johnson

syndrome and ocular cicatricial pemphigoid. Conjunctival cicatrization
destroys the lacrimal gland ductules and meibomian gland orifices,
severely reducing the aqueous and oily constituents of the tear film.
Unfortunately, the progressive nature of ocular pemphigoid may
present continued medical and surgical challenges. Medical
management with immunosuppressive agents such as
diaminodiphenylsulfone (Dapsone), azathioprine (Imuran), or
cyclophosphamide (Cytoxan) should be attempted before surgical
intervention.5658 Severe side effects of these immunosuppressive
agents necessitate cautionary use in older patients, and these
patients should be monitored by an oncologist, hematologist, or
rheumatologist. Subconjunctival injections of mitomycin C have been
reported as a means of arresting ocular pemphigoid,59 but these
results are preliminary. Eyelid or ocular surgery may aggravate ocular
cicatricial pemphigoid and convert a chronic form to an acute form,
worsening conjunctival shrinkage. Mitomycin C has been reported as a
useful adjunct in surgery for cicatricial entropion to prevent additional
scar tissue formation.60Standards for its use in these cases have not
yet been established.
Mild to moderate degrees of cicatricial entropion are best treated with
a Weis (transverse tarsotomy) procedure (see Fig. 16), in which the
tractional forces of the posterior lamella are transferred to the
anterior lamella to promote eversion of the eyelid margin. Unlike
involutional entropion, moderate degrees of cicatricial entropion do
not generally require horizontal lid tightening.
Kersten and coworkers61 re-evaluated the use of tarsotomy with
rotational sutures, for mild to moderate degrees of cicatricial
entropion (Fig. 17). This procedure consists of fracturing the tarsus
approximately 2 mm below the eyelid margin. Double-armed sutures
are passed from the tarsus of the inferior edge of incision, and then
passed through the orbicularis muscle to exit the skin in an infralash
position. Tying these sutures everts the eyelid margin. These authors
reported a 94% success with a minimum follow-up period of 6
months.

Fig. 17. Transverse tarsotomy and lid margin rotation. A. Fullthickness incision of the tarsus approximately 2 mm inferior to the
eyelid margin. B. Placement of horizontal mattress everting sutures
from the inferior tarsus to exit the skin in the infralash
position. C. Final everted eyelid position. (From Kersten RC, Kleiner
FP, Kulwin DR: Tarsotomy for the treatment of cicatricial entropion
with trichiasis. Arch Ophthalmol 110:714,
1992.)

Severe posterior lamella contracture with obliteration of the inferior

fornix requires lengthening of the posterior lamella by grafting. Donor
materials should provide a mucous membrane and a rigid supporting
structure; possible materials are (1) autogenous tarsus and

conjunctival (2) nasochondral mucosa, (3) hard palate, and (4) fullthickness buccal mucous membrane and ear cartilage. The use of
donor sclera from eye banks has been advocated, but it produces a
chronic inflammatory response and is not lined by conjunctiva,
limiting the utility of scleral grafts.62,63 In the lower lid, the composite
graft is placed between the inferior border and recessed eyelid
retractor and conjunctiva (Fig. 18). Attempts to place the graft in the
midaspect of the tarsus may be difficult secondary to contraction and
shortening of the tarsus. Contraction of the tarsus creates technical
difficulties in incising the tarsus and placing the graft within the
divided tarsal plate. Ear cartilage or scleral grafts can be used, but
these are most effective if they are lined with mucous membrane.

Fig. 18. Cicatricial entropion lower eyelid. A. The tarsus is incised and
recessed. (If excessive contracture occurs and the lower lid retractors
may be recessed from the inferior tarsal border.) B and C. The graft
is sutured between the recessed tarsal margins, everting the eyelid to
its normal position.

Worldwide, upper eyelid entropion is most often encountered with

trachoma; however, this is rare in the United States. Modifications of
lower lid procedures are necessary because of gravitational forces and
the length of the tarsus. Mild degrees of cicatricial entropion may be
treated with a Weis procedure as in the lower lid. The tarsus is
fractured across its horizontal dimension about 4 mm from the eyelid
margin, and sutures are used to rotate the lid margin away from the
globe. A modified Tenzel64 tarsal trough procedure may also be used
to rotate the tarsus; this is a variation of the Weis procedure in which
a full-thickness tarsal incision is avoided (Fig. 19). Closure of the
tarsal trough will evert the lid margin from the globe. Additional
everting forces are induced by the formation of a lower eyelid crease
about 4 to 5 mm above the lid margin and the removal of skin and
muscle, in essence shortening the anterior lamella. A relaxing incision
of the eyelid margin at the gray line, approximately 3 mm in depth,
will further evert the ciliary portion of the eyelid margin.

Fig. 19. Tenzel tarsal trough procedure. A. A low eyelid crease

incision is formed and redundant skin is excised to increase everting
forces. A lid margin relaxing incision at the gray line approximately 3
mm in depth will permit eyelid rotation. B. A tarsal wedge is excised
and suture approximation (C) will evert the eyelid
margin.

Reacher and coworkers65 evaluated the efficacy of various surgical

procedures in the management of trachomatous upper eyelid
entropion. For mild to moderate degrees of entropion and trichiasis,
the transverse tarsotomy (Weis) procedure was the most effective.
Electrolysis and cryotherapy were best used to remove individual
recurrent lashes. Initial cryotherapy was associated with a 21%

Back to Top

TRICHIASIS
The eyelid margin is best viewed as a transition zone between the
eyelid skin and palpebral conjunctiva. The anterior half of the eyelid
margin is the ciliary portion, with eyelashes directed anteriorly away
from the globe. The slight indentation or groove in the central aspect
of the eyelid margin is the sulcus intermarginalis of Graefe, more
commonly known as the gray line. The posterior half of the eyelid
margin is the tarsal portion; the meibomian gland orifices are
visualized in the central aspect of this half of the eyelid margin. The
meibomian glands are unique in that they do not have a pilar
apparatus associated with the sebaceous unit.
Trichiasis is an acquired condition in which eyelashes are misdirected
posteriorly toward the conjunctiva or cornea. If contact is made with
the conjunctiva, a foreign body sensation and localized conjunctival
vascular injection result. Corneal involvement produces pain and
photophobia, generally correlating with the degree of epithelial
involvement. The etiology of trichiasis may be obvious following
trauma or surgical interruption of the eyelid margin. However, chronic
inflammatory conditions, ranging from blepharitis and chalazion to
conjunctival cicatricial disorders such as ocular pemphigoid or
Stevens-Johnson syndrome, also frequently result in trichiasis.
Scarring conditions of the conjunctiva produce a particularly
frustrating combination of features: entropion, trichiasis, distichiasis,
and epidermalization of the eyelid margin. Trichiasis is simply a
misdirection of lashes toward the globe. In distichiasis, lashes or hairs
emanate from the meibomian orifices. Anderson and Harvey71 have
histologically evaluated congenital and acquired distichiasis and have
identified pilar units associated with the meibomian glands; these
authors view this as representing a reversion toward a pilosebaceous
apparatus. A chronic inflammatory stimulus such as chronic cicatricial
pemphigoid, erythema multiforme, chemical injury, trachoma, chronic
blepharitis, and chronic allergies may initiate this regressive
metaplasia of the meibomian glands to produce acquired distichiasis.
Scarring of the posterior lid lamella can lead to a rotation of the ciliary
portion of the lid margin towards the globe. In this situation, it may
appear as if lashes are emanating from the posterior lid margin, but
close examination with the slit lamp will show that the most posterior
lashes are not arising from meibomian gland orifices and are not
distichiasis.
The management of trichiasis can be challenging for both the patient
and the physician. Recalcitrant or recurrent lashes are not unusual,
despite a systematic approach to this condition. Initial consideration
determines the etiology of trichiasis. Trichiasis following interruption
of the lid margin either from trauma or surgical manipulation will have
a corresponding local lash abnormality. These abnormalities are often
avoided with careful approximation and tension-free closure of the
eyelid margin (see Fig. 4). In addition, removal of tumors from the
eyelid margin, such as papillomas and dermal nevi, should employ a
chopping-block type shave biopsy parallel to the surrounding surface
of the skin or lid margin. A shave biopsy extending beyond this plane

would produce a divot at the eyelid margin and would also interrupt
the pilosebaceous apparatus at the anterior lid margin. Trichiasis may
result from scarring around the lashes, producing some posterior
misdirection of the lash. If complete eyelid margin tumor excision is
desired, a full-thickness resection of the eyelid (see Fig. 4) should be
performed.
Epithelialization and dryness of the caruncle,73 progressive
conjunctival inflammation, cicatrization, subepithelial fibrosis, blunting
of the fornices, symblepharon formation, trichiasis, distichiasis, and
entropion characterize the clinical presentation of ocular pemphigoid.
The disease can progress to keratinization or vascularization of the
corneal surface, leading to blindness. The relentlessly progressive
nature of ocular pemphigoid can be interrupted by the institution of
immunosuppressive therapy, after histologic confirmation of the
disorder.5658
The management of trichiasis requires a stepwise approach. The
degree of trichiasis and type of lashes are important in planning
therapy. Localized abnormal lashes generally respond better to the
ablative procedures than does diffuse trichiasis. Electrolysis is best
suited for localized normal sized lashes. Finer lanugo hairs are
generally less responsive to electrical ablative techniques. Extensive
electrolysis may produce scarring of the eyelid margin and secondary
cicatricial changes, complicating later management.
Local anesthesia (2% lidocaine with or without epinephrine) is first
administered, then the lid is everted from the globe and an
electrolysis needle is introduced directly into the lash follicle under
slit-lamp visualization. A useful instrument for electrolysis is the
Prolectro epilator with a power setting of 4. The orientation of the
follicle generally corresponds to the direction of the lash emanating
from the follicle. The electrolysis needle should be advanced into the
full extent of the lash follicle, which is approximately 2.4 mm in the
upper lid and 1.4 mm in the lower lid.72 Current is applied until frothy
bubbles emerge from the lash follicle, which generally requires
approximately 15 to 20 seconds of electrical stimulus. A circular or
rotating motion of the needle around the lash will fully ablate the
follicle. After adequate treatment, the lash is easily removed. Another
effective instrument for electrolysis is the Ellman radiosurgery unit
using the 0.004 wire electrode, which is insulated except for the tip. A
power setting of 2 using the partially rectified current works well.
Again, it is essential that the electrolysis tip penetrate the full extent
of the eyelash follicle so that it can be ablated. The Ellman unit
requires only a few seconds compared with the Prolectro instrument.
The success rate for electrolysis should be 80% to 90% with a single
treatment. Trichiasis recurrences can be retreated with repeat
electrolysis.
Fine lanugo hairs present a challenge for electrolysis. They typically
do not have a large enough follicle to permit the advancement of an
electrolysis needle. It is possible to create a pathway for the
electrolysis needle by first introducing a hypodermic needle. However,
this may not actually pass along the true path of the hair follicle. It is
also possible to use the blended cutting action of the Ellman unit so

that the electrode tip can advance through the tissue to the desired
depth as electrolysis is being performed. Again, this may not follow
the precise path of the hair shaft in its follicle.
In the past, cryotherapy was considered the optimal treatment for
treating trichiasis. The authors have abandoned cryotherapy and now
rely on electrolysis and surgical techniques, because of cryotherapy's
damage to the integrity of adjacent tarsus and lid margin transitional
epithelium. Various techniques of lid splitting in which the cryotherapy
is limited to the affected anterior lid lamella have been proposed but
do not completely eliminate the shortcomings of cryotherapy. For
completeness, the following information is provided regarding
cryotherapy. Sullivan and colleagues74 reported the use of cryotherapy
for trichiasis, and his guidelines are still recognized as surgical
standards. A double freeze-thaw cycle is required for cellular
destruction. This is best accomplished by a rapid freeze to -20C
followed by a slow thaw, which causes cell destruction by cell
membrane rupture and the formation of intracellular crystals. Liquid
nitrogen probes are the most effective means of supplying the rapid
level of freezing necessary for ciliary destruction.
A local anesthetic with epinephrine is administered, and cryotherapy is
delayed until blanching of the eyelids evidences the full
vasoconstriction effect of the injection. Lidocaine may be used, but
bupivacaine offers the advantage of prolonged anesthesia with less
posttreatment pain. The vasoconstriction facilitates adequate eyelid
freezing. A thermocouple is used to monitor tissue temperatures and
to ensure freezing to the -20C level. Care is taken to place the
thermocouple near the offending lash follicle. A cryoprobe is placed on
the tarsal conjunctive, and the lid is elevated from the globe. The
freezing is then initiated, while closely observing the globe to ensure
that the cryoprobe does not inadvertently touch the cornea or the
bulbar conjunctiva. About 30 to 60 seconds are required to obtain a
temperature of -20C. Placement of the cryoprobe on the anterior lid
margin, directed posteriorly, would increase the chance of
complications.75 This placement makes it difficult to adequately control
the posterior extent of the freeze, resulting in potential injury.
Depigmentation of the eyelid is often associated with cryotherapy,
limiting its use in darkly pigmented individuals. Additional
complications include visual loss (secondary to corneal opacification),
corneal ulceration, symblepharon formation, and cellulitis.75 In
addition, the destructive process is not selective; normal lashes are
also destroyed. Anderson and Harvey71 have described a lid-splitting
procedure with selective cryotherapy to the posterior lamella.
Laser ablation of lashes has been advocated76,77 but is best used for a
few scattered lashes in patients with disorders such as ocular
pemphigoid in which production of minimal inflammation is important.
The recommended argon laser settings are a power of 1 watt, a spot
of 50 mm, and duration of 0.2 second using the blue-green
wavelength. The initial laser spot will vaporize a lash; however,
approximately 20 to 30 additional burns are required to destroy the
lash follicle. Bartley and Lowry76 reported success in ablating 59% of
misdirected lashes with a single treatment. The laser beam must
ablate the entire length of the eyelash in its follicle to destroy the

follicle. Creative positioning of the eyelid is necessary to align the

aberrant orientation of trichiasis follicles with an ophthalmic laser
beam. Anesthesia is required for laser lash ablation, just as it is for
electrolysis.
Buccal membrane grafting can be used as a last resort in the
management of recalcitrant trichiasis, distichiasis, and
epidermalization of the eyelid margin. The eyelid margin is split at the
gray line, and the superior 2 to 3 mm of the tarsal portion of the
eyelid is excised (Fig. 22A and B). Contained within this excised tarsus
are the offending lashes and keratinized epithelium. Without buccal
membrane grafting, the area of lid excision would likely scar to create
cicatricial entropion. As such, buccal membrane is grafted onto the
eyelid margin to create nonoffensive eyelid surface (see Fig. 22C).
The graft may be obtained from either the lower lip or lateral portion
of the mouth at the interdental line. If a slight degree of entropion
exists following graft fixation, rotation sutures can be used to
establish appropriate eyelid position (see Fig. 14).

Fig. 22. Buccal membrane grafting for trichiasis. A. Abnormal

posterior eyelid margin with aberrant lashes is marked and excised
(B). C. Placement of buccal membrane graft to the posterior lid
margin.

Hard palate mucosal grafts have been proposed for internal lamellar
grafting.78,79 There is, however, a risk of ocular irritation from the
epithelial surface of this grafted tissue. This makes it a risky
replacement for grafts placed in the upper lid or close to the lid
margin in the lower lid. Split-thickness dermis grafts have also been
proposed. Autogenous split-thickness dermis grafts require a donor
surgical site and occasionally develop hair growth. Acellular
autologous grafts (Alloderm) eliminate the need for a donor site and
do not lead to hair growth; however, their use in cicatricial disorders,
such as pemphigoid, has not yet been established.80,81
Back to Top

REFERENCES
1. Wulc A, Dryden RM, Khatchaturian T: Where is the grayline? Arch
Ophthalmol 105:1092, 1987
2. Hawes MJ, Dortzbach RK: The microscopic anatomy of the lower
eyelid retractors. Arch Ophthalmol 100:1313, 1982
3. Stefanyszyn MA, Hidayat AA, Flanagan JC: The histopathology of
involutional ectropion. Ophthalmology 92:120, 1985
4. Neuhaus RW: Anatomical basis of senile ectropion. Ophthalmic

Plast Reconstr Surg 1:87, 1985

5. Jones LT, Wobig JL: Surgery of the Eyelids and Lacrimal System.
Birmingham, AL: Aesculapius Publishing, 1976:3336
6. Anderson RL: Medial canthal tendon branches out. Arch Ophthalmol
95:2051, 1977
7. Gioia VM, Linberg JV, McCormick SA: The anatomy of the lateral
canthal tendon. Arch Ophthalmol 105:529, 1987
8. Kersten RC, Hammer BJ, Kulwin DR: The role of enophthalmos in
involutional entropion. Ophthalmic Plast Reconstr Surg 13:195, 1997
9. Hosal BM, Tekeli O, Gursel E: The role of enophthalmos in the
development of involutional ectropion. Orbit 18:7, 1998
10. Jones LT: The anatomy of the lower eyelid and its relationship to
the cause and cure of entropion. Am J Ophthalmol 49:29, 1960
11. Wesley RE, Collins JW: Combined procedure for senile entropion.
Ophthalmic Surg 14:401, 1983
12. Nowinski TS: Orbicularis oculi muscle extirpation in a combined
procedure for involutional entropion. Ophthalmology 98:1250, 1991
13. Carroll RP, Allen SE: Combined procedure for repair of involutional
entropion. Ophthalmol Plast Reconst Surg 7:123, 1991
14. Lance SE, Wilkins RD: Involutional entropion: A retrospective
analysis of the Weis procedure alone or in combination with a
horizontal shortening procedure. Ophthalmic Plast Reconst Surg
7:273, 1991
15. Doane MG: Blinking and the mechanics of the lacrimal drainage
system. Ophthalmology 88:844, 1981
16. Hill JC: Treatment of epiphora owing to flaccid eyelids. Arch
Ophthalmol 97:233, 1979
17. Collin JRO: A Manual of Systemic Eyelid Surgery. Edinburgh:
Churchill Livingstone, 1982:30
18. Smith B: The Lazy-T correction of ectropion of the lower
punctum. Arch Ophthalmol 94:1149, 1976
19. Dryden RM, Doxanas MT: Eyelid malpositions, Part II. Ectropion
and entropion. In McCord C (ed): Oculoplastic Surgery. New York:
Raven Press, 1981:124
20. Edelstein JP, Dryden RM: Medial palpebral tendon repair for medial
ectropion of the lower eyelid. Ophthalmol Plast Reconst Surg 6:28,

1990
21. Howard GR, Nerad JA, Kersten RC: Medial canthoplasty with
microplate fixation. Arch Ophthalmol 110:1793, 1992
22. Jordan DR, Anderson RL, Thiese SM: The medial tarsal strip. Arch
Ophthalmol 108:120, 1990
23. Smith B. Cherubini TD: Oculoplastic Surgery: A Compendium of
Principles and Techniques. St Louis: CV Mosby, 1970:9294
24. Tenzel RR, Buffam FV, Miller GR: The use of the lateral canthal
sling in ectropion repair. Can J Ophthalmol 12:199, 1977
25. Anderson RL, Gordy DD: The tarsal strip procedure. Arch
Ophthalmol 97:2192, 1979
26. Jordan DR, Anderson RL: The lateral tarsal strip revisited. The
enhanced tarsal strip. Arch Ophthalmol 107:604, 1989
27. Shorr N. Seiff SR: Cosmetic Blepharoplasty: An Illustrated
Surgical Guide. Thorofare, NJ: Slack, 1986:70
28. Meyer DR, Linberg JV, Wobig JL et al: Anatomy of the orbital
septum and associated eyelid connective tissues. Implications for
ptosis surgery. Ophthalmic Plast Reconstr Surg 7:104,1991
29. Doxanas MT: Orbicularis muscle mobilization in eyelid
reconstruction. Arch Ophthalmol 104:910, 1986
30. Hester TR, Codner MA, McCord CD: The centrofacial approach
for correction of facial aging using transblepharoplasty subperiosteal
cheek lift. Aesthetic Surg Q 16:51, 1996
31. Putterman AM: Ectropion of the lower eyelid secondary to Mller's
musclecapsulopalpebral fascia detachment. Am J Ophthalmol
85:814,1978
32. Wesley RE: Tarsal ectropion from detachment of the lower eyelid
retractors. Am J Ophthalmol 93:491, 1982
33. Tse DT, Kronish JW, Buus D: Surgical correction of lower-eyelid
tarsal ectropion by reinsertion of the retractors. Arch Ophthalmol
109:427, 1991
34. Brown BZ, Beard C: Split level full thickness eyelid graft. Am J
Ophthalmol 87:388, 1979
35. May M: Tearing, salivary flow and taste with facial nerve
disorders. In May M (ed): The Facial Nerve. New York: Theime,
1986:238
36. Adour KK, Ruboyianes JM, Doersten PG et al: Bell's palsy

treatment with acyclovir and prednisone compared with prednisone

alone; a double-blind, randomized, controlled trial. Ann Otol Rhinol
Laryngol 105:371, 1996
37. Levine RE: Eyelid reanimation surgery. In May M (ed): The Facial
Nerve, p 690. New York, Thieme, 1986
38. Kelly SA, Sharpe DT: Gold eyelid weights in patients with facial
palsy: A patient review. Plast Reconstr Surg 89:436,
39. May M: Gold weight and wire spring implants as alternatives to
tarsorrhaphy. Arch Otolaryngol Head Neck Surg 113:656, 1987
40. Seiff SR, Sullivan JH, Freeman LN et al: Pretarsal fixation of gold
weights in facial nerve palsy. Ophthalmic Plast Reconstr Surg 5:104,
1989
41. Elner VM, Ahmad AZ, Fante RG: Mullerectomy as a primary
procedure for exposure keratitis secondary to seventh nerve paralysis.
ASOPRS Sci Symp 29:77, 1998
42. Culbertson WW, Ostler HB: The floppy eyelid syndrome. Am J
Ophthalmol 92:568, 1981
43. Netland PA, Sugrue SP, Albert DM et al: Histopathologic features
of the floppy eyelid syndrome: Involvement of tarsal elastin.
Ophthalmology 101:174, 1994
44. McNab AA: Floppy eyelid syndrome and obstructive sleep apnea.
Ophthalmic Plast Reconstr Surg 13:98, 1997
45. Karesh JW, Nirankari VS, Hameroff SB: Eyelid imbrication: An
unrecognized cause of chronic ocular irritation. Ophthalmology
100:883, 1993
46. Dutton JJ: Surgical management of floppy eyelid syndrome. Am J
Ophthalmol 99:557, 1985
47. Moore MB, Harrington J, McCulley JP: Floppy eyelid syndrome:
Management including surgery. Ophthalmology 93:184, 1986
48. Quickert MH, Rathbun E: Suture repair of entropion. Arch
Ophthalmol 85:304, 1971
49. Iliff NT: An easy approach to entropion surgery. Ann Ophthalmol
8:1343, 1976
50. Danks JJ, Rose GE: Involutional lower lid entropion: To shorten or
not to shorten? Ophthalmology 105:2065, 1998
51. Jones LT, Reeh MJ, Wobig JL: Senile entropion. A new concept for
correction. Am J Ophthalmol 74:327, 1972

52. Dryden RM, Leibsonn J, Wobig J: Senile entropion. Pathogenesis

and treatment. Arch Ophthalmol 96:1883, 1978
53. Schaefer AJ: Variation in the pathophysiology of involutional
entropion and its treatment. Ophthalmic Surg 14:653, 1983
54. McCord CD, Tanenbaum M, Dryden RM et al: Eyelid malpositions:
Entropion, eyelid margin deformity and trichiasis, ectropion, and facial
nerve palsy. In McCord CD, Tanenbaum M (eds): Oculoplastic Surgery.
2nd ed. New York: Raven Press, 1987:286
55. Wesley RE, McCord CD, Jones NA: Height of the tarsus of the
lower eyelid. Am J Ophthalmol 90:102, 1980
56. Mondino BJ, Brown SI: Immunosuppressive therapy in ocular
cicatricial pemphigoid. Am J Ophthalmol 96:453, 1983
57. Maza MSDL, Tauber J, Foster CS: Cataract surgery in ocular
cicatricial pemphigoid. Ophthalmology 95:481, 1988
58. Neumann R. Tauber J. Foster CS: Remission and recurrence after
withdrawal of therapy for ocular cicatricial pemphigoid. Ophthalmology
98:858, 1992
59. Donnenfeld ED, Perry HD, Wallerstein A et al: Subconjunctival
mitomycin C for the treatment of ocular cicatricial pemphigoid.
Ophthalmology 106:72, 1999
60. Secch AG, Tognon MS: Intraoperative mitomycin C in the
treatment of cicatricial obliterations of conjunctival fornices. Am J
Ophthalmol 122:728
61. Kersten RC, Kleiner FP, Kulwin DR: Tarsotomy for the treatment of
cicatricial entropion with trichiasis. Arch Ophthalmol 110:714, 1992
62. Flanagan JC: Eye bank sclera in oculoplastic surgery. Ophthalmic
Surg 5:45, 1974
63. Dryden RM, Soll DB: The use of scleral transplantation in
cicatricial entropion and eyelid retraction. Trans Am Acad Ophthalmol
Otolaryngol 83:669, 1977
64. Tenzel RR: Repair of entropion of the upper eyelid. Arch
Ophthalmol 77:675, 1967
65. Reacher NH, Munoz B, Alghassany A et al: A controlled trial of
surgery for trachomatous trichiasis of the upper eyelid. Arch
Ophthalmol 110:667, 1992
66. Tse DT, Anderson RL, Fratkin JD: Aponeurosis disinsertion in
congenital entropion. Arch Ophthalmol 101:436, 1983
67. Bartley GB, Nerad JA, Kersten RC et al: Congenital entropion with

intact lower eyelid retractor insertion. Am J Ophthalmol 112:437,

1991
68. Quickert MH, Wilkes TDI, Dryden RM: Nonincisional correction of
epiblepharon and congenital entropion. Arch Ophthalmol 101:778,
1983
69. Biglan AW, Buerger GF: Congenital horizontal tarsal kink. Am J
Ophthalmol 89:522, 1980
70. Sires BS: Congenital horizontal tarsal kink: Clinical characteristics
from a large series. Ophthalmic Plast Reconstr Surg 15:355, 1999
71. Anderson RL, Harvey JT: Lid splitting and posterior lamella
cryosurgery for congenital and acquired distichiasis. Arch Ophthalmol
99:631, 1981
72. Elder MJ: Anatomy and physiology of eyelash follicles: Relevance
to lash ablation procedures. Ophthalmic Plastic Reconstr Surg 13:21,
1997
73. Francis IC, McClusky PJ, Wakefield D et al: Medial canthal
keratinization (MCK): A diagnostic sign of ocular cicatricial
pemphigoid. Aust N Z J Ophthalmol 2:350, 1992
74. Sullivan JH, Beard C Bullock JD: Cryotherapy for treatment of
trichiasis. Am J Ophthalmol 82:117, 1976
75. Wood JR, Anderson RL: Complications of cryotherapy. Arch
Ophthalmol 99:460, 1981
76. Bartley GB, Lowry JC: Argon laser treatment of trichiasis. Am J
Ophthalmol 113:71, 1992
77. Huneke JW: Argon laser treatment for trichiasis. Ophthalmic Plast
Reconstr Surg 8:50, 1992
78. Cohen MS, Shorr N: Eyelid reconstruction with hard palate
mucosa grafts. Ophthalmic Plast Reconstr Surg 8:183, 1992
79. Beatty RL, Harris G, Bauman GR et al: Intraoral palatal mucosal
graft harvest. Ophthalmic Plast Reconstr Surg 9:120, 1993
80. Rubin PAD, Fay AM, Remulla HD et al: Ophthalmic plastic
applications of acellular dermal allografts. Ophthalmology 106:2091,
1999
81. Shorr N, Perry JD, Goldberg, RA et al: The safety and applications
of acellular human dermal allograft in ophthalmic plastic and
reconstructive surgery. Ophthalmic Plast Reconstr Surg 16:223, 2000